The intensive therapeutic group homes provide a safe, supportive, structured and predictable environment for youth experiencing severe emotional disturbance and developmental disability. The 2:1 staff ratio allows for close supervision and fosters interpersonal relationships with good communication, honest expression of feelings and unconditional care. Developing and maintaining a trusting relationship with the youth served are essential for therapeutic change. Staff offers a corrective emotional experience meaning the youth experience relationship differently than they have in the past. In our facilities, youth experience adults as trusting, forgiving, available, in control of their emotions and behavior and generally fun to be around.
The foundation of our philosophy is a belief of unconditional care. We teach the youth that, while their behaviors are sometimes unacceptable, our care for them is never faltering. Staff communicate that feelings are always respected, but the expression of them may need to change. Feelings are validated while new ways of expressing them are taught. The youth served are accustomed to the adults in their life giving up on them when the going gets rough. Our staff communicates with words and behavior that they will not give in to the testing limits. At the same time, staff knows the youth need to test limits to establish trusting relationships. In this way, staff provides safety and positive expectations while teaching the youth a new way to build relationships.
Interpersonal interactions are often viewed by the youth in terms of control. Many of the youth believe that if they comply with a staff request, such as brushing their teeth when asked, they lose their control. The youth perceive meeting staff expectations as a loss of power. Additionally, they are afraid of expectations because of the loss and abandonment they have experienced in their lives. Loss hurts more when your needs go unmet or when you expect something from someone in relationship and they do not meet your expectations.
The concept of normalization is fully incorporated into service delivery. We believe that youth learn best in natural environments and need to be kept close to the people they perceive to be supportive. Very few youth need the security of a residential facility. Our organization has documented success serving the same type of youth usually sent to residential facilities in community group homes located across Montana. That way, the youth experience life similar to other youth their age. They attend public school, community events, cultural gatherings, spiritual worship and recreational activity typical of most youth their age. Additionally, the treatment program implemented in the homes favors normalization. Instead, our program relies on natural and logical human reactions and establishes clear consequences for misbehavior and rewards prosocial behavior. Our organization believes that the youth served transfer skills better from this type of environment as opposed to an artificial residential setting
The other elements included in our philosophy of care are borrowed from the wraparound philosophy. Services are individualized to meet the unique needs of the youth served. The youth is not expected to meet the program needs. The program must meet the needs of the youth. Further, interventions are tailored to maximize the strengths of the individual not just focus on his or her problem area. A focus on individual strengths helps improve self-esteem and confidence, making problem areas seem less significant. A family focus is central to wraparound philosophy. AWARE Inc. believes that the family must be fully included in the treatment of the youth for achievement of success. Staff works to empower the family and view the parents as the people who know him or her best. Staff recognizes that parents’ do the best they can to care for their youth with the resources available to them. Education about developmental needs and skill building activities help parents make necessary changes. If the youth has been removed from his or her parent’s care because of abuse and neglect and parental rights have been terminated, it may still be important for the youth to know his or her parents. If this is the case, staff will monitor visits for safety.
Because services are offered in community, they are cost effective. Treatment costs in a therapeutic group home are less than a stay in a residential facility. Services are also comprehensive. All domains of the youth’s life are addressed including school, social, family, mental health and legal. The individualized treatment plan identifies goals and interventions for each area, and the individuals responsible for completion. The plan is reviewed and updated monthly by the treatment team.
Cultural sensitivity is an important element of wraparound philosophy. Cultural, religious, ethnic and spiritual practices are honored and respected by staff. Values are openly discussed at team and staff meetings. Traditional practices are incorporated into the treatment plan for youth. Other youth and staff are encouraged to participate in cultural activities as well believing that exposure to these events increases understanding.
Lastly, the gathering of outcome data tracks satisfaction and success with services. The youth and community members fill out feedback forms. The information gained is used to improve the quality of services offered. Data is also collected to monitor length of stay and discharge information. Our goal is to discharge 75 percent of the youth served to less restrictive settings. Currently, we are proud to beat that goal. Approximately 83 percent of youth were successfully discharged to less restrictive settings.
The elements of wraparound coupled with the founding principles of unconditional care and normalization make the service philosophy of AWARE unique. The organization continually strives to improve service delivery by listening to the needs of those served and the staff whom deliver services.
The youth served must meet the state definition for severe emotional disturbance. In practice, this means that the youth served has experienced severe trauma that contributes to a delay in behavior and emotional expression. Because the youth has never experienced clear and consistent limit setting, a predictable living environment or emotional safety, they have not internalized controls. The result is acting out behaviors and poor emotional control. The staff works with the youth to improve coping and helps them develop necessary skills, such as anger management.
To be authorized for services, the youth must meet the following criteria:
- The youth is experiencing psychiatric symptoms of a severe or persistent nature, which require a more intensive treatment and clinical supervision that can be provided by outpatient mental health services.
- The recipient is at significant risk for placement in a more restrictive environment, or the recipient is currently being treated or maintained in a more restrictive environment and requires a structured treatment environment to be successfully treated in a less restrictive setting.
- The recipient’s prognosis for beneficial treatment at a level of care lower than therapeutic living is poor because the recipient demonstrates one or more of the following: significantly impaired interpersonal or social functioning; significantly impaired educational or occupational functioning; lack of family or other community or social networks; impaired judgment; poor impulse control.
- The recipient exhibits an inability to perform daily living activities due to a mental, emotional or eating disorder.
- The recipient exhibits maladaptive or disruptive behaviors due to mental, emotional or eating disorder.
Further, many of the youth served are dually diagnosed. This means that besides the mental health diagnosis they also meet criteria for a cognitive delay or learning disability. These youth are especially challenging because of the complexity of their needs.
Practice of Care
The residents receive all basic needs, including food, shelter, clothing and personal care items. Clothing budgets and an allowance given weekly to the residents provide for the purchase of personal needs and other items. AWARE employs clinical staff (program director) to provide and/or supervise the treatment of the youth in the homes. The average length of stay in the homes is nine months. This is due to the chronic nature of their disturbances and their extensive history and failure in other levels of care. Past placements include foster care, therapeutic foster care, family, adoptive care, residential treatment and psychiatric hospitalization. The youth AWARE serves average six previous placements before placement with AWARE. The number of placements contributes to feelings of abandonment, lack of trust and defensiveness. The youth interpret that rather than the placement failing, he or she is a failure. AWARE believes the failure is not the youth’s but is due to the lack of creativity by the provider’s involved.
The staff-to-youth ratio is two adults to four residents during awake hours and one awake night staff to four residents to monitor the safety of the residents during the early morning hours (not in the six-bed homes). A program manager who has a bachelor’s degree supervises each home and has experience working with this special needs population. The manager oversees the implementation of the treatment plan and reports observations and concerns to the program director.
The residents are directly supervised by direct care staff in the home and during outings into the community. Direct care staff ensures safety at all times. The structure of the group home furthers feelings of safety because of the predictability established. All residents attend public school, some receiving special education services if necessary. AWARE staff provides transportation by a company van. Transportation to school is generally provided by the local school districts.
The referring agency provides all relative records, evaluations and placement history for review by AWARE professional staff prior to accepting a resident. Information gathered includes school, familial, social, medical and psychological documentation. Recommendations from the last admitting facility are also included. Once admitted, staff contacts the youth to introduce themselves and answers the questions he or she may have about the program. At admission, the legal guardian and the youth sign a placement agreement detailing program expectations.
For the first 48 hours, the youth is placed on one-to-one supervision. For the following 28 days, staff observes the youth and identifies strengths and challenging areas. The treatment team meets to develop the individualized treatment plan. The youth is fully involved in the development of the plan.
Each resident participates in a behavioral support program. The supports offered are categorized into prevention of behavior, teaching appropriate skills and intervention. The level system provides the overall structure to the home.
Responsibilities and privileges are identified and acquired based on the youth’s behavior. Levels are evaluated on a daily basis. The levels are: a) Grounded; b) Citizen; c) Ace.
- Grounded is the most restrictive level and is applied to the youth who have violated safety rules. Because the youth is assessed to be unsafe, he or she loses the privilege of attending community events and other privileges in the home.
- Citizen provides youth access to all privileges although restrictions may be placed for misbehavior or developmental appropriateness.
Ace is the highest level. The youth is demonstrating good emotional and behavioral control and has the endorsement of the treatment team to receive additional privileges. Unsupervised time is the privilege earned that youth on ACE level experience to be most rewarding. Other rewards are given as well to reinforce appropriate behavior.
Timeout procedures are used to consequence inappropriate behavior. The location and length of the timeout matches the seriousness of the behavior. For example, threatening to harm someone would be met with a room timeout while rough housing would result in a brief chair timeout. A timeout interrupts the misbehavior and encourages the youth to gain internal control.
All residents participate in group and individual sessions and family therapy, if appropriate. Group is a time for residents to express feelings and talk about needs openly and honestly. Constructive feedback is encouraged, and active problem solving occurs. Additionally, each resident meets with an AWARE professional twice a week. The sessions focus on individual problems or unresolved issues identified on the individual treatment plan. Family therapy is offered by the program director. For the youth whose discharge plans are to return to the family (includes therapeutic) home, family meetings are held consistently. For other youth, the family therapy may be used to maintain a relationship. If that is the case, staff may supervise phone calls or visits. Meetings would be more irregular.
Participation in community activities is an important component of treatment. Structured activity allows the youth opportunity to practice skills in a more normalized environment than in the group home. Activities are scheduled every day. The activity varies, and youth are included in the planning process so that individual interests are respected. Recreational activity is always encouraged. Camping, hiking, swimming, skiing and other activities assists with building coping skills and socialization.
The residents are expected to complete chores and be responsible for personal care. As in a family setting, their participation helps the functioning of the home. Natural consequences are used for youth who refuse to comply. Residents who want to earn extra money can be assigned additional chores. In turn for their participation, they are given a weekly allowance. Staff works with the youth to develop budgeting skills. Chore assignment also helps build independent living skills.
Developing trusting relationships, preventing problem behaviors, teaching skills and intervening based on individual needs, maximizes functioning and leads to success for each youth receiving services. Youth are discharged from services when staff assess this level of services are no longer necessary. A planned discharge occurs when the youth completes his or her treatment goals. An unplanned discharge occurs when youth runs from the facility or staff cannot contain the acting out behaviors of the youth. The legal guardian and other treatment team members are actively involved in the discharge planning process.