Follow your program!

There are approximately 14 rating classification levels of care for children in California, each of which represents more therapeutic and more restrictive care. With a rating classification of 14, a short-term residential therapeutic program is the highest level of placement that offers intensive mental health services for youth with severe emotional and behavioral problems. The level of care and services necessary to generate a level 14 rate setting should have been reflected in the following ways:

Child Care and Supervision
“Social Work Activities”
“Mental Health Treatment”

In terms of the quality of care, I believe some STRTP’s focus is on supervision and not the social work activities or mental health treatment. In my opinion, the services provided in the program do not improve the children’s level of functioning in the areas of education, career planning, transition out of foster care, physical or behavioral or social or emotional well-being, and self-sufficiency.

After a child is placed in an RCL 14 placement, this is what should happen next. Within 30 days, the social work staff will obtain the children’s records, develop an individual needs and service plan (NSP), predict the anticipated duration and timeframe of the treatment, and plan for the child to transition to a less restrictive family environment. The NSP should identify the children’s needs in the following areas:

Reason for placement
Education
Training and other practical skills that may support transition-age youth and nonminor dependents in achieving success in adulthood
Personal care and grooming
Ability to manage his/her own money
Visitation
Other specific services to the child’s parent(s) or guardian(s)

Let’s get into the program

The program here is straightforward. A point system whereby the kids are scored from 0 to 100 if they complete their morning and evening routine. At the end of the week, staff count their points and determine what level they were on. If they have a point average of 70 percent or higher, they are on a level because 70 percent is a passing grade that is level “C”.

What do letter grades mean?

“S” being the lowest level, which means suspension or shutdown (60 points)
“C” being average, which means: “You’re on level! Congratulations! (70 points)
“B” being good (80 points)
“A” being excellent performance (90 points)
“T” being trustworthy, which means: “You’ve been on level A for 4 weeks consecutively.” (90 points)
“L” being leader, which means: “You’ve been on level T for 4 weeks consecutively.” (90 points)

When residents are on a level the benefits of following their program can include:

Incentives

access to the multipurpose room (MPR room)
access to the recreational room (REC room)
ability to cook in the kitchen (please read my story about Juan here)
ability to go on outings
able to hold onto their monthly allowance (that is if they were not a runaway risk or were caught using contraband)

Personal Allowance

The base amount shall not be less than the following amounts per week, starting with the first full week of placement.

$7.50 (5-7 years)
$12.50 (8-10 years
$15.00 (11-13 years)
$20.00 (14-15 years)
$25 (16-20 years)

Allowances may be increased beyond the base amount according to a point/level/rewards behavior management system as described in the CONTRACTOR’s Plan of Operation and Program Statement.

The program is basically a schedule that keeps the residents accountable, lets them know what to expect, and gives them something to control— themselves. Children need structure and predictability in their lives. “A routine helps kids practice making simple predictions, as well as understand concepts such as before and after.”

Transitioning from morning hygiene to school, to chore, to therapy, and to evening hygiene was a schedule set in place that provided structure and repetition. If you look at how new behaviors are formed, you have to work backward. Routine is followed by repetition; repetition is followed by habits, and habits are how you form new behaviors.

New behaviors, such as making their bed, doing their chore, and following staff directions were habits the treatment counselors encouraged the residents to practice. If not, the morning staff would be the ones to clean their room, or the evening staff would have to help out and do their chore.

The good thing about the CCLD is that the facility never knew when licensing was going to check in and inspect. So as staff we were constantly dating food products or trying to comply with licensing requirements. On the downside, even though the CCLD inspect, in my opinion, their standards were very low. The couches were so dirty, accumulation of dust particles would scatter or suspend in the air when someone sat down on them. The air vents attached to the air ducks would shoot out little wisps of dust, every time the air conditioning system turned on. The white cinder block walls had food splatter, dust, and dirt all over the grooves of the walls. The comforters, towels, and pillows were so worn out and flat. They barely had any down filling. But enough about the CCLD.

After the residents started following the program, the incentives listed above didn’t motivate them to listen when staff redirected them or to follow the cottage rules. When rules were broken the residents would get 0 points for listening within 3 redirects, 0 points for disrespecting staff/peers, and 0 points for not following the program. Other behaviors such as smoking, refusing to go to school, fighting, or breaking property would automatically place residents on level “S” for 72 hours.

Here are the rules:

Rules:

No eating on the couch, living room, bedroom, or kitchen counter
No feet on the couch
No room visiting (this includes standing in front of another child’s bedroom door)
No cottage visiting (children cannot visit any child in front of or inside another child’s cottage. Keep in mind the 13-16-year-old cottage is connected to the 17-21-year-old cottage. The little kid cottage is about 100 feet separated.)
No cussing
No fighting
No running
No touching another child or staff member (such as rough housing or hugging)
No leaving your room before 6:30 am or after 10 pm (unless you have to go to the bathroom, then straight back to your room)
No handling the remote (only staff)
One person at a time in the communal bathroom
Keep the bathroom door open (except bathroom stall door)
Letting staff know when you want to go outside
No wandering off where staff can’t see you.
Always be with a staff member on campus grounds
Following redirects within 3 warnings
Pool rules: no splashing, no touching, no jumping inside the pool, no running, no touching the rope, and no yelling.

Here was their program:

Clean room every day (floor, bed, countertop perfectly and once a week change their sheets)
Do laundry on your specific day
Chore every day (Rotating chores every week between windows, floors, indoor trash, bathroom, cleaning dining tables and chairs, sweeping the front door outside along with taking out outdoor trash, and wiping the kitchen counter.)
Morning and evening hygiene
Therapy
Attend school
Attend any other “social work activity” (ex. group, activity, study hall)

Now here is where I find the loopholes in the program. The program is a behavior-modification system in which children receive points in exchange for desired behaviors like brushing their teeth, cleaning their room, or doing their chores. The points for doing these expected behaviors didn’t provide extrinsic motivation for the children to clean their room or do their chores because the outings were never consistent or desired.

The MPR room was literally just an empty room and the REC room needed at least one staff member to watch them. There would be four staff in the afternoon from 12 through 4 pm and only seven boys to each cottage. Some days, one child was on a medical appointment (one staff member was with him), three were in their room (one staff in the cottage), one was outside sitting at a table (one staff watching outside) and two were at the basketball court (one staff at the basketball court). The child who was on a level in the cottage, if he decided he wanted to go inside the REC room, wouldn’t be able to go.

Since there are two other boys in the cottage, the staff watching him couldn’t take him. If one child was in the cottage, one staff member was required to watch inside. So that child who was on a level couldn’t go inside the REC room, even if there were four staff members. The child on a level would have to wait to see if one staff member became available. His chances for four staff members to be available and on campus were better during the weekend or on Wednesdays. As staff members were more able and free to watch residents in the REC room.*

As staff members, we told the residents they could earn extra points to get on a level if they could help us take out the kitchen trash. But they said, “No, thanks! Now what?” With the right incentives and structure, the system could have been an effective way to get the kids in the habit of brushing their teeth or doing their laundry for example. Getting them to run their program when most of the children had nothing to gain when being on level wasn’t going to make them want to earn extra points. As children, they didn’t understand the bigger picture which was moving to a less restrictive environment by meeting their NSP, ILP/ emancipation, educational, and mental health treatment goals.

Some examples of less restrictive environments include parents, NREFM or relative home, foster home (RFA), transitional housing (SFH), and therapeutic foster care home (FFA). Although the incentives on and off the grounds were unmotivating, being discharged to a foster home other than a group home would have been the reason to do your best to follow your program. That being the only extrinsic motivation to follow your program so the child can transition to a lower level of care.

Off Grounds Incentives

The level system should have encouraged the residents to follow their program. However, the incentives for running their program were never worth it. And here I will tell you why. When a resident who was on level A, B, or C left the campus once a week (if that) for an outing, as a staff member we were given an average outing budget of around 75 to $100. This budget would cover the outing funds to take about seven young men off-grounds. Let’s just assume seven go on the outing… three from the 13 through the 16-year-old cottage and four from the 17 through the 21-year-old cottage, who are on a level and wanted to go, which gives the treatment counselors around 10 to $14 to budget for each resident.

Staff would have to choose, “Do I take the residents to eat food or do something fun like go to the movies.” If the team decided on food, there was nothing left in the budget to do anything fun that cost money, like going to an arcade, skating rink, or even bowling alley. If staff chose something fun, what can you do with only $14, and depending on how long you took, would you feel comfortable knowing the children would probably feel hungry if you stayed out too long.

When you think about how much money an STRTP makes for every resident – $14,035 – you have to question why there is no money in the budget to do off-ground activities? The kids running their program do it because they need to live and survive in a group home, not because they want to. The level system doesn’t motivate the residents to follow their program because, in the end, the payoff is too little.

For example, once you’ve done x,y,z, that means you’ve shown me you’re responsible for leaving campus and going to the movies. However, there’s no money in the budget to buy you food. And if you’re hungry, I hope you can wait till dinner time because lunch is not in the budget for today (assuming they leave between 10 am to 4 pm)! Sometimes the residents didn’t have money to eat on their outing. Either they ate and did something free or did something fun that had to cost within their budget of $10 to $14.

The outings were always postponed until the afternoon when there was four staff available to each cottage, any time after 1 pm. Then we started waiting until the cottage mom felt ready to drop off the money. If there were too many children who could go on the outing but not enough staff to watch the residents because the cottage mom came too late after 4 pm, only two staff watched the residents versus four. The residents couldn’t go on their outings, and this happened quite a lot. The ratio was one staff to every four residents. The cottage mom didn’t care.

Everything had to be done on her own time, and if she couldn’t get there the residents couldn’t leave the facility. It was their one opportunity to leave for that week unless they went on a medical run or court appointment. She pretended that residents had to be on a level to get a haircut or get their clothing allowance. She would ask, “Are you on a level? Let me think about it.” She would sneak through the back door of her office and never be available to the residents or staff. And when you wanted to speak to her, she would make you wait for a few days.

But enough about the supervisor, let’s talk about the on-campus benefits of following your program and see if those were worth it.

Campus Ground Incentives

Their reward was access to the multi-purpose and recreation room. The REC room was located in another building near the cottages. Every door on the facility was locked except their bedroom and bathroom. The activity coordinator had the key to the REC room.

Now what we have inside the REC room is nothing more than a few computers, a music room/ billiard room (that they almost always kept locked up), a small workout room (items were mostly broken), a closet full of disorganized board games, a locked room of bikes, and a larger TV (maybe around 50 inches) mounted in the corner of the ceiling.

The speaker on the TV barely worked as the volume wouldn’t change. The floors look like they haven’t been vacuumed or swept for a couple of months. The art on the walls was peeling. The kitchen was regularly dirty having old food all over the counter, food or plastic dishware inside the sink, and trash overflowing with garbage.

The multipurpose room was a locked room inside the cottage. Staff wore a lanyard that kept two keys: one for the front door and other rooms inside the cottage and another for the bolt locks. Some examples of where these bolt locks were installed included: snack, medicine, cleaning supply, and office supply cabinet which was where they kept any personal belongings that were “dangerous.”

The MPR room has a 40 inch TV which had no cable or satellite to watch your local TV channels. There were some plastic folding chairs around a wobbly circle table and a broken bookshelf where there would be a few board games, Inside was a plastic cart full of movies and Xbox games but no video game console or DVD player to watch the film or play the Xbox games.

Can you picture it? If so, can you tell me would this motivate you to be on level? A room with movies you couldn’t watch, Xbox games you couldn’t play, or board games you’ve already played about a dozen times or more? For a while, I got really good at monopoly, Uno, and Scramble.

The MPR room had nothing inside that would motivate the residents to listen when staff redirected. The team was split: some thought the residents needed more incentives in the MPR room while others stated, “They get too many perks!” In my head, I thought, “Are you serious? They are acting out and running away because we are too strict and they are bored!”

My supervisor, the cottage house mom, one day walked through the cottage and saw the decorations I just put up and a plate full of cookies I just baked that was left on the counter. She angrily stated, “This isn’t camp Snoopy!”

I would go as far as to say that she didn’t want the boys to have a video game console or DVD player. Because in her mind, she rationalized the belief, “none of the boys even if they were on a level, deserved to play video games or watch movies. In the end, one of them would one day break it. So, why even buy one.”

This all-or-nothing cognitive distortion was unfair to the rest of the boys who would be able to handle their behaviors in appropriate ways. If one boy wasn’t able to handle his anger and smashes the Xbox console, is it fair that his behavior should penalize the rest of the boys in his cottage? Who’s to say the boys who were on a level were not capable of playing Xbox or watching movies. They were never given the opportunity to show their direct care workers that they wouldn’t break either device since the cottage house mom never purchased a DVD player, Xbox, or Playstation system.

Mind over matter

But I did. I donated an old DVD player, books, movies, board games, and Roku device that I purchased from Goodwill to motivate the children to be on a level. The kids never knew I donated the items.

Filling the room with items I could fit inside my backpack, I slowly filled each shelf and cart with new books and DVDs. A few times when the kids would ask, “Who bought this?”, referring to a new monopoly game I purchased.

Staff wouldn’t tell me directly, “Don’t buy them anything!” whenever new items would appear inside the MPR room unless they saw me. But I can still remember the feeling when I explained to the child who asked, “I bought it.” And getting those side-eyes with that constant reminder: “Don’t buy them anything!”—it was definitely heartbreaking to see how angry and hateful they truly were.

Although I never expected the kids to treat the items like they purchased them, I was always grounded in reality. I primed my subconscious response to feeling the worst-case scenario and with that all the emotions it would bring up. After holding those feelings within my body, I became emotionally detached from those items as my mindset was decided.

“If items went missing or became broken, I wasn’t going to be mad. They served their purpose and I was okay with that. I purchased those items to be used and in the process, if they became broken, smashed, or lost. They brought joy and motivation in the time it needed.”

Taking time to adjust my thoughts and emotions to remove any negative response. I primed my thoughts to realize the teens inside the facility were probably going to mess up whether I liked it or not. Even though I was mentally set on not reacting, the youth never gave me a reason to ever regret buying anything I purchased. The truth is, if the staff was able to stay unemotional and simply teach the children the right way to behave, without drama, then we could have mastered the ability to contain the children in the STRTP in a conscious way without creating a toxic environment of control or manipulation.

Though the children could have been encouraged by having an Xbox in their cottage or going to an outing where they can both do an activity and have dinner, the on-and-off-campus incentives provided no extrinsic motivation to follow their program. The children could have also been motivated by an intrinsic desire to listen if the program itself had the right combination of structure in their lives and if there was kindness which would have cost nothing!

There also had to be a balance between empathy and the people working in the program not being punitive. They had to work with these children in a way that conveyed the message, “We care about you. We’re not just controlling you.” The successful programs that are willing to do that kind of curriculum will keep more kids from running away and meeting the children’s NSP goals, as well as discharging them to a less restrictive environment. But programs that are just focused on control for the sake of control aren’t going to work!

Q&A: How would you motivate middle and high school boys to be on level?

*School weekdays

During the school year, Monday, Tuesday, Thursday and Friday left the children with a 1-hour window where four staff members would be available to take them to the REC room. That is after the children came home from school by 3:00 pm. Why? The morning staff would be done with their shift by 4 pm, leaving only two evening staff members.

Summer weekdays

During the summer, Monday, Tuesday, Thursday, and Friday had the REC room open after 12 pm. However, from 1-2 pm, one staff member from each the morning and evening shifts had to attend a mandatory meeting to discuss hot spots. This left the children with only a 2-hour window for four available staff members to take them to the REC room. That is, between 2-4 pm. Why? The morning staff would be done with their shift by 4 pm, leaving only two evening staff members.

Weekends

Since the children didn’t have school and the REC room was open by 12:00 am. The children had a 4-hour window where four available staff members between the hours of 1-4 pm could take them. Why? Because on weekends, staff didn’t have their weekday meetings from the hours of 1-2 pm (Monday, Tuesday, Thursday, Friday) or training from 1-3 pm (Wednesday). This left the staff available to take the resident’s from their cottage to the REC room for 4 hours.

Wednesdays

When the four front-end and four back-end staff members worked together for one day, there was always a mandatory meeting from 1-3 pm. This left the children with a 1-hour window where eight staff members would be available to take them to the REC room between the hours of 3-4 pm. After the morning staff left, there was still another 2-hour window, where the four evening staff members could take the residents to the REC room between 4-6 pm. Why? The four-morning staff ended their shift by 4 pm but left the four evening staff from both front-end and back-end to work together.

Work Cited