Welcome to the first episode of Becoming Centered.  This episode begins the Residential Counselor Orientation series, designed for the new Residential Counselor.  It introduces a way to understand your role, your relationship with clients and other counselors, and introduces some basic tools for becoming a skilled Residential Counselor. 

Episode 1 focuses on a specific understanding of the role of a Residential Counselor.  For related resources check out the Bear Clan, llc website at www.BearClanllc.com.    

There’s different types of residential treatment programs for serving school-age children.  The length of treatment and the setting can greatly vary.  

The extent to which residential treatment is a therapeutic and transformational experience will greatly depend on the quality of the relationships formed between residential staff and the clients.

Staying in a professional role can be challenging for a variety of reasons.  However, that’s the ideal for which to strive.

“Counseling” can be thought of as helping people improve their ability to become centered.

It’s helpful to understand the brain and personal psychology in terms of four domains of functioning:

1. Emotions
2. Cognitions
3. Behaviors
4. Executive Skills

Possible areas on which to focus during your orientation period include:

• ·       Assist clients with becoming emotionally centered by presenting yourself in a calm and organized fashion.  It’s okay if that feels like you’re just acting; give yourself time to grow into this complex role.
• ·       Assist clients with becoming cognitively centered by learning the daily schedule and helping clients be organized and prepared for the tasks associated with the different parts of the schedule.
• ·         Assist clients with becoming behaviorally centered by attending to their basic physical needs for hydration, food, rest, sleep, exercise, etc.  Also take care to attend to your own basic needs so that you’re able to function at a high level despite the difficult hours of your work day.  Help clients learn to co-regulate their nervous system with yours by playing with them and having fun with them.
• ·         Assist clients with their developing executive skills by supporting their self-regulation of their own emotions, cognitions, and behaviors.  Asking clients what comes next in the schedule and what preparation is needed, is a simple way to get them to think ahead and practice their executive skills.

Professional boundaries includes:

1.         the schedule of when you’ll have contact with the kids,

2.         limits on physical touch,

3.         limits on personal disclosure, and

4.         the general tone of the professional relationship.

1.  Your contact with clients is during scheduled hours.

•         Be polite but minimize any accidental contact with clients outside of work.
•          Don’t talk about your clients in public.

2.  Limits on physical touch.

•          Providing Physical Assistance:  If your clients require physical assistance with hygiene, always be business-like and clinical.
•          Affectionate Touch:  Kids thrive on affectionate touch but because of the treatment issues common in residential programs your organization likely has guidelines to avoid types of affectionate touch that are too intimate.
•          Sexualized Touch:  Sexualized behaviors toward clients is clearly a boundary violation.  You may have to set limits on sexualized clients trying to relate to you in a sexualized or harassing fashion.
•          Directive Touch:  If your clients require physical assistance with hygiene, always be business-like and clinical.  Only use directive touch in a manner consistent with your organization’s trainings, policies, procedures, and practices.

3.  Limits on personal disclosure.

•          Your relationships with the kids are based on the time you spend together, not on your personal history, your life outside of work, or the type of information you might exchange with peers in order to develop a relationship.
•          Kids will test to see if you have professional personal disclosure boundaries, so have in mind some respectful ways to not answer questions about your life outside of work.
•          Don’t disclose personal issues that overlap with issues that the kids bring into treatment, such as drug use, unless your program directly trains and supports you in how to use that sort of disclosure in a therapeutic way.

4.  The general tone of the professional relationship.

•          Dress like a professional.  Speak like a professional.  Carry yourself in a confident fashion.
•          Don’t promise to keep any secrets.  You’re part of a treatment team and may be professionally obligated to share any information you learn from a client.
•          Allow yourself to develop genuine caring feelings for the kids, but maintain a level of clinical distance to create an important professional emotional boundary.

Therapeutic relationships help your clients become centered in four domains of psychological functioning.  This can be visualized using The Domain Compass:

·       In the East, there’s the domain of emotions, consisting of feeling and moods.

·       In the South, there’s the domain of cognitions, consisting of thoughts and beliefs.

·       In the West, there’s the domain of behaviors, consisting of both all external actions and the internal actions of the physical body.

·       In the North, there’s the domain of executive skills and self-regulation. 

1.  Three relationship qualities to strive for within the domain of emotions.

·         Focus on increasing clients’ awareness of their own emotions.

o   The Check-In technique helps clients express their feelings and moods in words or in various kinds of rating scales.

·         Help sooth emotions that become too powerful or chaotic.

o   The Low and Slow approach helps to cool down an overheating nervous system.

o   The Organized Activities approach helps to structure a chaotic nervous system.

·         Build up clients’ fragile and/or low self-esteem.

o   Praise works through high frequency repetition to help kids see their own strengths and worth.

o   Attention helps kids feel their own worth.  Often times, older kids in residential treatment still need the intense level of attention that people appear to intuitively give to pre-schoolers.

2.  Two relationship qualities that help kids within the domain of cognitions.

·         Increase external structures to reduce cognitive chaos.

·         Break sequences down into smaller chunks.

3.  Three relationship qualities that help kids become behaviorally and physiologically centered.

·         Attend to kids’ basic physiological needs (water, food, sleep, exercise, rest).

·         Become an active and skilled listener.

·         Co-regulate with kids through joining them in play.

4.  One key relationship quality that helps kids in the domain of executive skills.

·         Help each kid make and keep friends. 

High level team work is an absolutely essential aspect of being an effective Residential Counselor. 

There’s a classic way to think about the formation of effective teams.  It breaks team development into 5 over-lapping phases:  Forming, Storming, Norming, Performing, Adjourning.

(1)  Forming refers to all the dynamics that happen between team-mates when you’re relatively new to working with one another. 

·         The key to moving through the forming phase is constant communication among team members.  Let your partners know where you are, what you’re doing, and which kids, or zone, you’re covering.

(2)  In the Storming Phase, little conflicts among your team-mates have appeared. 

·         The key to moving through the storming phase is feedback.  Make giving you feedback as easy as possible.  Make it clear to your teammates that you want to know how to excel at being an effective teammate.  At least at first, focus on getting feedback on how you’re doing as a member of team, rather than your work directly with the kids.

    (3)  In the Norming Phase routine tasks, including transitioning through all the different parts of the daily schedule, are generally going smoothly. 

·         The key to supporting this normative level of teamwork is appreciation.  Don’t take for granted when parts of the shift go well.  That only happened because of you and your team-mates.  Be generous in expressing your appreciation for your fellow staff do.

T  (4)  The Performing Phase of team development.  Now, it’s not just the routine parts of the shift that are going well, but the team skillful adapts and overcomes various challenges. 

·         Find ways to recognize and celebrate when your team performs at a high level.

5  (5)  The Adjourning Phase in residential treatment is most relevant in the context of how each shift is ended.  That’s when you’re most likely able to speak with one another.  That’s when you can ask for feedback, express appreciation, and celebrate the team’s successes.  However, there’s also a really important team function that should be prioritized – and that’s debriefing; specifically what’s known as “Critical Incident Stress Debriefing”.

·         Residential treatment work frequently exposes staff to extreme situations that can have trauma-like effects.  Checking-in with fellow staff at the end of the shift and sometimes telling the story of what happened, in a calm fashion, can blunt the neurological effects on your brain of intense experiences with clients.

Residential work is highly stressful and the skilled Residential Counselors attend to their own self-care.  You can’t effectively take care of others if you’re not also taking care of yourself.

This episode reviews The Domain Compass, which is a way to visualize four domains of psychological functioning.

In the East, there’s the domain of emotions, consisting of feelings and moods. 

In the South, there’s the domain of cognitions, consisting of thoughts and beliefs.

In the West, there’s the domain of behaviors.  That’s includes both external behaviors and all the internal workings of your physical body and nervous system.

In the North, there’s the domain of executive skills.  That’s where self-control is found.

Another helpful way to visualize personal psychology is captured by The Aspect Compass.

The Artist expresses emotions to communicate to others and experiences the world, largely in terms of emotions.

The Scout is in charge of exploring the world, trying to make sense of it, and reporting its findings to the rest of your brain. 

The Warrior includes the parts of your brain that control your muscles and entire physical body.

The Chief gets feedback from the other aspects of your personal psychology and provides regulation through executive skills.

Labeling is a key technique for giving each kid’s inner Chief the feedback it needs to do its job of self-regulation of emotions, cognitions, and behaviors.  It begins with increasing each kid’s awareness of their own behaviors.

Labeling is simply stating, with no attached judgment or direction, what a kid is doing, that specific moment.  Attentive adults instinctively do this with very young kids; however, even older youth in residential treatment tend to have developmentally delayed executive skills.

Labeling develops kid’s inner Chief through repetition.  Eventually, the clients will replace your voice with an internal voice (their inner Chief’s) that helps them monitor their own behaviors.  As that ability strengthens, their inner Chief will also become more skilled at monitoring, at maintaining awareness of, their own emotions and thoughts as well. 

This episode uses The Aspect Compass to frame the role of a Residential Counselor as serving as The Chief function with the clients to set limits, to help regulate, the kids’ emotions, cognitions, and behaviors.

When residential staff don’t set enough limits, you’ll see a phenomenon called contagion.  This comes from firefighting and describes how a fire will spread from one tree to another.  It’s also used to describe how a disease will spread from one organism to another.

The Artist responds to emotional appeals, highly dependent on your relationship with each kid.  This can work quickly to regulate kids, but has the downside of “do it for me” and so doesn’t necessarily lead to inner growth in self-control. 

The Scout responds to questions.  This can lead to more thoughtful behaviors but is dependent on the kid being cognitively organized enough to think before acting (or speaking).   

The Warrior responds to commands.  This can work quickly, and may be crucial in a behavior crisis.  However, cooperation is preferable to compliance.  The goal is always for the clients to become more independent and to learn more self-control, rather than just obeying. 

Check-In’s help each kid’s inner Artist learn how to use words, or a rating scale, to express emotions, rather than acting out. 

Likewise, being a skilled listener, asking for clarification, getting kids to use different ways to express themselves, develops their inner Artist’s abilities to communicate.

The Low & Slow approach and Organized Activity help each kid’s inner Scout become organized enough to think before acting.  Every time they “practice” becoming more cognitively organized, it becomes easier to do (on a neurological level). 

Implementing program structures in a consistent and predictable fashion allows kids to make the connection between their own choices, their own  behaviors, and positive and negative consequences that are enforced by staff.  This trains their inner Scout in understanding a key way in which the world works, rather than believing that things just happen to them.

Playing with the kids allows them to co-regulate their neurology with your own.  This helps emotionally soothe them and cognitively organizes them. 

When you do have to blatantly be directive, two excellent related strategies are the Forced-Choice and Weighted-Choice techniques.

The Forced-Choice Technique is when a counselor presents the client with two choices, and won’t engage in any unrelated discussion.

The Weighted-Choice Technique is when the counselor presents one of the choices as being more attractive.  Nevertheless, the client still gets to choose and may decide on the larger consequence.  That’s unfortunate, so don’t make the weighted choice too disproportionate to the situation, but either way you’re still developing the client’s executive skills, forcing them to exercise their inner Chief.

Physical Restraints are a complex and controversial subject that might be triggering for some people. 

There are scholarly articles on this subject and many national organizations have expressed opinions on the use of physical restraint.  My perspective is primarily driven by my professional experiences participating in physical restraints, mechanical restraints, chemical restraints, and seclusion; and reviewing and reporting on thousands of these sorts of incidents.

Ethical concerns around the use of  physical restraints, per Scheurmann in the Journal of Disability Policy Studies 27(2), include:

1.  Potential for death or injury.

2.  Failure to use the least intrusive intervention.

3.  Inappropriate restrictions on liberty and removal of access to education.

4.  Repeated use of a potentially dangerous and ineffective intervention.

5.  Disproportionate use with certain critical groups.

6.  Insufficient professional training, supervision, and monitoring.

I would add that some kids who get restrained probably would not become that aggressive if they weren’t living in programs where extreme behaviors are commonplace.

Physical intimidation and force are contrary to treatment.

However, if residential treatment programs simply don’t accept, or simply discharge, clients with aggressive behaviors the alternatives for these kids are even more problematic. 

Children and youth end up back at home where their parents, siblings, and the community are terrorized by their violent behaviors and their own safety is at greater risk.

The police and public schools end up having to address these behaviors, and they are less specifically trained than residential staff in how to help these kids.

Psychiatric hospitalizations are used, but the result is, all too often, the use of medications that have unwanted side effects such as flattening emotions and physical discomforts.  Medication has to be continually monitored and changed as kids grow.  Often times, these kids will cycle in and out of short-term psychiatric hospitalizations with no sense of the child having actually changed and learned new levels of self-control.

Juvenile incarceration will be the path that some of these kids face.  These setting seem to struggle even more than residential treatment programs with becoming abusive toward the kids.  It’s even harder to provide these kids with effective treatment that will change the trajectory of their lives for the positive.

In my opinion, the ethical concerns around the use of physical restraints are best addressed in a treatment program setting.   

Physical Restraints are, in my opinion, the best option for safely dealing with violent behaviors among children and youth in residential treatment.

Self-injurious behaviors need to be stopped before they lead to permanent, or at least significant, damage.  Assaultive behaviors need to be stopped before they lead to harm.

Runaway behavior is a more nuanced judgement call.  Sometimes staff can continue to monitor a runaway child or youth.  However, allowing a troubled kid to be on their own in a wilderness, urban, or other environment can place them in serious danger.

Property damage can sometimes be monitored without physically intervening.  However, in my experience, when kids are allowed to rage they tend to escalate to the point where they are creating a real safety risk to themselves and others.  There are also practical limits to how much damage a facility can financially endure. 

There are alternatives to physical restraint, including mechanical restraint, chemical restraint, and seclusion.  However, each typically are preceded by a physical restraint.

In addition, mechanical restraints tend to be very frightening for the child or youth, require a separate type of training for the staff, require constant monitoring, and the transition into the mechanical restraint frequently requires more directed force than a physical restraint.  They also lack any tactile feedback for staff to help determine when the level of restrictiveness on the restraint can be lessened. 

Chemical restraints require specifically trained personnel, and most residential treatment programs are not licensed to use them. 

Seclusion tends to result in either the client raging in the seclusion room to the point where a physical restraint may have to be re-established to prevent self-harm, or the client calming down which implies that they don’t really need seclusion.  In my experience seclusion can be an effective tool to ending a violent situation; however, in most cases I have not seen it provide enough advantages to outweigh the added risks and the dehumanizing treatment of the client. 

Some physical restraint systems train staff in the use of pain compliance holds.  These can greatly shorten a physical restraint and may be a legitimate tool for programs that can’t bring enough staff into a restraint situation (such as wilderness therapy programs that are in isolated setting rather than operating as part of a multi-unit campus).  However, inflicting pain on children is morally repugnant and it may be that programs that can’t, when needed, devote four or five staff to a physical restraint simply can’t serve some clients. 

Performing physical restraints subjects staff to “small t” trauma.  There are things staff can do to minimize the effects of that trauma on their nervous system, which will make the staff person more resilient to this stress.