PATHWAYS: JOURNAL OF OUTDOOR THERAPEUTIC PROGRAMMING

Editorial Board: Rick McClintock, Chris Burns, Mike Angstadt, Steve Cockerham, Journal Editor.

Welcome to the first issue of the NATWC Journal. At the January, 2001 Board meeting in Atlanta, members became convinced that it was time to part ways with Wilderness and strike out on our own. The relationship has been quite positive, allowing for some publication of research related to wilderness programming. Of course, NATWC has enjoyed the production in the past of a newsletter but had been depending on this journal for member communication. So we’re taking the name with us and upgrading to a new format. We really hope that you will enjoy reading about outdoor therapeutic programming and the people within the community of interest in this process.

We set a target date for publication in anticipation of communicating about the upcoming conference in the Fall at the Unicoi Conference Center. In keeping with the theme of the conference, we requested submission of manuscripts to focus on Best Practice in Outdoor Therapeutic Programming. As suggested topics, categories were mentioned such as health and safety, gender issues, therapeutic approaches, staff training and qualifications, etc. Hopefully, you will find the articles illuminating, definitive, intriguing, and compelling.

A list of the current members of the NATWC Board of Directors follows:

Mike Angstadt

Stay tuned for further information...

NATWC Publication Committee

Mike Angstadt, Twin Cedars Youth Services, Inc., LaGrange, GA

Rick McClintock, Pressley Ridge Schools, Ohiopyle, PA

Chris Burns, Three Springs, Inc., Huntsville, AL

Steve Cockerham, East Tennessee State University, Johnson City, TN

Editorial Staff

Journal Editor…………Steve Cockerham

Assistant Editor……….Jamie Owens

Assistant Editor……….Kiley Triplett

NATWC BOARD OF DIRECTORS

Mark Lawrence, John de la Howe School, McCormick, SC - Chair -

Mike Angstadt, Twin Cedars Youth Services, LaGrange, GA

Chris Burns, Three Springs, Inc., Huntsville, AL

Steve Cockerham, East Tennessee State University, Johnson City, TN

Bebe Gaines, Woodside Trails, Smithville, TX

Tom Harris, Inner Harbour, Douglasville, GA

Mark Hobbins, Aspen Health, Cerritos, CA

Reggie Jackson, Timber Ridge Treatment Center, Inc., Gold Hill, NC

Rick McClintock, Pressley Ridge Schools, Ohiopyle, PA

Larry Olson, Anasazi, Buhl, ID

Mike Siver, City of Orlando, Community & Youth Services Dept., Orlando, FL

Linda Tatsapaugh, Stone Mountain School, Black Mountain, NC

Shep Young, Eckerd Youth Alternatives, Inc., Clearwater, FL

Ross Whitney, Salesmanship Club Youth Camp, Hawkins, TX

Welcome to the first issue of the NATWC Journal. At the January, 2001 Board meeting in Atlanta, members became convinced that it was time to part ways with the International Journal of Wilderness and do our own publication. This relationship has been quite positive, allowing for publication of research related to wilderness programming. Of course, NATWC has enjoyed the production in the past of a newsletter but had lately been depending on the Wilderness journal for member benefits. So we’re taking the concept to another level and upgrading to a new format. We really hope that you will enjoy reading about outdoor therapeutic programming and the people within the community of interest in this process.

We set a target date for publication in anticipation of communicating about the upcoming conference in the fall, September 16-18, at the Unicoi State Park in Helen, GA. In keeping with the theme of the conference, we requested submission of manuscripts to focus on Best Practice in Outdoor Therapeutic Programming. As suggested topics, categories were mentioned such as health and safety, educational practices, physical restraints, staff training, and therapeutic approaches. Several fascinating studies were received that indicate fruitful research and illustrative perspectives. Hopefully, you will find the articles illuminating, definitive, intriguing, and compelling.

By Joyce L. Moore, David Rumberger, and Stephen Sparks

By Jim Natural

By Tom Coates and Steve Cockerham

By Gerald Maxwell

By Steve Cockerham and Julie McCloud

 Printed by East Tennessee State University Press. East Tennessee State University is a Tennessee Board of Regents institution and is fully in accord with the belief that educational and employment opportunities should be available to all eligible persons without regard to age, sex, sexual preference, color, race, religion, political identity, socioeconomic status, national or geographic origin, disability, or veteran status.

Joyce Lynn Moore, B.S., Evaluation Assistant

David T. Rumberger, M.S., Treatment Coordinator

Stephen Sparks, M.S., Staff and Training Specialist

Pressley Ridge Schools

Physical restraints, a major concern within outdoor therapeutic programming, are analyzed with statistical analysis and logical processing to begin shedding light on this necessary therapeutic intervention. This report makes recommendations yet will be followed by additional information as more data are collected from later stages of research. A collaborative project with Vanderbilt University is supporting this study.

In early March, Pressley Ridge Schools Child Protective Task Force submitted a mandate to reduce critical incidents by 50%. The Pressley Ridge School Child Protective Task Force is an internal body that reviews incident reports to ensure safe, quality programming. Incidents are restraints. Although additional incidents can occur within the program, this narrative summary and statistics are related only to full restraints. This mandate was quickly endorsed by Pressley Executive Administration and then disseminated to programs as a matter requiring immediate attention and cogent response. Since that issuance, a flurry of activity has occurred in all programs, with the Pressley Ridge School at Ohiopyle being no exception. This narrative summarizes the efforts of an attempt to not only reduce incidents but also to more acutely analyze the factors associated with them.

Throughout this narrative several statistics and/or statistical concepts will be utilized. To begin with, incident ratios were computed by dividing the number of incidents per month by the number of days students were served in the program. Pressley Ridge School at Ohiopyle is a year-round, outdoor program; however, the "homevisit" days were not included in the computation of this ratio. Staff experience was computed by adding the experience recorded in a particular group alone and dividing by the number of staff involved with a particular group. In this way, a teacher/counselor with 2 years experience, who has just moved to a new treatment group 2 months ago, would only post 2 months experience. Experience within the program is presumed not transferable; thus, staff experience was computed in this way.

Student experience is relatively straightforward. It simply represents the length of time that a student has been a resident within the program. Mean ratios represent the average ratio score. Mean ratio scores were calculated by adding each month’s IR ratio scores to form a total and dividing this number by the number of months for the evaluation Standard deviations were also calculated to determine dispersion or "extremeness" for the distribution. Specifically, Z scores were used to "pinpoint the location of a score in any distribution…this is simply a way of telling how far a score is from the mean in standard deviation units" (Bartz, 1981). Z scores are also a necessity when calculating the area under a normal or bell shaped curve (Bartz, 1981).

Theory Testing

For many years, program personnel have explained increases and reductions in incident reports as a function of experience. Greater staff and student experience correlate with a lower number of incident reports. Conversely, when less experienced staff and new students are on board, the more likely incident report counts will rise. An evaluation of this concept has not been performed, however. A quick analysis in March (done shortly after the mandate), based upon a comparison of Fall 99 (September, October, November) and Winter 00 (December, January and February) counts, suggested that PRSO had already met the 50% reduction. Nevertheless, there was little evidence to sufficiently explain the reduction. As a result, program representatives began to postulate additional reasons for the decrease. A more detailed analysis was initiated.

Method

As stated earlier, incident report counts were converted to ratios for individual groups and program aggregates. Program aggregates were calculated by adding individual group IR ratios and dividing by the number of groups. Z scores were then calculated for both individual and group aggregates to determine the dispersion of the distribution. Using the normal curve as a mathematical model, categories of program and individual group health were ascertained. These categories, arbitrarily named, are "poor", "acceptable", and "excellent" health. An IR ratio score was deemed "poor" if it posted a z score of 1.00 or higher. 

Remembering that in a normal curve 68% of the scores in a distribution will be within +1S or –1S (one standard deviation above or below the mean), then half of 68% (or 34%) will be above and below the mean. Given that 50% of all scores would be below the mean, then adding this 50% and 34% brings us to 84%. A similar method was used to determine "excellent" health. Excellent health meant that a score would have to fall –1S or alternately, below the mean ratio score for the particular distribution. The balance of the scores, those that fell between –1S and +1S, were deemed as "acceptable".

The current method of evaluation includes several components. Student experience, staff experience and unplanned departures have been tracked and compared to incident report ratios for the last 9 months. This information is readily available and easily calculated for the program. Although this report discusses the inclusion of staff proficiency, CAFAS scores and Therapeutic Alliance measures, that information could not be included in the evaluation. These are viewed as future research directions. Both program and individual group’s IR ratios (number of restraints per number of days served), mean IR ratios, and standard deviations were calculated for the entire distribution. Scores are presented monthly, which reflects PRS Task Force’s current evaluation increments. Individual groups were assessed separately to more acutely assess program successes and areas of improvement.

According to the data, the program experienced excellent relative health for two months or 25% of the evaluation period. These months were December and February. Both months had low incidents of unplanned departures. Conversely, the program saw poor relative health in both October and November. In this way, the program evidenced relative poor health 25% of the evaluation period. The remaining 50% of the time (4 months), the program posted acceptable IR ratios. A similar analysis was completed for individual groups. Individual groups experienced excellent relative health 8 out of the 48 months or 16% of the time. Conversely, individual groups experienced poor relative health 8 out of the 48 months or 16% of the time. The remaining 66% of the evaluation individual groups were within acceptable health range.

October and November of 1999 posted the highest IR ratios during the evaluation period. During both of these months, 3 unplanned departures (staff immediately leaving the job or not returning from "time off" without working out some form of exit plan with program administration) occurred. It is important to note that in ten days in late August six staff departed with a cumulative 13 years of experience. These staff departures seemed to have impacted upon IR ratios for these two months as new staff members were hired and supervisory and administrative staff filled in while new teacher/counselors oriented to the program. This reaction to staff departure also occurred in March and April. The program lost 8 years of supervisory experience and had 4 unplanned departures in a 4-week period of time. After experiencing the highest relative health for the evaluation in February (IR ratio=.25), both March and April posted progressively increasing IR ratios, apparently rising as a result of these staff departures.

Discussion

It should be clearly stated that the program did not meet the 50% reduction of incident reports. Certainly, as stated earlier, a 42% reduction between Fall 99 and Winter 00 did occur but a reduction from Winter 00 and Spring 00 did not occur. In addition, this analysis is not a "smoke and mirrors" statistical justification for falling short of this mandate. Rather, the study is an attempt to move the Ohiopyle program and the overall agency in a positive direction when evaluating incidents. A particular treatment group can be used to illustrate the correlation between experience and IR ratios. This group maintained the lowest IR ratio for the eight-month period with a figure of 0.1.

In March, when the senior teacher/counselor moved to another group, the staff experience dropped to 3 months and incident report ratio rose to .08, which doubled the nadir reported in February. Notably, this group process covaries in accordance to the conceptual model of staff and student experience. Even though both these group IR ratios might follow the model, generally a direct correlation between student and staff experience and IR ratios has not always been demonstrated for the entire program. A transition group provides some evidence to suggest that staff inexperience does not necessarily translate into increasing restraints. This group has had the second lowest incident report ratio (.16), although they maintained the lowest staff experience average for the course of the evaluation.

Therefore, staff experience alone does not sufficiently explain the reason for incident report reduction. In this way, a one dimensional, direct correlation between incident report ratios (or counts) and staff experience is not presently verifiable. This exception to the rule suggests other factors. Since a direct correlation between staff and student experience and IR ratios was not evident across the entire program, then other areas invited investigation that might be related to incident report ratios.

One proposed component possibly related to IR ratios may be staff proficiency. As stated earlier, the transition group provided evidence for other factors impacting IR ratios. A supervisory and administrative analysis of this information stated that strongly proficient employees made up the transition treatment team. Logically, some staff, even extremely proficient staff, experience incidents as a result of meeting the pronounced "testing" of students. A certain number of incidents are probably inevitable within any program model and among this population served. Notwithstanding, repetitive incidents (those reoccurring with same staff or same students) and thus, high counts, may very well be linked to staff proficiency. Staff proficiency is not currently defined in formal terms.

Evaluations are standardized for all staff but they lack even interval ratings or other Likert Scaling to produce a staff proficiency quotient or aggregate. Devising a more quantitative measure and applying it to existing staff evaluations would provide greater evidence that staff proficiency and incident report counts or ratios are linked. Although not specifically referenced, the most recent PRS Task Force meeting supported this idea. The meeting focused heavily on additional training as a means to reduce incident report counts. Although this is a positive recommendation, it tends to lack a specific focus.

Programs need the autonomy to determine what type of training for staff is necessary to reduce incident reports yet connecting staff evaluations and subsequent action planning to specific crisis training strategies is really the only way in which training can actually reduce incident occurrences. In addition, during the fall of 1999, one cardinal aspect of staff proficiency, the ability to develop a therapeutic alliance, was thoroughly analyzed by the program. Currently, PRSO possesses a Therapeutic Alliance (TA) Measure, which could be administered to students. The scores from TA Measures could conceivably be paired with IR ratios to determine whether staff proficiency (specifically, the ability to develop a therapeutic relationship with a student) shows a correlation with IR ratios.

Although it is not clearly stated, the agency uses Incident Report counts as a measure of program health. Good reasons exist to support this perspective. Certainly, crisis management is critical to value-based, safe, and therapeutic programming. Furthermore, every incident of crisis that is mishandled and results in tragedy (or potential tragedy) highlights the need to evaluate incidents. National attention to this issue ensures that the agency’s use of incidents as a health measure is well founded and prudent. Now, it is clear that incident reports will continue to be used as a health measure in the future. Because the use of incident reports as a relative health measure is likely to continue, it behooves program representatives to evaluate the accuracy with which the health measure actually measures relative program health.

Identifying and understanding the components or factors that impact incidents within a program is the first step in managing (or reducing) these numbers. Currently, simply using incident report counts does not serve the agency in determining program health. Because human behaviors (and the crises associated with them) are complex, they cannot be viewed uni-dimensionally. As stated earlier, it is critical for program representatives to identify and manage those factors that are either clearly or intuitively associated with IR ratios. Ohiopyle program representatives assert that reducing IR ratios is really about managing the factors that produce instability for students. Clearly, the program does well managing some factors which produce this instability.

An example of this management is illustrated by the static nature of student experience. Largely, student experience remained relatively consistent throughout the evaluation period.

Obviously, new students entered the program during this period and students moved from treatment groups to transition groups during the same time; however, the change seems consistent and constant. Conversely, unplanned departures produce an extreme example of instability, which do seem connected with IR ratios. Some factors certainly are more easily managed than others but movement toward specific program interventions that address these areas will only produce improved quality and decreasing IR ratios. At this time, the program does not fully understand how these factors interact with IR ratios or each other. For example, it is not clear how the factors interact or compensate for each other? Does a high Therapeutic Alliance override low staff experience? Does functionally severity of a population override all other factors? Many of these questions remain unanswered but provide inspiration for future program evaluations

Move away from simple incident reporting counts as a method of tracking and use some form of ratios. Ratios are a more stable, meaningful number. Counts frequently rise and fall more dynamically, providing illusions of performance change due to factors entirely unrelated to actual program intervention. As this evaluation is "intra-programmatic," any type of program could adopt a similar approach. If other program representative are intimidated or feel daunted by the statistical aspects of the evaluation, they need not be. The School at Ohiopyle will offer its assistance for those interested in adopting this approach. As stated earlier, it is critical for program representatives to identify and manage those factors that are either clearly or intuitively associated with IR ratings.

References

Bartz, A.E. (1981). Basic Statistical Concepts, (2^nd ed.). Minneapolis, Minnesota: Burgess Publishing Company.

Jewell, S. (2000, April). Pressley Ridge's response to the OMHSAS draft bulletin on seclusion & restraint. [Letter to the editor]. OMHSAS draft bulletin.

by Jim Natural

This article examines four different manifestations of the adult persona in group-oriented residential treatment programs. These separate approaches are seen in terms of a continuum from a least effective platform to the optimal. The article then presents a much closer differentiation between a compliance-oriented approach and an empowerment-oriented approach. The compliance-oriented approach is corrective. The educative or empowering perspective is nurturing and more in line with the original vision of pioneers like Campbell Loughmiller and Nicholas Hobbs. The paper provides a useful tool for staff training and for professional self-examination as it outlines both philosophical and behavioral differences between the two most commonly encountered forms of adult direction.

In a residential setting with a reliance on group process, effective treatment depends heavily upon program staff 's ability to play the part of an adult. Troubled children generally have very high expectations for the professional adults in their lives; after all, staff persons are well paid for their services.

Kids expect staff to be fair. They expect them to be consistent. They expect a very high degree of sensitivity and an acute awareness of the need for clear boundaries, and they expect all of these qualities in the same person.

Often the failure of a young staff person in the initial stages of a career in youth work happens because he/she has had little preparation to play a role that is hard to define for an audience of young critics who have spent their years shaping very strict criteria for this performance. And yet training for these young staff persons will very often emphasize the technical, the tangible and the "hard skills". These are important, to be sure, but more young staff fail because of role confusion than because they could not pack a canoe, write a treatment review, build a shelter or bake a cobbler in a Dutch oven.

This article will attempt to define various interpretations of the adult persona. It will place each manifestation (a combination of attitude and behavior) on a continuum from the least effective (Level 1) to the most (Level 4). Also elaborated are the differences between a compliance-oriented adult role and an empowerment-oriented approach.

At this level there is a lack of distinction between the role of the adult and the role of the children in care. Its main cause is staff immaturity. It could stem from a lack of training or experience, but very often the cause is purely attitudinal. This complicates corrective action. Staff interactions with children are similar to the interactions children have with each other (nicknames, petty bickering or even loud arguments). Generally a high degree of acting out exists because young people are anxious and fearful of power being wielded by an individual who gives signals that he/she is at the same emotional level as they are.

This is exaggerated when the staff person swings arbitrarily from the role of "one of the kids" to "authority figure" according to his/her mood. The group is like an airplane with a pilot who is no more qualified to fly than the passengers are! At this level there is a high degree of supervisory presence (terrible things would happen if the adult was gone).

At this level the adult plays the role of a distant monitor whose involvement is minimal. Its major cause is, sadly, the presence of persons who view their work only as a means to earn a paycheck. It can also be caused by the presence of staff who are less intellectually or socially capable than the kids are. Staff interactions with children are minimal.

A typical situation at this level is staff ignoring kids' behaviors completely, unless a supervisor happens to be observing. Then the interactions are simple, directive and usually begin with the word "don’t". It is common at this level to find staff paying attention to superficial, often "low priority" tasks at critical times when more immediate or pressing needs are ignored. An example of this would be a staff person diligently working on paperwork while kids in his/her charge carry on like little gangsters just out of hearing distance (swearing, boasting of delinquent exploits, threatening or challenging each other). The level of acting out is not as intense as with the first level (or it doesn't seem so) because the dirty deeds are done covertly. This is what makes this level so dangerous. Aggressive kids move to the top of the food chain.

Weaker or less assertive kids are like mice to the hawks. If the supervisor is not sophisticated enough, there is less supervisory presence at this level. Kids don't want to draw attention to the fact that they are really setting their own parameters, and they try not to do anything to bring the supervisor around because he/she might discover this.

At this level the adult plays the role of authority figure. He/she is genuinely concerned that the young people in his/her charge learn to curb "deviant behaviors", but he/she has a conventional perception of authority. This convention goes something like this "I am the adult and all children will respect and obey me because that is the way it is supposed to be." It is easy to understand the origins of this.

Most people are taught from childhood that it is wrong to challenge authority. Authority is generally represented by a person wielding power through appointment (a parent, a teacher or a "boss"). Most of us have learned to hear and obey these individuals because, for the most part, they are well meaning and deserving of our respect.

However, even though they understand the need for guidance from a "higher power", most children resent the idea that "adult" equates to "authority" because of its inherent inequity and must learn through experience with healthy adult role models that this power holder generally has their best interests.

Children eventually let go of this resentment and learn to get along with swaggering adults (in preparation for a life of subservience to swaggering authority figures of one sort or another). There are those children who cannot learn to do this. These are the children who cannot come to terms with the notion that a person should be a link or two above them on the "great chain of being" simply because of age. An overexposure to childish adults is surely a factor here, but these children come to residential settings because they have "authority issues".

There is a clear distinction between "authority by appointment" and "authority by merit". Staff at this level haven't learned this yet. Interactions with kids are often confrontational, or harsh. There is a tendency to punish under the guise of "applying consequences". Conflict cycles are frequent.

There is a high degree of supervisory presence here because the staff often get tangled in nets they cannot undo themselves. This is also a very dangerous level because frustration can escalate (especially if the same scenarios unfold repeatedly) and staff behavior can become abusive in the same way a spark can become a 4-alarm fire in a house with a natural gas leak. Everything (a positive relationship, a career in youth work, and even a program) could be lost in one short, destructive flash.

At this level the adult embodies what early juvenile justice pioneers intended when they coined the phrase "in loco parentis" The staff at this level are acutely aware of their full responsibility for the welfare (safety, emotional needs, educational motivation) of the children in their charge.

Staff approach this responsibility with the same degree of gravity and in the same spirit of caring as they would approach the task of raising their own children! Interactions between staff and children are characterized as natural with casual conversation that does not occur only on those occasions where corrections are needed.

If behaviors are addressed verbally, it is often done in an inclusive way that places emphasis on conformity for all members of the group instead of singling out the errant individual. The level of acting out is low because problem solving has a comfortable, solution-focused flavor. It is not an exercise in blame. Supervisory presence is low, also. Usually, staff and kids are making responsible choices of their own, and there is little need to monitor these choices other than to praise and encourage.

Levels 1 and 2 are not worth discussing in depth, simply because quality residential programs do not retain people at these stages. Either a carefully written and diligently implemented action plan corrects the attitudes and behaviors of such people, or they are driven to other careers by the "natural consequences" of their habits.

Level 3 is perhaps the most commonly encountered interpretation of the adult role in the residential setting. Level 4 is the most desirable. Hobbs described the Re-Ed Teacher-Counselor as an adult with a level 4 attitude (Hobbs, 1982). So how is it that we aspire to level 4, but spend so much of our time foundering and repeating our mistakes at level 3? Can the attitude of level 4 be taught? Can the technical nuances that are indicators of level 4 be identified and transmitted?

The contention here is that it is a very simple process of differentiation to discern a Level 3 approach to working with troubled kids from a Level 4 approach. The philosophical foundations for each are quite separate. The behavioral nuances that are indicators for one or the other are as easy to recognize as the difference between the wing beats of a bird and those of a bat. Both creatures fly, but only the bird is truly at home in the air. Note the table contrasting key principles or priorities.

For the sake of clarity, the contrasting perspectives are elaborated upon next in point-by-point fashion.

Rules or Standards

A rule is steadfast and it is usually expressed in negative and absolute terms (thou shalt not covet thy neighbor's goods; never draw to an inside straight; always I before E, unless after C; no talking in the hall between classes). A standard evolves with the group or culture that gave rise to it (the right of all white men to vote is now the right of all persons regardless of gender or race).

The compliance perspective is reliant on rules for the maintenance of order. This reliance is doomed to fail because it assumes obedience. This is faulty logic, obviously. When the rule-monger finds himself/herself in a circumstance where, much to his/her surprise, shock and disbelief, the rule is ignored, then some contingency (usually a bogus one) is attached to the offense of disobedience.

The nurturing perspective is reliant on principles that are universally accepted and adhered to for the sake of their truth. No one will disagree with the principle that all members of a group have the right to feel safe, for example. Individuals might vary in the interpretation of this principle, and a universal interpretation can only be achieved through a long, participatory process of applying this general principle to many specific situations. That is, ideally, the purpose of problem solving.

It is belittling and disrespectful to take charge over another person because this action implies the person’s incompetence. Yet look at the history of our western culture. We had the imposition of law and military order by the Roman Empire, the benevolent rule of "Holy Mother Church," feudalism, colonialism. In modern times dictatorship is an attractive alternative to the people who, in troubling political or economic times, willingly relinquish their responsibility to exercise free will.

Paternalism is easy to recognize in a staff member's actions. The children are rarely afforded an opportunity to make choices. What, when, how and to what degree are all put forth by decree.

In an empowering approach, time is taken to allow for choice (even poor choices). Then time is taken to reflect upon these choices and the consequences of these choices. The approach emphasizes where and how an individual's choices fell short of staff"s expectations or the group’s standards in general. This approach implies the capability of youngsters to choose responsibly ("if I have high expectations of you, I believe in your capability").

Which is a more moving message?

"I trust you to use your own good judgment in choosing a course of action you know is right. If you choose poorly, we'll talk about it so that eventually you will learn otherwise."

Or

"I don't trust you to choose because your judgment is bad so I'll tell you what to do. Comply with my directives and you'll stay out of trouble."

The fact that a child or youth has been placed by the order of a juvenile judge in residential care is proof enough that something is "wrong" in this young person's life. Every young person in residential care believes that what is "wrong" is very personal in nature, and that correction is impossible.

Attempting to "fix" it is a waste of time. The compliance approach locks onto this and bases its "therapeutic" strategy on the fact that something needs to be fixed. A compliance-oriented staff person is "diagnostic". He/she looks for the problem and points it out as often as it is observed. This is counter-productive with young people who are already very aware of their own shortcomings.

A nurturing approach bases its strategy on the fact that every young person has strengths as well as weaknesses. Now a nurturing staff person points out these strengths as often as they are observed. He/she does not ignore or fail to censure damaging behavior. He/she is simply not preoccupied with what is "wrong".

This seemingly simple distinction is the cause of much confusion and misunderstanding in the arena of residential treatment. We live in a punishing culture. Compliance is coerced by the threat of specific unpleasantries prescribed for each infraction. Compliance is rarely inspired by recognition or reward.

This is such a prevailing notion in our culture that the idea of rewarding someone for living in accordance with our society’s precepts is absurd. Have you ever been pulled over by a state policeman and given a fifty-dollar bill because his radar indicated that you were driving within the speed limit? Perhaps this is why the distinction is difficult to make. One could not tell chocolate from vanilla if he/she had not tasted both.

To clarify, punishment is not at all related to the offense or omission it is prescribed for. A natural consequence is, and the best natural consequences actually stem directly from a person’s actions. As the name suggests, there is no element of contrivance to a "natural" consequence. The logic is indisputable (not that kids don’t attempt to dispute). There generally is no sound rationale where punishment is concerned. Often punishment carries the flavor of revenge.

Often the punishment-oriented staff person will spell out contingencies with little regard to appropriate timing, demonstrating even more emphatically a spiteful motive. Here is an example of the distinction between consequence and punishment using the same, simple situation. It should illustrate the timing factor, as well as the motive.

Consequence: "Ah, you did not eat your peas. We are having chocolate cake with butter pecan ice cream for dessert. You cannot have dessert, even though you love cake and butter pecan ice cream, because you did not finish what was on your plate. If you eat those peas, you can get dessert."

Punishment: "You cannot have chocolate cake and butter pecan ice cream for dessert because an hour earlier this morning you called me a %#@! * and were very disrespectful to me. Now it's my turn. No ice cream. No cake. How does it feel to be disrespected?"

Not all authority figures deserve the respect entitled to their rank, but the conventions of our culture hold that we should "respect the office" even if the person holding it is someone less than worthy. This is an old paradigm, dating back to a time when subservient people were convinced that the kings who held life and death power over them received that power directly from God.

The kids in our care have learned that there are immature, mentally unstable and abusive adults who are supposed to be obeyed and respected simply because they are adults. They have generalized their distrust to all adults. Because life has taught them this erroneous perspective, it is the staff’s responsibility to teach them a perspective that is a little more in line with the truth.

As adults in a position of authority, every action is under close scrutiny. When staff are inconsistent, hypocritical, unfair, insensitive, and indifferent or when organizational needs are prioritized needs over therapy, then the beliefs these kids have already formed are being reinforced. In order to teach kids that most authority figures are deserving of respect, staff must be the authority figures who exemplify the merit of accordant rank.

Compliance oriented staff generally approach their work with a "fire hall mentality". They wait until the alarm sounds and then ride into action. Staff who operate from a nurturing perspective look ahead of any scheduled activity and identify possible impediments and use preset criteria to clarify structuring parameters. There is generally an element of re-direction about a nurturing approach.

Problem solving can always look back to when the expectations were set and identify which expectations we are failing to uphold. There is generally an element of blame about a compliance approach. Problem solving usually expends time and effort determining who did what, said what or didn't do what he/she was supposed to do, most of which is all hearsay anyhow because the staff person was not fully enough involved in the little drama to know truth from tattling.

There is very often a seriously damaging misinterpretation of the premise in "reality therapy" that only the here and now (the what, not the why) should be discussed. This misunderstanding usually happens because staff base their problem solving on compliance with rules as opposed to adherence to standards.

Problem solving becomes a rote and insincere mumbling of "my problem was_____; it was wrong because______; in the future I won't do that again." But the behavior is repeated over and over again, and the problem solving talk never changes either.

If a holistic view of behavior is the foundation of the problem solving process, behavior is examined in terms of its relationship to everyone affected by it. Behavioral standards are the outgrowth of group process, not a list of rules handed down by those who would be in power.

Present problem solving sessions in essence are precedents for future discussions. Evaluation can be used to point out a developmental sequence, showing a contrast between past and present stages. Young people can tangibly perceive that they have made changes and understand that further growth is expected of them as well.

The compliance oriented staff person often makes statements that suggest kids should make behavioral changes to achieve a relatively shallow result. Here is an example.

"Why don't you learn to handle your frustration so that you can get out of this program?"

Even kids with troubled thought processes understand that the task of self-actualization is far more complex than basic cause and effect. They distrust the helping intent of anyone who would reduce the process to something so simple as "do as you are told and you will get what you want."

Now a higher level of behavioral achievement is more difficult to define. It is usually put in abstract or even vague terms. Here is the same example.

"You have so much potential. You could become a fine person if you could just learn to respond more appropriately to frustrating situations."

Youth do not immediately respond to this sort of counsel. They don't know what to think of it. It might seem sincere, but only consistent application of this approach over months will erode their suspicions. This process builds the staff’s credibility, establishes a trusting relationship.

A compliance-oriented staff person is playing the part of "conventional authority figure," a part defined by others (teachers, coaches, scout leaders, preachers, college profs, bosses) in this staff person's personal history.

The mission of a conventional authority figure is to "teach right from wrong," and it is imperative for one with such a lofty calling to always be right. A false sense of dignity, an inflated or self-important attitude is generally found in this person's performance.

A nurturing staff person is playing the part of himself/herself, a part that is never really completely defined as it evolves with all of life's changes and lessons. The mission of this authority figure is to share by example what he/she has learned up to this point about what it means to be a human being.

And now, for those persons who are at least uncomfortable with or perhaps even hostile to the discussion of ideas, here are some behavioral examples of the adage that "actions speak louder than words," urging all who work closely with "troubled kids" to consistently examine the messages their own deeds communicate.

"It says in the manual, chapter three, paragraph 15 under the heading community deportment, sub-heading dining hall dress code that all students will comb their hair before entering the dining hall for meals. (So it is written, so let it be done)"

"You must comb your hair before entering the Dining Hall. This is a simple program standard."

-Frequent citing of a higher authority instead of citing the immediate expectations that the group has set

" The program director has stated many times that all students will comb their hair before entering the dining hall for meals"

-Frequent verbalizations that underscore kids’ dependence (often belittling)

"You wouldn’t even be able to comb your hair in the morning if I weren’t here to remind you."

"I just don’t understand it, kid. I work these unreasonable hours under these uncomfortable conditions and I give up any hope of having a personal life, and you can’t even comb your hair when I ask you to."

"Look here, I’m trying really hard to help you. Why can’t you just comb your hair like I asked you to so we can all move on from this."

"You always do this, kid. You always try to get into the dining hall without combing your hair first."

-Verbalizations that overtly exhibit a belief that something is "wrong"

"Do you know what your problem is, kid? I’ll tell what your problem is. You don’t even care enough about yourself to comb your hair in the morning when you get yourself out of bed."

-Frequent verbalizations that put a genuine natural consequence in the role of a penalty

"It's a shame that you can't comb your hair. Your group will be forced to miss this meal on account of you."

"Fine! You don't want to comb your hair. You want to defy me. You and your group will not go to play basketball at the community center tomorrow."

-Verbalizations that imply directives are backed by some unseen power

"You will comb your hair, child. Why? Because I said so, that's why!"

"Shut up. Comb your hair. What part of that don't you understand?"

"You say you want to get out of this program, why can’t you comb your hair like I asked you to so you can show everybody that you’re ready to discharge."

Hobbs, N. (1982). The troubled and troubling child. San Fran: Jossey-Bass.

Meeting National Association of Therapeutic Wilderness Camps

· Conceptual foundations

· Leisure services profession

· Leisure services delivery system

· Programming strategies

· Assessment, planning, and evaluation

· Administration/management

· Legislative and legal aspects

· Field experiences (Houghton, 1995)

By Gerald Maxwell, M.S.

This retrospective study was conducted as part of an ongoing risk management effort to reduce high-risk special management procedures within Three Springs programs. Terminology is defined with "Special Management Procedures" being the primary term used to describe a high-risk class of physical interventions utilized with adolescents in residential care. The national trend has been toward the reduction or elimination of Special Management Procedures. Many accrediting and licensing agencies have made it mandatory for programs to establish procedures governing the use, the systematic monitoring, and the documentation of SMP. Specific strategies are discussed to develop the best practices regarding Special Management Procedures. This study has evaluated the current information from TSI programs and external sources, making recommendations based upon the findings. The population of this study consisted of adolescents, 12 to 18 years of age, placed outside the home in a structured living environment due to emotional and behavioral disturbance. A retrospective review of the information provided by programs and a review of current literature was conducted and examined for common themes, trends, and divergences. A list of specific recommendations is provided.

This retrospective study was conducted as a part of an ongoing risk management effort to reduce high-risk special management procedures within all of Three Springs programs. While each of Three Springs facilities maintains a level of uniqueness in composition, population served, and therapeutic approach, there are certain cohesive elements across all the programs.

Therefore, the approach and findings of this study are meant to be generalized company wide. Due to a variety of terms used at the various facilities and sources to refer to similar procedures, it is important to define a set of terms and the scope of this study.

The term "Special Management Procedure" (SMP) is utilized within this study to classify a group of high-risk procedures employed by Three Springs Inc. (TSI) employees to manage the behavior of an adolescent residing in a TSI program, to include (1) physical management using bodily contact, (2) the forced isolation of a resident, and (3) using mechanical devices to prevent movement of the limbs.

The largest percentage of Three Springs’ programs use only physical management as a Special Management Procedure. The term "contact" is variously referred to at the programs as holds, therapeutic holds, restraints, basket holds, and use of force.

The term "Seclusion" is used for the forced isolation of a resident, either in a locked room or through a staff member physically preventing a resident from leaving a room. Seclusion is variously referred to at the programs as segregation, isolation, and time-out. This "time-out" is distinguished from voluntarily taking a few minutes of time to themselves.

The "seclusion" or "segregation" referred to in this paper does not refer to the prescriptive use of segregation/isolation as a result of a due process hearing employed by some of the corrections based programs.

The term "Restraint" is used for the use of mechanical devices such as straps, leather cuffs, backboards, bed-netting, etc., to prevent a resident from freely moving the arms and legs. The terms restraints, mechanical restraints, four-point-restraints, cuffing, or shackling are used at the various programs to refer to Restraint.

The use of Special Management Procedures has long been a controversial issue, especially in psychiatric settings. Over the last few years, there were a number of highly visible incidents around the country where children and adults died while having Special Management Procedure performed upon them in treatment settings.

Increasingly, the national trend has been towards the reduction or elimination of Special Management Procedures. Many accrediting and licensing agencies have made it mandatory for programs to establish procedures governing the use, the systematic monitoring, and the documentation of Special Management Procedures.

The National Mental Health Association contends that the overuse and abuse of Special Management Procedures are symptoms of poor quality care in facilities. In a study for the Department of Juvenile Justice, the Virginia Poverty Law Center found that Special Management Procedures and especially "isolation… does not teach more appropriate behaviors, it puts rehabilitated efforts on hold and may only cause physical and physical harm" and when a violent child is locked in a sparsely furnished room and left alone he feels panic which may cause him to persist in his violent outbursts, which may in turn cause staff to justify his continued isolation."

It is clear from the current literature, the use of Special Management Procedures is not therapeutic and may be counter-therapeutic.

Additionally, a number of findings from a variety of child care settings, including juvenile corrections, residential treatment, hospitals, and schools show the potentially disastrous results in the use of special Management Procedures, especially in Physical Management and Restraints.

A study on Positional Asphyxia Death by EMS Texts found that "Restraining in the prone position, or in the use of ‘hobble restraint’ creates pathophysiologic interference with adequate respiratory bellos system function. … the behavior and activity that precedes the use of hobble or prone restraint can lead to extreme energy expenditure, creating a respiratory muscle fatigue. …If restrained in a prone position, the individual will continue to expend extreme energy and continue to struggle against the total body restraint. Rapidly, the individual becomes lethally exhausted. …In published studies of police-involved deaths attributed to restraint-induced positional asphyxia,… ‘the average time between hobble restraint application and onset of death was 5.6 minutes."

The risk is to staff as well as to residents. Based on a study commissioned by the Hartfort Courant, "the injury rate to staff during the use of restraints was higher than that found among lumber workers, construction workers, and miners."

It is apparent that the use of Special Management Procedures with children under our treatment and care requires special attention to reduce use and to ensure the proper application of these procedures when they must be used.

This study evaluates the current information from TSI programs and external sources and makes recommendations based upon the findings.

The population of this study consisted of adolescents, 12 to 18 years of age, placed outside the home in a structured living environment due to emotional and behavioral disturbance (including criminal behavior).

The facilities from which specific information was obtained were located in the South Eastern United States, specifically in Alabama, Tennessee, Georgia, Maryland, and Florida. The facilities chosen were deemed a representative sample of the various levels of care and populations served by TSI, including two outdoor treatment programs, one intensive residential treatment program, and one residential program for adjudicated youth.

Three Springs also collaborated with another company to include findings from the program "Twin Cedars", and an intermediate level residential treatment center for females.

Information for this study was gathered through 1) interviews with key program staff, 2) data analysis and review of risk management reports and studies from the various programs, 3) review of the correlated study conducted by Twin Cedars which provides similar service delivery to TSI, and 4) a review of Internet studies and professional publications.

A retrospective assessment of the information provided by programs and a review of current literature was conducted and examined for common themes, trends, and divergences. An overall stance of Special Management Procedures was developed and guidelines for programs were compiled.

The findings reveal that Special Management Procedures have been inconsistently applied within and among the various programs nationwide.

There is a strong need for nationwide standardization on the philosophy, procedures, documentation, and goals surrounding Special Management Procedures. These procedures are high risk to the safety and security of residents, staff, and the company as a whole. Special Management

Procedures should never be viewed as a therapeutic intervention as they offer little to no therapeutic benefit to the residents’ rehabilitation and may be counter-therapeutic.

In accordance with the position of the National Mental Health Association, Special Management Procedures"…should be used only after other less restrictive techniques have been tried and failed, and only in response to violent behavior that creates extreme threats to life and safety." Findings show that any facility that utilizes Special Management Procedures should have written procedures governing the use of Special Management Procedures that prohibit their use for discipline, punishment, convenience of staff, or as a prescriptive intervention (this does not apply to state mandated segregation following a due process hearing in accordance with state regulations.)

Based upon the research, policies should abolish the seclusion of children who self mutilate. These procedures should require documentation of alternative, less intrusive, intervention approaches that were tried and the rationale why these failed or were not appropriate.

It is evident from the nationwide sources that other counter-therapeutic factors, such as poor supervision of residents, maltreatment of residents, and poorly designed schedules often lead to resident behavior requiring the use of Special Management Procedures.

There is also significant evidence that covert sexual behavior by residents, in spite of ordinarily adequate supervision, also leads to a treatment conducive to acting out and the use of Special Management Procedures.

Additionally, programming with less structure, low staff members, and significant changes in staffing stability, such as changes in key staff and leadership, lead to increased use of SMP through scheduling, structure, meeting the therapeutic and educational needs of children, and effective early intervention and de-escalation.

Training should ensure that staff proficiently utilize the least restrictive intervention necessary. Administrative and supervisory review of incidents should reinforce periodic competency evaluation of staff performance and an appropriate retraining schedule.

The environment in which residents live and receive services should be responsive to youths’ needs for support and security, including adequate numbers of trained staff. Admission, intake evaluation, and case management strategies should facilitate appropriate early interventions geared to the individual need of each child.

Quality Improvement programming should be based upon a model similar to that of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), which systematically measures, assesses, and improves performance throughout, and by all levels of the program and company. For example, it is common for facilities to view an increase in the number of risk incidents to a small number of individual residents because they account for a disproportionate percentage of overall incidents.

However, numerous risk management reports from a variety of facilities over long periods of time show that it is common for a small number of residents to be involved in a disproportionately high number of risk incidents, including SMP.

Therefore, quality improvement evaluations, root cause analyses, and intervention strategies should consider increases in risk incidents as indicative of a larger problem rather than discount incidents as the result of a few "bad apples" who should be isolated or discharged.

Lastly, the implementing of a healthy "positive peer culture," resident input mechanisms (student government sub-committees, participation in program committees and action focused upon the reduction of Special Management Procedures), multi-disciplinary case reviews which include direct care staff, and a healthy staff culture/teamwork which enhances communication, are effective at promoting a safe environment and reducing SMP.

The following is a list of recommendations, regardless of how many types of Special Management Procedures are used at each program, and are consistent with the findings of this study.

It is acknowledged that many of the following recommendations are effectively utilized at individual TSI facilities. In fact, many of these recommendations come directly from positive results generated by these facilities.

These recommendations were all frequently cited as effective actions as to what works to reduce special management procedures.

*Development of systemic solutions to reduce

SMP.

*Development of strategies and interventions

for individual residents to reduce Special

Management Procedures.

*Expand the TSI "Position Statement –

Physical Holds, Seclusion, Restraints" which

identifies the company stance on Special

Management Procedures and provides

company-wide goals concerning their use.

This expansion or addendum should include

specific "do’s and don’ts", the terminology

to be used by all programs, conditions in

which Special Management Procedures

should be used, steps for employing a

"physical management or hold" (such as the

steps outlined in the "Prevention and

Management of Aggressive Behavior"

(PMAB) training curriculum, and any

uniform differentiation in the use of Special

Management Procedures due to service line

(intensive psychiatric, outdoor treatment, or

corrections). The current position statement

has already been provided to each TSI

facility to guide the facility specific policies.

*Each facility should have clear policies and

procedures regarding Special Management

Procedures and their documentation driven

by the overall TSI policy, but based upon the

specific population served, the level of care

provided, and federal and state requirements.

*Each facility should institute target goals and

rewards around peaceful conflict resolution.

*Development of consistent, written

company-wide staff training programs that

address the following:

-Developing a staff

identity that is based upon therapeutic

intervention rather than that of an

authoritarian stance

*Developing staff skills in the following

areas:

-Early recognition of antecedents of acting

out

-De-escalation skills such

as cognitive diversion

-Active listening

-Personal spacing

-Use of alternative

interventions such as time-out and

individualized intervention

-How to give and receive appropriate

touching

*Teaching staff members personal coping

skills for handling stress and crises using

classroom and role-play training techniques.

Also identifying and addressing staff

members’ issues which impact their ability

to effectively intervene such as the improper

use of authority/power, low boundaries, or

negativistic thinking.

*Training staff on the effective

implementation and usage of "positive peer

culture" (sometimes referred to as "group

process" within TSI). This training should

be multi-level with expectations for

increasing proficiency and with formal

competency assessment at each level.

*Training staff to identify cues and behaviors

of residents which indicate significant

underlying problems, such as inappropriate

sexual behavior, which can lead to acting out

incidents which may require the use of

Special Management Procedures.

*Conducting monthly and quarterly re-

training should be focused on direct-care

staff and those likely to be in a position to

intervene to prevent or sue use Special

Management Procedures as determined by

the regular systematic analysis of incidents

(a part of the Continuous Quality

Improvement program). The quarterly re-

training should be more comprehensive and

serve as a refresher training. This quarterly

refresher training is especially vital as

facilities become effective at the reduction

of SMP, since staff would have less

opportunity to practice their skills in the

filed. Also, competency assessments should

be conducted with staff involved in every

incident and individualize training provided

for those staff members based on that

assessment.

*Training staff on proper documentation of

incidents involving SMProcedures.

Include descriptions of antecedents, less

restrictive interventions used or why they

were not appropriate, justification for the use

of SMP, duration, injuries, medical care,

medication the resident was taking, how

resident was processed back into the daily

routine, any follow-up by clinical and

medical staff, and administrative review.

*Increasing direct-care staff members’

knowledge and involvement in each

resident’s case by:

-Training direct-care staff in how to be an

effective treatment team member.

-Provide information to direct-care staff

about new admissions, their etiology

(causal pattern of abnormal behavior), and

case information.

-Training all staff on teamwork which

includes utilization of specific on- call

guidelines for SMP incidents.

*Special Management Procedures should be

considered as emergency crisis interventions

of last resort that should only be applied in

response to violent behavior that creates

extreme threats to

life and safety.

*Development of crisis response procedures

in which the remaining resident population

is in a safe place with a structured activity

and extra staff are available to assist with the

SMP. These procedures should be practiced

as with any emergency situation, e.g. a fire

drill or severe weather drill.

*When a Special Management Procedure is

used, apply techniques and/or devices which

require the individual to be fully inclined

without inhibiting breathing. When

performing a Physical Management, strictly

follow the "PMAB" "follow-down" method

except that it is very strongly recommended

that more than one staff member should

perform the Physical Management whenever

possible. A trained staff member who is not

performing the Physical Management should

be used to verbally process with and de-

escalate the resident.

*Creation and/or refinement of the systematic

analysis of data regarding SMP. Utilize

process-based indicators rather than rate-

based, sentinel events, and anecdotal

evaluation. Utilize a JCAHO type model for

quality improvement program design.

*Consideration of architectural and structural

layout of each facility when planning

resident activities and staff placement to

maximize supervision and emergency

response. Whenever possible, consider the

utilization of video surveillance of areas

most likely to see conflicts. The use of fixed

and mobile video equipment is encouraged

as a deterrent to incidents, an encouragement

to proper staff supervision, as an

investigative tool, and as a training aid.

*Ensure an adequate staffing plan. Include

frequent involvement between an

experienced supervisor and direct-care staff

during resident activities. Plan for extra

staff in scheduling, and hiring as possible,

especially on historically low structure

times, e.g. weekends, which removes the

relative isolation of direct-care workers. *Continue to provide smaller resident to staff

ratios through the creative use of staff such

as Adventure Specialists, Family Service

Workers, Teachers, Supervisors, Case

Managers, etc. Plan for the presence and

structure the contact between case

management staff/family counselors and

families during family visits and

visitation days.

*Provision of specific procedures for the use

of "Time Out" (referring to the voluntary use

of time alone to calm ones self as opposed to

a Special Management Procedure). As

stated in the "Rehabilitation or Ruin?"

guidelines for the Department of Juvenile

Justice, "Provide ‘time-out’ for juveniles

whose behavior is out of control. The ‘time-

out’ shall last only for the amount of time it

takes for the juvenile to calm down and

regain control of his/her behavior… and

he/she shall receive appropriate supervision

for the duration of the time-out."

*Utilization of a staff-guided "positive peer

culture" which includes peer counseling and

peer mediation. Utilize group privileges

based upon pro-social behavior.

Consequences should be considered

therapeutic interventions and education, not

as punishments. Only utilize SMP as an

emergency intervention to prevent harm.

*Institution of systems which provide for the

early intervention with new admissions

specifically to reduce or eliminate the need

for SMP later. Assure that assessment at

admission/intake to identify high prior usage

of SMP. Screen for the appropriateness of

the admission based upon each facility’s

level of care.

*Individualize strategies, based upon these

assessments, to meet the therapeutic needs of

individuals in order to pro-actively meet

their needs before the resident begins a cycle

of acting out. Use the assessment to

develop and list special interventions on that

resident’s treatment plan specifically written

to reduce the need for SMP.

*Develop advance directives (plans for

intervention) to meet the needs of these

high-risk residents to reduce SMP. Involve

residents, parents, probation officers, social

workers, and direct-care staff in pro-active

planning to prevent SMP at admission.

Also, involve them in problem solving when

that resident is involved in a SMP.

*Evaluation and improvement of the

residents’ schedule at each facility based

upon analysis of incident reports with the

following considerations:

-Patterns of incidents during the daily

schedule, day of the week, season, and

special events.

-Increase structure and fill the residents’

schedule with substantive and consistent

programming. Even "free time" should be

structured.

-Provide non-competitive and non-contact

large muscle physical exercise daily,

especially in the early morning, in addition

to quality education and other

programming.

*Training of residents on self-control and ITP

communication including at least the

following:

-Appropriate anger expression and resolution

-Team building

-How to give and receive appropriate

touching

-Personal spacing

*Institution of a system of meaningful youth

involvement such as student government.

The JCAHO also recommends resident

involvement in quality improvement teams

and review of SMP.

*Early identification and transfer/discharge of

residents whose needs cannon be met at the

facility, as evidenced by continued frequent

or prolonged incidents.

The recommendations above provide guidelines that are research based, consistent with national trends, and have been proven to be effective in meeting the goal to reduce or eliminate the need for SMP. The recommendations should also serve as a guideline for the safest possible practice of SMP, if their use proves necessary.

Various TSI facilities already practice a great many of these recommendations. The final conclusion of this study is that ALL of these recommendations should be applied to all programs and facilities.

This study would not have been possible without the significant contribution of programs. Thanks and appreciation is extended to all the Three Springs programs which contributed and especially the staff of the Duck River, Daytona, and Courtland programs. And a special thanks is extended to Dr. K. Birkeli and Mike Angstadt of Twin Cedars for their contributions and cooperation towards meeting our shared goal of determining what works to reduce Special Management Procedures.

While research, policies, procedures, system design, training, and recommendations such as the above are necessary, they are not solely sufficient to the creation and maintenance of stable, positive, safe, supportive environment.

An environment of care which is conducive to the therapeutic gain and to the reduction of Special Management Procedures requires strong staff leadership and effective modeling of positive and professional staff performance.

The leadership of a program, particularly the Administrator and Program Director, must expend significant effort to plan, enact, and evaluate to ensure a cohesive and positive "staff culture" which permeates every level of the program.

Birkeli, K. (2000). "What works to Reduce critical Incidents". Columbus, GA: Twin Cedars Youth Services, Inc. – Anne Elizabeth Shepherd Home, June.

Boesky, L., Trupin, E., & Fenton, R. (1999). "Enhancing Mental Health Services for Juvenile Offenders in Washington State". American Association Corrections Compendium, Vol. 24, No. 8, 6-7.

Budeiri, P.R. (1998). "Rehabilitation or Ruin? An Information Packet Regarding Policies Governing the Isolation of Children and Youth Committed to the Department of Juvenile Justice". Richmond, VA: The Virginia Poverty Law Center, December.

Budeiri, P.R. (1999). "The Department of Juvenile Justice Officially Sanctions Staff’s ‘Striking’ Children Committed to Its Care and Provides Training in Techniques to Use, An Information Packet". Richmond, VA: The Virginia Poverty Law Center, February.

Budeiri, PR., Ohrlein, H.S., & Speidel, J. (1999). "One Size Does Not Fit All, A Summary of a Confidential Survey on Juvenile Corrections Center Treatment Personnel". Richmond, VA: The Arc of Virginia, Mental Health Association of Virginia, & The Virginia Poverty Law Center, August.

Hill, C. (1999). "Use of Force". American Correctional Association Corrections Compendium, Vol. 24, No.6,6.

Miller, C. (1998). "Positional Asphyxia-Death, By EMS". MERGInet.News: March, Part 2.

National Mental Health Association. (1998). "Position Statement on the Use of Restraints and Seclusion for Persons With Mental or Emotional Disorders". NMHA Program Policy: Internet, 41-43.

National Mental Health Association. (1999). "Tipper Gore Announces Stringent New Seclusion and Restraint Guidelines". Alexandria, VA: Capitol Hill Update, June.

New Dominion Maryland, Three Springs Courtland, Three Springs Daytona, Three Springs Duck River. (1998-2000). Risk Management Reports, Huntsville, AL: Three Springs, Inc.

Ort, R.S. & Favier, K.L. (1998). "Mental Illness as a Chronic Condition, Chronic Mental Patients in a Correctional Setting". Lanham, MD: American Correctional Association Correction Compendium, Vol. 23, No. 5, 1-6.

Roser, B. (1999). "Capitol Hill Update: Senate Finance Committee Holds Hearing on Seclusion and Restraint": National Mental Health Association, October.

The Joint Commission on Accreditation of Healthcare Organizations. (1999). Comprehensive Accreditation Manual for Behavioral Health Care". Oakbrook Terrace, IL: JCAHO.

by Steve Cockerham and Julie McCloud

The wilderness school is integral to outdoor therapeutic programming, placing educational services related to degree acquisition in a prominent position of concern. The following reflections characterize the theoretical underpinnings that substantiate the general nature of education in this type of environment. By utilizing the research from educational psychology and adding the practices of experiential education within the context of environmental relevance, an ideal composition of educational excellence emerges as a positive standard in therapeutic wilderness camps. A specific example from a school in East Tennessee is used for comparison.

When considering recommendations of quality educational services for wilderness camps, an intersection of experiential and environmental education with the tenets of educational psychology brings together an ideal combination of paradigmatic contributions to how school is best run in an OTP.

Experiential education stresses the active engagement of students physically, mentally, and emotionally in applications of problem-solving activities under environmental constructions (Ewert, 2001).

Environmental education has emerged as a set of values, knowledge, and individual/social behaviors to increase understanding of the natural world and facilitate ecologically responsible lifestyles (Saddington, 2001).

The overarching field of education represents a composite of theories with educational psychology as a subdiscipline focusing more on principles and practices of instructional methodology.

These three areas combine to emphasize the opportunities in OTP’s for active student involvement in learning, effective and ethical science education, and the application of current educational research.

Experiential education finds outdoor therapeutic programming the embodiment of its process oriented approach to learning. Some of the key values promulgated by wilderness programs are reiterated by the field of experiential education -- empowerment with personal and collective responsibility, the process of group therapy, and transformation of experience through learning into productive action.

OTP characterizes a quintessential application of experiential education and is well known to be fully representative of membership in that professional association.

Wilderness camps, obviously, are succinct locations for environmental education. Spending the majority of time out of doors and often engaged in moving thru multiple natural settings offer up many opportunities to learn about the natural environment.

Many of the sciences can readily utilize outdoor experiences to facilitate student learning in a "real life" laboratory. An excellent example is demonstrated by the Cedar Creek Learning Center, a residential school sponsored by the TN Valley Authority and a consortium of Northeast Tennessee school systems that has provided environmental education to youth for over 20 years.

Students from the entire region visit this elementary school converted to a dormitory with learning centers and spend the days nearby hiking in the Cherokee National Forest, canoeing TVA’s Nolichucky Waterfowl Sanctuary and Environmental Study Area, and caving in Cedar Creek Cave.

These activities serve as the base for several learning objectives including plant and animal identification, ecosystem descriptions like habitat/biome analysis and watershed profiles, and ecological assessment including water quality testing, mining practices evaluation and paper chromatography.

Returning to the school building after being out all day enables students to perform computer projects analyzing data and creating simulations besides engaging in design and construction of hands-on projects such as solar and wind energy devices, nature slide shows, and orienteering adventures.

The Center is filled to overflowing with detailed posters of environmental processes and stuffed endangered species for which official permission must be obtained. Injured wild animals are often kept in specially built facilities on site until released after rehabilitation as a service provided for wildlife.

A respective and appreciative attitude is fostered so that students can become better "stewards of the earth" (Ratledge, 2001). Cedar Creek exemplifies the some of the best in environmental education.

A review of generally accepted practices for effective school programs and substantiated by educational research was reported to Congress by the General Accounting Office (1989) and lists 5 features: 1)effective educational leadership that builds consensus in the learning community, 2)higher order cognitive processes that are tapped over reliance upon rote memorization, 3)school environments that are safe and orderly, enabling students to attend to learning, 4)an achievement orientation that expects all students to learn, and 5)improvements in quality of educational programming that are continually evaluated and updated.

The following analysis relates these principles to educational programs in wilderness camps and produces some intriguing observations.

Consensus is the hallmark of the treatment team approach with the treatment (or program) plan the documentation of participatory goal planning.

By meeting the initial recommendation of the GAO with the addition of certified faculty completing IEP’s and working in concert with counseling staff, an exemplary educational program can be characterized. Including group process with positive peer pressure and leadership training, then OTP’s can model very effective schooling.

Parental participation completes the circle with regular sessions with parents, meaningful ceremony to mark student progress, and follow up during home visitation and after program completion.

Rarely will one find a regular school with anywhere near the degree of parental involvement and collaboration found in a typical wilderness camp!

Simply referring back to experiential education explicitly defines the addition of higher order processes including the integration of emotional and physical components with the cognitive. Since time is also spent in standard classroom settings at wilderness camps, offering desk and multimedia interaction, this advises classroom teachers to coordinate with program staff to augment class objectives through coordinating with group and individual program goals.

Students in wilderness programs constantly challenge their problem solving abilities, engage in significant group discussions frequently, and daily reflect thru counseling on meaningful personal and interpersonal experiences. It can be arguably concluded that OTP better facilitates higher order thinking, especially for students who may not be taking advantage of educational opportunities.

Safe schools occupy the forefront of concern in today’s atmosphere of violent incidents. It’s noteworthy to comment here that the type of students at risk of delinquent acts profiles the admission criteria for OTP.

Risk management is of utmost priority with wilderness programs for obvious reasons and also because the newness of this type of programming portends sometimes unfair criticism. The truth is…public schools are far more dangerous than wilderness camps (www.nea.org).

This third feature of effective schooling also emphasizes order. The concept of ritual and order permeates the Loughmiller model of wilderness programming (Loughmiller, 1965). Ceremony is widely recognized as enhancing the effectiveness of a program.

Planning the schedule followed by the therapeutic groups is integral to OTP, occupying an important position in the daily task list.

The fourth characteristic of quality schooling, positive expectations, may possess the most questionable concern for wilderness camps. This speculation is based on the assumption that many consumers might fail to anticipate any rigor to the school curricula at wilderness camps.

It may even come as a surprise to learn that education is as central to OTP as counseling. Even so, there is a tendency for the school programs at OTP to generate a heightened student motivation for regular secondary school attendance.

In longer term programs, discharge planning often allows advanced students to enroll in local public schools, usually at the delight of the student. And who can deny the practical benefits of an air conditioned classroom on a hot day or especially the warmth and ease of central heating during those long winter months to create a positive association to being in school! Another logical and natural outcome from OTP…

Continuous quality improvement is an acknowledged procedure in business and industry today. Well-managed wilderness programs incorporate this management process as a fundamental aspect of their organization.

When wilderness camps seek licensure and accreditation, they must effectively interpret the highest standards in program operation. It has been an interesting process to formalize appropriate accreditation standards for outdoor therapeutic programming and it continues to be an issue.

Do these standards model best practice or do they actually stand in the way of effectiveness? How does a program meet standards not applicable to an outdoor setting?

Nevertheless, the school renewal process applies to wilderness program, too, and encourages practitioners in outdoor settings to view the organization as having the potential of a high functioning group. In an atmosphere that encourages personal and professional development, with competent and intensive staff training, OTP’s can meet the qualifications projected by the current state of research in organizational growth.

References

Ewert, Alan (2001) Horizon. Issue 30. Association for Experiential Education: Boulder, CO.

Loughmiller, C. (1965). Wilderness Road. Austin: Hogg Foundation for Mental Health.

Saddington, Tony (2001) International Consortium for Experiential Learning. University of Cape Town, Rondebosch, South Africa. http://www.eluct.ac.za/icel/

Ratledge, D (2001) Adventures in Nature. Cedar Creek Learning Center: Greeneville, TN

The purpose of Pathways is conceived as a forum for exchanging research, knowledge, information, wisdom, opinions, ideas, summaries, reflections, and graphics on the endeavor of outdoor therapeutic programming. As an extension of the National Association of Therapeutic Wilderness Camps, the journal focuses on the model initially described by Campbell Loughmiller in Wilderness Road (Hogg Foundation, 1965) and further promulgated by William Glasser (Reality Therapy) and Nicholas Hobbs (The Troubled and Troubling Child, 1987). Its purpose seeks to explore and explain the experiences of youth and caregivers in this therapeutic manner of transforming lives for the better.

Often called wilderness programs, these residential treatment centers offer counseling and education to youth having difficulties in adolescent development. Located in challenging wilderness environments, the schools have long and short-term residencies, providing a variety of services that centers on the use of the natural environment for establishing therapeutic community. Therapeutic wilderness camps do not use military style, boot camp procedures for forcing compliance but instead focus on longstanding, research-based counseling and educational methods for promoting positive change and appropriate adaptation.

As the professional association grows, a body of literature will document the veracity of teaching and counseling in the natural environment. Pathways invites readers to submit manuscripts for consideration of publication. Articles should deal with research (qualitative and quantitative), current issues, and trends in the field. Book reviews are encouraged and opinions/letters to the editor are welcomed. Notices about upcoming events and other noteworthy comments can be contributed.

Pathways: Journal of Outdoor Therapeutic Programming is published semi-annually by the Publication Committee of the National Association of Therapeutic Wilderness Camps and the University Press of East Tennessee State University. Copies of the journal are included with membership into the Association. Membership inquiries can be directed to our website, www.natwc.org .

Manuscripts should be submitted electronically on 3.5 inch disk DS/DD or DS/HD containing one file for the entire manuscript OR as an attachment to email sent to cockerha@etsu.edu . To reiterate, submit electronically. For questions of format, refer to the most recent edition of the Publication Manual of the American Psychological Association. Length of manuscripts should generally not exceed 2-8 pages.

Send manuscripts to: cockerha@etsu.edu

Correspondence: Steve Cockerham

HDAL Box 70548

East Tennessee State University

Johnson City, TN 37614

Office: 423/439-4189