Triad of Techniques Lessens Holds, Improves Care for Outbursts

Mandt Training

“This made me feel like I have a lot of power, where I can pick where I want to go.”

So said a boy in one of SaintA’s Residential Treatment units about how things have changed in recent months. The boy, who we’ll call David, used to cut himself and attack staff. He has a history of violent, aggressive and sexualized behavior and experienced almost daily holds (previously called “restraints”).

“He’s done a complete 180,” said Will Allen, manager of David’s Residential unit. The second shift supervisor on the unit, Blair Grover, said David used to have blowups that lasted from one to four hours; now he has almost none, and when he does act out, it is for no more than 15 minutes.

Why the change?

Chief Clinical Officer Tim Grove attributes successes such as David’s to the confluence of SaintA’s continued work with Trauma Informed Care, new practices and leadership in Residential, plus a switch to a new crisis prevention model called Mandt.

Mandt is based on relationships – one of SaintA’s Seven Essential Ingredients, or 7ei, a framework to understanding and functioning with trauma informed care – and it minimizes the use of restraint. It is a program that requires intensive and ongoing training and re-certification of all staff. It functions with an understanding of how childhood trauma affects the brain and teaches new behaviors to replace challenging ones. It looks at principles that underlie behavior, not just ways to respond to it, and stresses preventing aggressive behavior in the first place.

Mandt was chosen for SaintA as a part of a review of the agency’s behavior management curriculum and with an invitation from FEI (a behavioral health agency that is part of the Alliance for Strong Families and Communities) to consider being part of a storefront project.  It was one of several models examined in conjunction with Residential, Tim said, and was chosen with a lot of staff input.

“It was an elaborate process; we weighed all the factors, and Mandt was a better fit for us,” Tim said. “It has a great synergy with trauma informed care; it was compatible with how we look at trauma; and some of Dr. Bruce Perry and the ChildTrauma Academy’s material are part of their content.” Dr. Perry is a psychiatrist and physician with whom SaintA has worked for a number of years on how to help individuals who have experienced childhood trauma. SaintA’s trainings include Dr. Perry’s Neurosequential Model of Therapeutics (NMT).

The Neurosequential Model is not a specific therapeutic technique or intervention; it is a way to organize a child’s history and current functioning. The goal of this approach is to structure assessment of a child, the articulation of the primary problems, identification of key strengths and the application of interventions (educational, enrichment and therapeutic) in a way that will help family, educators, therapists and related professionals best meet the needs of the child.

Although the switch to Mandt was not easy for everyone at first, “It has really caught on in some parts of the agency,” Tim said. Residential is a prime example. Evidence of the changes that have occurred in recent months includes dramatic reductions in the number of holds required in Residential. (See chart below). In August of 2016, for example, there were no holds in Residential, compared to 15 during the same month last year.

Hold Rate Graph

How has this happened?

“We saw same remarkable changes in Residential practice a few years ago when we implemented NMT – holds and incidents dropped dramatically as staff got more comfortable implementing some of those core concepts,” Tim states. “But over time and facing some of the challenges that occur in our industry (turnover, etc.), we lost some of our momentum.”

“We’re pretty proud of how the triad of our TIC practice via NMT, and this behavior management model, plus new and energized leadership, have come together. The most recent restraint numbers are the byproduct of this blend of initiatives,” Tim said.

Key factors are a greater focus on understanding a child’s baseline behavior, knowing when a kid is escalating and intervening as quickly as possible, said Nicole Grice, Residential director.

How has Mandt helped?

“It’s a structured process; here’s how you go about it, and how you can be more trauma informed,” she said. Residential staff are taught that “Sometimes it’s best to let things run their course, not say anything and not to get into battles with boys.” Physical intervention is to be used only when a child presents a danger to himself and others.

“We’re teaching kids not to become physical, because hands-on creates a risk for the kids and the staff,” said Grice.

That teaching includes working with the boys to have them explain what are called their baseline options, things they can do when they feel their behavior escalating.

“We ask a kid, ‘What coping skills can we use with you when you feel you are escalating?’ “Will said. “The kids do a really good job of recognizing when they are becoming escalated and what helps.”

Some things the boys have chosen for their baseline options are walking, listening to music, climbing agency stairs, going outside to sit at a picnic table, and doing extra chores, like cleaning out a fish tank. Staff follows up with the boys to find out what they think worked for them, and let the boys choose different options to replace ones they think are not effective.

For David, talking about his hero, Stephen Curry of the NBA’s Golden State Warriors, does the trick.

“A couple of months ago, I was not focused, not listening,” David said. “But now they talk to me about sports, about Stephen Curry and how I want to be like him when I grow up, and then I feel calmer.”

David’s other baseline options include walking, taking deep breaths and shooting hoops.

“Now I’m listening a lot more and using them a lot more. I’m happier now, and (no holds) make me feel a lot better. Now I only get mad once in a blue moon,” said David.

Other Mandt teachings that SaintA finds effective include what is called the escort technique. It’s how to use your body’s proximity to get an appropriate response from a child while using minimum touch, explained Bruce Christiansen, a youth counselor on SaintA’s Residential unit that houses the youngest boys. He said it is a safe way to direct a boy. He also likes that Mandt has taught staff how to break up peer-to-peer fights in a non-aggressive manner, and its crisis model, including the different phases of escalation.

“You will probably see crises daily, but this teaches what you should do about it, how to use the least amount of interaction to maintain safety,” Bruce said.

The new model also teaches staff about transference, understanding that agitated boys will focus their anger on staff, and how staff should not take that personally, to avoid frustration and burnout.

“With the techniques you practice, it increases your competence in situations; it gives you choices versus reacting,” said Bruce.

If staff does have to go hands-on with a child, they are taught to say “excuse my touch,” Will said. He said some of the boys now joke with staff about not saying that because without going into extreme detail, the boys have been educated on the new approaches, he said.

“We never want to go hands-on; we don’t want to pull the trigger early,” Will said. “It’s all about verbal de-escalation, talking it out, building relationships. And TIC is really involved in Mandt; all of our 7ei’s are. They loop into what Mandt’s talking about.”

Practicing and sharing are keys to SaintA’s new approach. Youth counselors share their experiences and thoughts weekly with therapists and unit leadership.

“We get good questions and concerns,” Will said.

How are results maintained?

SaintA has formed a restraint reduction committee, to which incident reports are forwarded. The group examines how things might have been done differently. Suggestions to staff may include looking more closely at their own tone of voice, volume or cadence.

“We want to ensure that we approach a kid in a calm, respectful level, not yell at a kid, being calm and mellow so as not to trigger further escalation,” Will said.

“We tell staff you have to be sure you get your message across, but think about how you’re saying it. Relationship is a huge part of all of this.”

Tim is very pleased with the progress made to date. But he understands this is a process that needs continuation.

“We started working with trauma informed care a long time ago. This is now a natural progression, and we look forward to continued improvement in the future. In the end, it is all about those we serve, and we’re happy to say that things just seem to be getting better and better,” said Tim.

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