Evaluating the Implementation and Impact of an Intervention Designed to Enhance Residential Treatment for Adolescents with Histories of Trauma
Jeanne C. Rivard, Ph.D.
Evaluating the Implementation and Impact of an Intervention
Designed to Enhance Residential Treatment for Adolescents with Histories of
Trauma is an evaluation study of the
implementation of an intervention program (the Sanctuary Model, developed by
Dr. Sandra Bloom) at several JBFCS residential treatment facilities for
adolescents. The program was originally
developed for implementation in adult, short-term facilities. An evaluation of its suitability for a
long-term adolescent facility has potentially important consequences for adding
to the treatment options for adolescents with a history of trauma. This article describes the Sanctuary Model,
the development of the intervention, and the challenges the intervention
presents to the researcher.
Despite the
strong associations between child maltreatment and psychological disorders in
childhood and adulthood, there is evidence that child victims of abuse and
neglect do not routinely receive mental health treatment specifically targeted
to prevent or ameliorate potential negative mental health outcomes. Few empirical studies document outcomes of
mental health interventions for abused and neglected children (Berliner, 1997; Cicchetti & Toth, 1995; Fantuzzo, 1990; Graziano &
Mills, 1992; Malinowsky-Rummell & Hansen, 1993).
This
article describes an initiative being undertaken by the Jewish Board of Family
and Children’s Services (JBFCS) to enhance residential treatment programming
for emotionally disturbed children with histories of maltreatment and exposure
to family and community violence. Under
the auspices of JBFCS and through the consultation of Dr. Sandra Bloom, the JBFCS
Saul B. Cohen Chair of Mental Health for 1998-1999, the agency is piloting a
model of trauma-based treatment for use in adolescent residential treatment
centers. The intervention will be applied to existing therapeutic programs that
are specialized in treating youth with conduct disorders and other serious
emotional disturbances, but which have not traditionally utilized a
trauma-based approach to directly treat the symptoms and consequences
associated with child abuse, neglect, and exposure to family or community
violence. The programs provide residential, therapeutic, and special
educational services for children and adolescents referred by public child
welfare, mental health, and juvenile justice agencies.
An evaluation
component has been integrated into the planning and development of this
multi-modal intervention. Several
challenges are presented in both implementing and evaluating the model. First, the model was originally developed in
a short-term, in-patient setting for adults suffering from traumatic
experiences, so it must be adapted for adolescents in long-term residential
settings. Second, in addition to adding
a trauma-based focus to an existing residential treatment program, the model
involves diffusing a new philosophical approach and changing the therapeutic
milieu of programs.
The Sanctuary
Model
The
intervention, referred to as the Sanctuary Model (Bloom, 1997), is composed of
three basic components: (1) philosophical tenets guiding the creation and
maintenance of a therapeutic community; (2) a treatment approach, based in
trauma theories and cognitive-behavioral treatment theories, that posits four
stages of recovery for trauma survivors; and (3) a range of therapeutic
modalities including psychoeducational modules
designed to provide skills for re-structuring thought processes, communication,
and behavior to facilitate movement through the stages of recovery.
A
primary goal of the intervention is to enhance the therapeutic milieu with a
philosophy of non-violence and democratic social action in which staff and
clients share responsibility for creating the therapeutic community. The
philosophy is based on tenets of a therapeutic milieu developed in the 1940s to
1960s in an effort to humanize treatment within institutions and has been
extended to other forms of community-based treatment (Bloom, 1997; Grob, 1991). The
core values of a therapeutic community are: the community itself is the most
influential factor on treatment; clients are responsible for their own
treatment; the operation and management of the community should be more
democratic than authoritarian; clients can facilitate each others’ treatment;
treatment is voluntary and conducted in the least restrictive environment; and
physical restraint is kept to a minimum.
The
Sanctuary Model adds to these values an emphasis on creating a “living-learning
environment” which is physically, psychologically, socially, and morally safe
for both clients and staff. In this
milieu, conscious problem-solving is encouraged on personal, interpersonal, and
community levels. Staff strive to create
a non-hierarchical working atmosphere where decision-making is democratic and
all members of the community are treated with high levels of respect and
dignity. The professional roles and
boundaries of staff are clearly distinguished from those of clients, without
setting up physical or psychological barriers, and while empowering clients as
influential community members and problem-solvers (Bloom, 1997).
This therapeutic community milieu
sets the stage for delivering the trauma-based treatment aimed at facilitating
client growth through four stages of recovery, represented by the acronym, SAGE
(Foderaro & Ryan, 1998). Safety
refers to creating a safe environment physically, psychologically, socially,
and morally in which clients can engage in the recovery process within a
non-threatening environment. Safety also refers to an individual’s personal
commitment to create internal safety by learning how to stop cycles of
re-enacting traumatic experiences through hurting themselves (i.e., self
mutilation, addiction, setting up situations where they will be rejected by
others, etc.). Attaining a feeling of safety is critical to the attainment of
all other treatment goals. Affect
modulation refers to the stage following safety in which individuals learn
how to manage effectively their emotional responses. Important tasks for the clients in this stage
are learning how to: accurately identify their various emotional states; discriminate
between positive and negative affect in self and others; use cognitive and
language skills to articulate their emotional states; read the emotional cues
of others; and appropriately “recalibrate” the intensity of their emotional
responses according to different levels of stimuli. Grieving
is the stage of recovery in which individuals mourn losses they have
experienced and practice managing the emotions that accompany such losses.
Successfully reaching and getting beyond this stage of recovery allows
individuals to re-focus--away from the past and toward the future. It calls for new effort to be spent in
creating a new sense of self. Emancipation refers to the stage of
recovery in which individuals are empowered to make choices to direct their
lives toward more life-sustaining and growth-oriented goals. It is “characterized by an on-going process
of self discovery and self definition, accompanied by an evolving sense of
mastery” (Foderaro & Ryan, 1999).
The SAGE
framework is operationalized through a range of
cognitive-behavioral oriented therapeutic modalities including individual
therapy, group therapy, and expressive therapies. Chief among these are group psychoeducational modules that are designed to teach the
concepts inherent to the SAGE framework, and to teach and practice the
cognitive, language, and behavioral skills necessary to move through the stages
of recovery within the safety of the therapeutic community.
Intervention Development and Research Challenges
Successful
implementation of the Sanctuary Model in a treatment facility requires change
at several levels--change in both the program philosophy and the milieu toward
a non-violent and community-oriented paradigm, change in the organizational
culture, change in the attitudes and behaviors of community members, and change
in treatment protocols. Establishing and
maintaining a therapeutic community in line with the Sanctuary Model requires
an active process of breaking down institutional, societal, professional,
cultural, and communication barriers that isolate clients and staff. Simultaneously, the re-building process
involves consciously learning new ways to relate as interdependent community
members, creating and modeling healthy and supportive relationships between
individuals, and developing an atmosphere of hope and non-violence. In the JBFCS implementation of the Sanctuary
Model, the primary means for effecting such change will be through increasing
communication among staff and clients and including all members of the community
in planning, shaping, and implementing the intervention within each specific
treatment unit involved in the pilot project. In this manner, the new
philosophy will be absorbed into the implementation process itself.
Measuring
such change in the therapeutic milieu will require qualitative analyses of key
events and interactions within the community, such as how plans and decisions
are made, how critical incidents and problems are handled, and how youth are
empowered to participate in planning, decision-making, and
problem-resolution. Other areas of
investigation related to implementation pertain to how individual, ethnic, and
cultural differences among staff and clients affect the change process. For example, how are aspects of the new
philosophy, such as non-violence, flattened hierarchy for decision-making,
and open communication, interpreted and accepted by different members of the
community? How do new feelings of
interpersonal trust and safety emerge?
How do staff involved in direct child-care interpret trauma theories and
integrate them into daily interactions with adolescents?
Evaluating
outcomes of this type of multi-level intervention presents many
challenges. The evaluation plan must
consider questions such as: how can change in program philosophy and milieu be
quantified and correlated with change in staff behavior/attitudes and client
outcomes; how is the SAGE treatment approach distinguished from existing
treatment protocols; and how can the effects of the Sanctuary Model be separated
from those resulting from the existing intervention? To evaluate the effects of
the intervention both intermediate and ultimate outcomes need to be considered.
Diffusion of the therapeutic community philosophy should lead to changes in the
therapeutic community (i.e., intermediate outcomes), such as: greater sense of
community/cohesiveness; more democratic decision-making and shared
responsibility in problem-solving; reduction in use of physical restraints; and
reduction of violent critical incidents.
Diffusion of the therapeutic community philosophy and full
implementation of the treatment approaches should result ultimately in gains
for youth, such as: reducing trauma symptoms; increasing self-esteem;
increasing self-control control; and utilizing social networks.
For long range planning, a
quasi-experimental, comparison group cohort design with repeated measures has
been proposed to evaluate the effects of the intervention on the therapeutic
milieu, staff, and youth. The evaluability of the
logic model is, however, highly contingent upon the successful diffusion of the
therapeutic community philosophy. This
intervention development and research project has strong support within JBFCS. Due to the democratic and somewhat
revolutionary nature of the new intervention, the programs are carefully
soliciting input and participation from all levels of the organization, and
they are cautiously advancing in embracing the new philosophy.
The study's principal
investigator is Jeanne C. Rivard, Ph.D.
References
Berliner, L.
(1997). Intervention with children who experience trauma.
In D. Cicchetti & S. Toth (Eds.),
Bloom, S. (1997).
Creating sanctuary: Toward the evolution
of sane societies.
Cicchetti, D.,
& Toth, S. L. (1995). A
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Fantuzzo, J. W. (1990). Behavioral
treatment of the victims of child abuse and neglect. Behavior Modification, 14(3), 316-339.
Foderaro, J. F., & Ryan, R. A. (1998). SAGE: Mapping the course of recovery. Unpublished
manuscript.
Graziano, A. M.,
& Mills, J. R. (1992). Treatment for abused children: When is a
partial solution acceptable? Child Abuse
and Neglect, 16, 217-228.
Grob, G. N. (1991). From
asylum to community: Mental health policy in modern America.
Malinowsky-Rummell, R., & Hansen, D. J. (1993). Long-term consequences of childhood physical abuse. Psychological Bulletin, 114(1), 68-79.