ALLENDALE ASSOCIATION RECEIVES PRESTIGIOUS AWARD FOR INNOVATIVE PRACTICES
Association recently received an Innovative Practices Award for
its REStArTsm treatment model. REStArT (Relational Re-Enactment
Systems Approach to Treatment) is a comprehensive systems-approach
to treatment with youth who struggle with emotional, behavioral,
and mental health challenges.
REStArT is based
on thirteen principles that guide human service professionals, family
members and youth in developing interventions to help break chronic
"conflict cycles", repair relationships and learn new
ways to be successful at home, in school, and in the community.
The award was
presented by The Council on Accreditation (COA), a 34 year-old independent
not-for-profit international accreditor of the full continuum of
community-based behavioral health care and human service organizations.
Allendale was one of three groups to receive the 2011 Innovative
so pleased to receive this special recognition because it validates
the work we are doing at Allendale", said Mary Shahbazian,
president of the Allendale Association. "This award also
acknowledges the REStArT program as an innovative and evidence-based
team approach to helping kids and families in need to learn better
ways to cope, deal with conflict and implement a positive life plan",
The COA Innovative
Practices Award was created to acknowledge accredited and first
time applicant organizations that implement new and forward thinking
practices that enhance the quality of services provided to vulnerable
children, youth, adults, and families and are consistent with theory,
practice, wisdom, and expert consensus reflected in current professional
Practices Award is designed to provide organizations the opportunity
to share and be rewarded for uniquely meeting the needs of a service
population and/or implementing distinctive methods for improving
a formal statement, the COA said, "It is extremely proud to
recognize the Allendale Association for their creative work and
innovative use of resources, and is honored that they are part of
the COA family".
CLINICAL CONSULTATION AS A FAMILY INTERVENTION IN RESIDENTIAL TREATMENT: EXPLORING WHAT IMPACTS OUTCOMES
Catherine McConnell PhD & Patricia Taglione PsyD
Click On Title to Download this 2015 Research Article (requires
WITH CLIENTS AND IMPROVING OUTCOMES: THE RELATIONAL RE-ENACTMENT
SYSTEMS APPROACH TO TREATMENT MODEL
McConnell PhD & Patricia Taglione PsyD
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RELATIONAL RE-ENACTMENT SYSTEMS APPROACH TO TREATMENT
Click On Title to Download Principles (requires
model, the Relational Re-Enactment Systems Approach to Treatment
(REStArT), is a comprehensive child and adolescent mental health
treatment model. Treatment is based on youth's "conflict cycles"
(i.e., relational trauma), which are defined by their re-enactments
of their attachment experiences in the present. By engaging all
systems involved with a youth and the experiences the members of
those systems have with him/her, the treatment team can develop
an understanding of how the youth sees themselves, others, and their
relationships. Plans for treatment, then, are driven by this conceptualization,
which is unique to each youth, but created within a model that uses
attachment theory, object relations theory, an understanding of
the impact of trauma and neurobiological underpinnings to organize
the youth's patterns into diagnostic categories. These plans are
developed to interrupt this cycle, which gives youth a chance to
experience the feelings that have been inaccessible to them because
they were being acted-out. The interruption of their re-enactment
also gives them a chance to find new ways of relating and responding.
model has thirteen principles that capture the philosophy, theory,
and practice behind the approach. These principles guide treatment
process and implementation with the goal of developing and executing
a successful life plan.
a Working Therapeutic Alliance: Client, family and service
providers agree on the goals and tasks of treatment. These goals
and tasks need to be youth and family driven.
of therapeutic alliance is an essential component in all
the treatment principles and needs to be established before treatment
can take place. More than just the quality of the relationship
between caregivers, service providers, and youth, a therapeutic
alliance is a collaborative relationship in which all parties
agree on the goals and tasks of treatment. Even before there can
be agreement about the goals and tasks of treatment, treatment
providers need to learn how youth and their family view the problem
to be addressed. The process of developing the therapeutic alliance
may stall if there has not been agreement about the very nature
of the problem behind the goals and tasks.
providers are viewed as experts not just of their profession but
also of the clients themselves, the development of a true collaborative
relationship can be undermined and the result may be compliance
from the family and youth without real ownership for the treatment
and treatment outcomes. Instead, an alliance allows providers
to do treatment "with" the client rather than "to" the client.
Each of the other twelve principles - from understanding the unique
experiences of the client to the need for systems to work as a
unified whole - is designed to build and maintain an alliance
with the client that puts their goals and choices at the center
Re-Enactment: Identify youth's attachment style through the
ways in which the youth re-enacts it in his/her behavior with others
(i.e., identify the conflict cycle).
and object relations theories and informed by research on trauma,
the treatment within the REStArT model begins by identifying youths'
internalized representations of their interactions with others
(Siegel, 1999; Bowlby, 1980; Masterson, 1976). The conflict cycle
consists of a youth's most potent relational stressors and the
feelings and behaviors that accompany these stressors. The process
becomes cyclical in that the youth's behavior pulls for particular
responses from adults - responses that perpetuate the youth's
responses either by managing the stressor for him or her or by
intensifying the impact of the stressor. Neurobiological research
(Schore, 1994) suggests that the responses generated in others
are a form of "right-brain" communication through which the youth
elicits emotional reactions in others as a way of communicating
their own internal experiences. Because these internal experiences
are not part of the youth's explicit memory, the experiences of
adults living and working with the youth - while sometimes difficult
to acknowledge - are valuable data in understanding the youth
and the meaning behind their behaviors.
Counter-Response(1): Identify the adult
counter-response (feelings and subsequent behavior) within that
youth's particular conflict cycle; identify the adult's unpleasant
reality (related to the youth's conflict cycle) that is being avoided
by the adult; face the adult's unpleasant reality and the adult's
feelings so that they are not driving the adult's behavior (counter-response).
and behaviors generated in adults when they are living with or
interacting with a particular youth in treatment are valuable
for conceptualizing the youth, as referenced above. However, these
responses - the feelings and behaviors that the adults use to
"counter" the behaviors of the youth - are also identified so
that the responses of the adults (family, significant others,
professionals working in the program) are no longer driven by
the youth's re-enactments, but are rather grounded in what is
in the best interest of the youth. Responses to the youth can
be characterized as "counter-aggressive", meaning adults counter
a youth's behavior with anger and frustration, wanting only for
the youth to change and losing sight of an understanding of the
youth's behavior; or "counter-indulgent" which are unbalanced
in the direction of understanding, that is, the adults understand
and align with the youth and lose sight of expectations for the
youth to be accountable for their own behavior.
counter-responses are maintained when adults working with youth
in treatment are unaware of one or more "unpleasant realities"
associated with living or working with the youth. While youth
themselves often have to confront unpleasant aspects of their
worlds - abusive experiences, personal limitations, losses - the
adults working with them face unpleasant realities, as well. For
example, youth may not have the same goals for themselves as the
adults have for them, or they may make choices contrary to the
choices the adults wanted them to make. In order to interrupt
the youth's cycle, adults need to be open with themselves regarding
the unpleasant realities they face interacting and working with
the youth. When these unpleasant realities are named and accepted,
adults can work toward managing their counter-responses to the
youth; this can be very powerful in helping the youth focus on
him/herself to gain insight into self-defeating patterns of behavior
and try new, more adaptive, behaviors to manage stress.
(1) Allendale Association Counter-Responsesm Training, Copyright
IV. Systems-Oriented: Identify all the adults involved with the youth and have them come
together to develop a shared understanding of and way of approaching
the youth and to identify a common interest or goal.
orientation of the REStArT model takes into account that each
of the youth's interactions with the adults in his or her life
takes place not in isolation but within a larger system. All of
the adults in the youth's life are a part of that system, and,
as a result, the interaction of each adult with that youth affects
all the other adults in that system. If one member of the youth's
treatment team is counter-indulgent with the youth, for example,
this will affect others who are trying to hold the youth accountable
for his or her behavior. The systems approach, then, is not simply
an invitation to be as inclusive as possible when considering
the youth's treatment team - although this, too, is important.
It also calls on all members (family, significant others, professional
staff, advocates) of the treatment team to consider the "ripple
effect" that will occur in the system based on their interactions
with the youth.
the Imbalance in the System: Identify polarities in youth's
behavior and subsequent polarities in adults' counter-response (i.e.,
splits/divisions within the system).
A system tends
to seek balance. In the physical world, for every action there
is an equal and opposite reaction. This seems to be true for the
emotional world, as well. When there is an extreme (unbalanced)
emotional reaction, it is usually responded to by an equally extreme
(unbalanced) opposite emotional reaction, resulting in polarities.
For example, one's counter-indulgence is often responded to by
another's counter-aggression and vice versa (i.e., one member
of the team does not hold the youth consistently accountable to
important rules of conduct while another applies overly negative
and rigid consequences for every small infraction).
the REStArT approach seeks to create balance in the systems surrounding
the youth, the identification of discrepancies in the way the
youth is understood is an important step in developing a plan
to work with each youth. Divisions in the system working with
a youth often represent the splits within the youth's own internal
experiences. Understanding the divisions can help family members
and treatment providers understand the internal conflict of the
youth. Because these internal conflicts are generally not in the
explicit awareness of the youth, they are externalized through
the youth's interactions with others. Because the internal conflict
is, by definition, divided, its re-enactment is done in such a
way as to allow some people to see one aspect of the conflict
and others to see only other aspects of the conflict. In treatment,
then, adults using the REStArT model identify their primary responses
to the youth (counter-indulgent or counter-aggressive) and the
behaviors from the youth to which they are responding in order
to better understand the youth as a whole.
consequence of imbalance when left unchecked is the "treatment
trap". In this imbalance, the system emphasizes understanding
the youth to the exclusion of expecting change. After some time
of indulging the youth in this way, members of the system become
frustrated at the lack of progress the youth has made, and become
counter-aggressive. The counter-aggression escalates until it
eventually takes the form of believing that the youth is misplaced
and should be moved either to a different milieu/team or to an
entirely different level of care.
the Whole Youth: Identify ways in which our view of the youth
has been compartmentalized (i.e., sees the youth in a particular
way). Work together and dialogue so that all parties see both sides
of the youth - the adaptive side and the maladaptive side.
theory and object relations theory both offer an understanding
of the importance of wholeness as it applies to an individual's
development (Bowlby, 1980; Fairbairn, 1958; Kernberg, 1975; Masterson,
1976). Internalized experiences with others that result in internal
models in which "good and bad" aspects of self and other are not
integrated lead to ways of interacting with the world that are
split, as well. Because youth are often acting-out their conflicts
in ways that are destructive, it follows that treatment aims to
help them integrate their feelings about their conflicts, allowing
them the opportunity to be in control of rather than controlled
by their experiences.
In order for
youth to integrate their experiences of the world, both good and
bad, the adults and systems around them will need to integrate
their various experiences of the youth. Wholeness from this perspective
is equivalent with health, and the focus on wholeness then promotes
the health of the individual as well as the health of the system.
This part of the REStArT model requires ongoing dialogue with
the involvement of as many parties as possible: parents, school
professionals, milieu staff, therapists, advocates, etc. Because
each view of the youth is valid, no party is considered an "expert"
on the youth. The goal of these dialogues is to create a whole
picture of the youth that involves an empathic understanding of
their behavior as well as an expectation that the youth can change.
It is not
necessary for each member of the team to experience or personally
witness the youth in all ways in order for an aspect of the youth
to be considered in treatment. Additionally, a "wholeness" approach
reminds treatment team members that even youth who are not acting
out currently still have the characteristics and potential for
behavior that resulted in their need for treatment. Similarly,
youth who are engaged in acting-out behaviors still have their
adaptive side, as well.
the Balance: Use dialogue and consensus to restore balance
in developing a plan to interrupt the youth's conflict cycle (integrate
both extremes of the adults' counter-response reactions in order
to arrive at a more balanced response).
this unified understanding of the youth, individual adults and
their respective systems can use this balanced view to create
a balanced response to the youth. This part of treatment does
not involve "brainstorming" techniques, but rather requires adults
to listen to one another's issues and concerns and to bring forth
one's own concerns without trying to convince, argue or debate.
Keeping in mind that splitting has been one way the youth involved
has coped with their conflict, adults trust that each person has
a view of the youth that is valid and may have been invisible
to them. The goal of this step is to reach a consensus about the
plan, not a compromise. Compromise often implies that someone
has "given in", and this is likely to maintain rather than resolve
the splits and imbalances in the system. Remaining grounded in
concrete evidence adults have about the youth is crucial at this
step, as it allows for a more disciplined approach which is more
likely to result in consensus than a debate that is based on personal
reactions to the youth.
of dialogue and consensus may not result in restoring balance
initially. There are a number of potential barriers that may need
to be addressed. The adults working with the youth may have an
easier time identifying the counter-response in others and therefore,
may not be open to looking at or managing their own responses.
When the plan is agreed on without true consensus, balance is
also not likely to be restored. Because youth have been engaging
in splitting to manage their own painful feelings, they will continue
to do so even if the lack of agreement between the adults in their
world is subtle. This split also allows the youth to avoid resolving
their own internal conflicts. If adults resonate with one side
of the youth's conflict, this, too, will stall the process of
restoring balance. The process of using one's own responses to
a youth to understand the youth and his/her conflicts is a challenging
one, and sometimes the focus of individual members of the treatment
team can become externalized as a way to manage this. While external
factors are not irrelevant, they are generally out of the control
of individual team members, and focusing on them can keep the
the Conflict Cycle: Implement a plan that interrupts the
way the youth typically responds to stressors which provides an
opportunity for the youth to respond in a new more adaptive way.
conflict cycle is unique to his or her own way of responding to
stressors and is based on the data that family members, staff,
and significant others have accumulated from their specific interactions
with the youth. However, the conflict cycle also offers a sense
of continuity within a framework that allows for great individual
variability. The conflict cycle itself is based on the work of
Nick Long (Wood & Long, 1991). The four classifications of conflict
cycles are related to the "core sensitivities" from the work of
Cooper, et al (2005). The classification of a youth's conflict
cycle into one of four categories provides a starting point for
treatment planning and intervention. The four classifications
are: control sensitive, closeness sensitive, independence sensitive,
and self-esteem sensitive. Each conflict cycle type refers to
the particular stressor or predominant precipitant for the youth's
conflict cycle as well as the nature of the responses the youth
generates in others. Because different behaviors can appear to
different people to be classified in any one of these categories,
conflict cycle determination is made by careful attendance not
only to antecedent events, but also to the youth's subsequent
behavior and the adults' responses, using specific and detailed
tracking of these cycles.
with REStArT is flexible in that no two treatment plans are identical.
Plans for interrupting the youth's conflict cycle are unique to
each youth and relevant to the understanding of that youth's particular
sensitivity. However, the approach is also one of continuity in
that treatment is based on a framework grounded in theory and
evidence. Like the REStArT model more broadly, these plans remain
cognizant of the need to maintain balance by being aware of typical
adult responses that may err on the side of only expecting change
in the absence of understanding or focusing too heavily on understanding
the youth's sensitivities with little expectation of change.
with Ambivalence: Be aware of and identify examples of ambivalence toward the current
circumstance in the family and the youth so that this can be verbalized
instead of expressed through behavior.
can be defined as having both positive and negative feelings toward
something. It is expected that youth and their families experience
polarized feelings about their individual goals, their discharge
goals, and their relationships. In an effort to see the youth
as a whole, participants in the REStArT model need to become aware
of the ways in which the youth and his/her family cope with ambivalence.
For example, if expressed intentions are different than actual
behaviors, this may represent conflicting feelings regarding the
stated goal. Rather than trying to get the family and/or youth
to commit to a decision, service providers within this treatment
approach encourage them to talk about both parts of their feelings,
so they can eventually develop a more balanced response to the
situation. As with other internal conflicts, however, the youth
and their family will be unable to talk about their ambivalence
as long as they are acting it out. If participants in the youth's
system take on the task of trying to resolve this ambivalence
- either by encouraging a particular outcome or feeling hopeless
about any outcome - the youth, family, and rest of the team will
remain stuck. The REStArT model guides the assessment of the ambivalence
so that treatment providers can remove themselves from the conflict
and, instead, assist the youth and family in acknowledging, discussing,
and resolving it.
Health: Trust the youth's ability to determine their own goals, tolerate
disappointments, and repair relational disruptions.
In order to
implement a plan to interrupt the youth's conflict cycle, the
treatment team needs to trust the youth's ability to determine
what the standard of "health" is for them and to support the youth's
goal in achieving this. This may mean relinquishing goals and
expectations that the adults have for the youth even when adults
believe that their vision for the youth is "healthier" than the
youth's vision for themselves. By allowing the youth to pursue
their own goals, within reason, the adults also trust the youth
to be capable, with appropriate support, of tolerating setbacks.
This requires the adults in the youth's system to create a balance
between remaining emotionally available for the youth while allowing
the youth to face situations that may be disappointing or frustrating.
In particular, by allowing the youth to experience natural disruptions
in their relationships with family/friends/caretakers/service
providers, the system gives the youth the opportunity to better
tolerate these relational events. This aspect of the REStArT model
calls on adults to be willing themselves to tolerate disruptions
in relationships, as counter-indulgence often serves to protect
both the youth and the adult from this experience. As with other
aspects of the model, dialogue and self-awareness promote the
ability of adults in the system to work through these disruptions
in healthy ways and expect that most disruptions can be repaired.
of health is not limited to the relationship between adults and
the youth. In general, adults within the system need to expect
health from one another, meaning that service providers need also
to apply this principle to their work with youths' families and
significant others. Additionally, this principle calls on staff
at each level of the system to expect health from other staff/professionals,
trusting in their ability to do their job and to work for better
solutions when there are disruptions and setbacks.
at Every Part of the System: Create investment in the model
across the entire system and support each part's contribution to
the plan, which promotes responsibility and accountability.
of treatment using REStArT - for example, utilizing imbalances
in the system (splitting) to better understand and treat each
youth - necessitate that every part of the system have an investment
in and contribution to the youth's treatment. Rather than treatment
planning and implementation stemming from a "top-down" model,
REStArT uses frequent consultation, dialogue, and a system of
checks and balances to ensure that all members of the youth's
treatment team are equal partners. While this does not negate
each individual's responsibility or unique role, it does provide
greater support for each person's role because each individual
knows that he or she is part of and has input into a larger plan.
System-wide input increases the likelihood that the members of
the system will feel that the plan belongs to them. Within the
theoretical structure of REStArT, this system-wide investment
also serves the function of creating the wholeness needed to interrupt
the youth's conflict cycle.
to wholeness is developed through "horizontal" dialogue in which
leaders across multiple settings (clinical, school, residential
milieu) are involved in dialogue, rather than communication being
primarily "vertical" (supervisors communicate to their supervisees).
Additionally, a collaborative relationship with family and collateral
team members, who are viewed as an equal and integral part of
the treatment team, is necessary. When families are not involved
or say they are supportive of a plan but do not follow through,
rather than viewing the family as resistant, the program is called
upon to reflect on their work with the family. Clinical consultation
is the family service that provides the bridge between all members
of the system.
XII. Evidence-Based: Use concrete data about the youth to determine conflict cycle and
plan development and to evaluate effectiveness and outcomes.
within the REStArT model, refers in part to the need for concrete
material to support the conceptualization of the youth, the plan
to interrupt the conflict cycle, and the conclusion that the plan
is working (or not working). Research on residential treatment
in particular has identified the following factors as characteristic
of an evidence-based practice: family involvement prior to discharge,
stability in the post-discharge resource, and availability of
after-care support (Frensch & Cameron, 2002; Hair, 2005). An evidence-based
program is also one whose foundation is a coherent treatment model
(Wampold & Malterer, 2007). And finally, evidence, in the context
of a broader research program, benefits from multiple informants
and objective data over the course of time to support conclusions
(e.g., Behrens & Satterfield, 2006; Curry, 2004). The REStArT
model serves as a coherent approach that directs the family-focus
and discharge-focus of treatment. The members of the system, including
the youth, make up the multiple informants. Objective data over
the course of time is gathered by tracking the youth's interactions
using specific examples across different settings and episodes.
Because similar behaviors can have different meanings for different
youth, closely tracking behavior and finding the themes that emerge
protects against imputing the meaning from observing the behavior
outside of its context.
and Reflexive Process: Establish a continuous process of
looking at our own responses/reactions and evaluating whether the
plan is effective.
re-enactment is at the heart of this model, the responses and
reaction of adults using the model are instruments in assessing
and treating the youth in care. These interactions are inherently
co-created, so adults in this process need to examine their own
reactions both to understand the youth but also to manage how
they respond to triggers of their own relational templates. Psychodynamic
theories and also research on practices such as Multisystemic
Therapy (MST) suggest that the treatment of others requires caregivers
to engage in a process of self-examination (Henggeler, et al,
1997; Shedler, 2006).
process itself can sometimes be a source of imbalance in a system.
Feedback may overly emphasize positive results at the expense
of continued learning. Alternately, it may be equated with criticism,
overlooking ways that the members of the system have worked well
together. However, results of outcome research indicate that therapists
have better results when provided with immediate feedback about
their sessions, regardless of the nature of the feedback (Lambert,
Hansen, & Finch, 2001). Feedback, then, is provided not as a consequence
or reward, but rather as a means to improving treatment delivery
and client functioning. Supervision and consultation offer ongoing
opportunities for treatment providers to not only reflect on their
own experiences but also receive feedback from others, as it is
often difficult to "see" our own responses.
of self-reflection - with "self" referring not only to the individual
but also to the treatment team as a whole (i.e., the system) -
creates an environment of continuous quality improvement. The
process is a repeating loop in that the results of one plan, in
the form of the youth's responses, are the feedback used as further
evidence to both understand and provide/modify treatment for the
youth. The youth's responses to treatment are examined and compared
to expectations of what change would mean for each particular
youth. When a plan does not result in change, the process of examining
how the youth's cycle is continuing in ways that may not be readily
apparent begins anew. This process again includes the response
of the treatment providers as it relates to this cycle.
As the name
of this principle implies, the task of working with these youth
is dynamic and, therefore, always changing. We may manage our
feelings adequately in one interaction with a youth only to find
the same interaction very challenging the next time we are confronted
with it. Similarly, a youth may alter his or her behavior in one
situation but then start acting out in new ways. While it can
be uncomfortable to maintain this activity of assessing the youth's
behavior and our responses, to do so is to take advantage of the
many inherent opportunities for intervention in this process.
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