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Staff cohesion in residential treatment Johnson, Susan Maureen 1980

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STAFF COHESION IN RESIDENTIAL TREATMENT by SUSAN MAUREEN JOHNSON B.A.Hon., The Univ e r s i t y of H u l l , England, 1968 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS i n THE FACULTY OF GRADUATE STUDIES (s p e c i a l Education) We accept t h i s thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA May 1980 "cj Susan Maureen Johnson, 1980 , In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of Brit ish Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the Head of my Department or by his representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of SPECIAL EDUCATION The University of Brit ish Columbia 2075 Wesbrook Place Vancouver, Canada V6T 1W5 Date APRIL 1 I98O i i ABSTRACT This thesis attempts to examine the e f f e c t of varying l e v e l s of s t a f f cohesion, a key process v a r i a b l e i n the r e s i d e n t i a l treatment of disturbed adolescents, on the q u a l i t y of treatment environment. In order to do t h i s the s t a f f from each of the three residen-t i a l cottages which constitute the Easton r e s i d e n t i a l unit were given the Seashore Index of Group Cohesiveness (1954). I t was then possible to delineate three l e v e l s of s t a f f coehsion, high, medium, and low. The same s t a f f groups also completed a treatment environment scale, namely the Community Orientated Programs Environment Scale (Moos, 1974), Forms R (real) and I ( i d e a l ) . The hypothesis here was that as s t a f f cohesion rose so the perceived q u a l i t y of the treatment environment would r i s e . The c l i e n t s from the cottages also completed the environment scale, the hypothesis being that t h e i r perceptions of the environment would be more p o s i t i v e i n the cottage containing the most cohesive s t a f f group. C l i e n t behaviours i n the low, medium and high cohesion cottages were also observed. The study showed that there were no s i g n i f i c a n t differences between the s t a f f groups concerning th e i r view of the i d e a l treatment en-vironment, but the l e v e l of cohesion did have an e f f e c t on the r e a l t r e a t -ment environment, as perceived by the s t a f f , s p e c i f i c a l l y on the v a r i a b l e s Support, Personal Problem Orientation, Autonomy, P r a c t i c a l Orientation and Staff Control. The number of locked room hours for c l i e n t s and the number of v i o l e n t incidents also seemed to follow the cohesion factor pattern. However, the c l i e n t s ' perceptions of t h e i r environment did not vary s i g -i i i n i f i c a n t l y according to cohesion l e v e l . Some d e s c r i p t i v e data comparing the factors i n the Easton treatment environment to the norms for such programs were also included. Implications for the planning and evaluation of such treatment programs have been outlined as well as suggestions for further research. i v TABLE OF CONTENTS Abstract ' i i L i s t of Tables v i L i s t of Figures v i i i Acknowledgements . . . . . i x Chapter Page INTRODUCTION 1 I BACKGROUND OF THE STUDY SECTION 1: Res i d e n t i a l Treatment 3 D e f i n i t i o n s of Residential Treatment . . . . 3 History of Res i d e n t i a l Treatment 5 Models of Res i d e n t i a l Treatment 6 Organizational Structure 10 Cl i e n t Population 11 Elements of Treatment 13 Treatment Goals 15 Adolescent R e s i d e n t i a l Treatment 15 Evaluation of Res i d e n t i a l Treatment . . . . 19 SECTION 2: Staff Cohesion 24 Significance of Sta f f Relationships i n Resi d e n t i a l Treatment 25 Staff Relations at Easton 27 The Concept of Group Cohesion 28 Conditions F a c i l i t a t i n g Cohesion 30 Consequences of Cohesion 32 Measurement of Group Cohesion 34 Summary and Hypotheses 35 II SETTING: EASTON RESIDENTIAL TREATMENT CENTRE Physical Description 36 Design and Intent 37 Cl i e n t Population 39 Staff 40 Cl i e n t Organization 45 Cottage P r i v i l e g e s , Rules, etc. 46 General Philosophy 48 Program 51 III THE STUDY D e f i n i t i o n of Terms 54 Population 56 Instruments 60 Data C o l l e c t i o n Procedures 66 Data Analysis Procedures 67 Assumptions and Limitations 68 V Page IV RESULTS AND DATA ANALYSIS STAGE 1: Item and Test Analysis 70 Delineation of Cohesion Levels 76 STAGE 2: E f f e c t s of Staff Cohesion Level on C l i e n t ' s View of Treatment Environment • • 79 Relationship between Cohesion Level and C l i e n t Behaviours 86 STAGE 3: Easton Program P r o f i l e s 89 V DISCUSSION OF RESULTS E f f e c t s of Staff Cohesion Level 96 Staff Perceptions of Ideal Treatment Environment (COPES, Form I) 99 C l i e n t Perceptions of Real Treatment Environment (COPES, Form R) 100 C l i e n t Behaviours 101 Program P r o f i l e s 102 VI SUMMARY AND CONCLUSIONS Summary of the Study 105 Conclusions of the Study 107 Implications of the Study 108 Suggestions for Further Research 108 BIBLIOGRAPHY APPENDICES A. Instruments: Seashore Cohesion Index 118 COPES Subscale D e f i n i t i o n s 120 COPES Form R 121 COPES Form I 125 S o c i a l Worker Questionnaire 129 B Letters Accompanying COPES Form R 133 Letters Accompanying COPES Form I 132 Taped Introduction to COPES Form R 131 C Easton Demographic Data 134 D COPES Form R Normative Data 141 COPES Form I Normative Data 144 Internal Consistencies and Average Item Subscale Correlations for Form R Subscales 142 Form R Subscale In t e r c o r r e l a t i o n s . . . . 143 Seashore Cohesion Index Item In t e r c o r r e l a t i o n s . . . . . . 145 E Easton Sample Treatment Sheet . 147 F Terms Used i n Residential Treatment 150 v i LIST OF TABLES Page Table 1: Cohesion Index, Test S t a t i s t i c s 70 Table 2: COPES FORM R, Test S t a t i s t i c s 7 2 Table 3: COPES FORM R, Subtest Correlations 73 Table 4: COPES Form I, Test S t a t i s t i c s 74 Table 5: COPES Form I, Subtest Correlations 75 Table 6: Cohesion Index, Means and Standard Deviation . . . . 77 Table 7: Cohesion Index Summary Anova Table 77 Table 8: Cohesion Index Post Hoc Comparisons • • 78 Table 9: COPES Form R, Means and Standard Deviation 80 Table 10: COPES Form I, Means and Standard Deviation 81 Table 11: COPES Form R, M u l t i v a r i a t e Analysis of Variance . . . 82 Table 12: COPES Form I, M u l t i v a r i a t e Analysis of Variance • • • 82 Table 13: Post Hoc Comparisons for Cohesion E f f e c t 83 Table 14: C l i e n t s , COPES Form R, Subscale Means 86 Table 15: C l i e n t s , COPES Form R Means and Standard Deviation • 87 Table 16: C l i e n t s , COPES Form R, Summary Anova Table 87 Table 17: C l i e n t s , Post Hoc Comparisons f o r Cohesion E f f e c t • • 88 Table 18: Cottage Observations f o r July 88 Table 19: COPES Form R, Subscale Means — Standard Scores • • 91 Table 20: C l i e n t s , COPES Form R, Subscale Means, Standard Scores 92 Table 21: Staff Groups, Length of Employment at Easton . . . . 135 Table 22: Staff Groups, Length of Employment i n Cottage . . . . 136 Table 23: Placement of Cl i e n t s before Admission 137 v i i Page Table 24: C l i e n t Prognosis, assigned by So c i a l Workers . . . . 137 Table 25: C l i e n t s , Length of Residence at Easton 138 Table 26: Age of Cl i e n t s at Time of Study 139 Table 27: Means and Standard Deviations of COPES Form R Subscales for American Normative Sample 141 Table 28: Internal Consistencies and Average Item Subscale Correlations for COPES Form R Subscales 142 Table 29: COPES Form R Subscale I n t e r c o r r e l a t i o n s for C l i e n t s and Staff 143 Table 30: Means and Standard Deviations of COPES Form I Subscales for American Normative Sample 144 Table 31: Seashore Index of Cohesiveness Mean Scale In t e r c o r r e l a t i o n s 145 v i i i LIST OF FIGURES Page Figure 1: The Easton Complex 38 Figure 2: Easton Organizational Chart 42 Figure 3: COPES Form R Subscale P r o f i l e s for Cottages . . . 84 Figure 4: COPES Form R Easton Program P r o f i l e 93 Figure 5: Program P r o f i l e , Staff and C l i e n t Perceptions . . . 94 Figure 6: Program P r o f i l e , Staff Real and Ideal Perceptions . 95 i x ACKNOWLEDGEMENTS The writer would l i k e to thank Dr. David Kendall and Dr. Bryan Clarke for t h e i r assistance and support throughout the study. Appreciation i s also extended to Dr. Robert Wilson for h i s continuous d i r e c t i o n and encouragement. The writer would also l i k e to express her gratitude to Dr. Todd Rogers for h i s advice and assistance on s t a t i s t i c a l procedures. Gratitude i s afforded to the Easton Supervisory Team for t h e i r support of t h i s project. 1 INTRODUCTION The c r i t i c a l demand for services i n c h i l d mental health has been r e f l e c t e d i n the marked growth of r e s i d e n t i a l treatment f a c i l i t i e s for d i s -turbed c h i l d r e n during the l a s t two decades, (Durkin and Durkin, 1975). At the same time there has also been growing c r i t i c i s m of the theory and prac-t i c e of r e s i d e n t i a l treatment i t s e l f . For example, the J o i n t Commission on the Mental Health of Children (1970) reports that the present i n s t i t u t i o n a l arrangements f o r the r e s i d e n t i a l care of disturbed c h i l d r e n are "inadequate i n many ways, req u i r i n g a c r i t i c a l a pparisal of both assumptions and pro-cedures." The task of describing, analysing, and evaluating such programs, however, i s a complex and d i f f i c u l t one. The f i r s t step i n t h i s task would appear to be the delin e a t i o n of the s i g n i f i c a n t process variables i n r e s i d e n t i a l treatment and t h e i r e f f e c t on the treatment environment and, consequently, on treatment outcome. Easton, a r e s i d e n t i a l treatment f a c i l i t y located i n a major Canadian c i t y , and the subject of t h i s study, i s at present facing the imminent pros-pect of a substantial expansion of i t s treatment program. The task of out-l i n i n g the e f f e c t s of variables believed by the Easton s t a f f to be of c r u c i a l s i g n i f i c a n c e i n the present Easton program i s then a p a r t i c u l a r l y urgent one, i n view of the massive planning procedures necessary before such an expansion can take place. The most s i g n i f i c a n t v a r i a b l e i n the process of r e s i d e n t i a l t r e a t -ment i s considered by t h i s unit and by other p r a c t i t i o n e r s (Easson, 1969; Bettelheim, 1974) to be s t a f f cohesion. This study, then, i s an attempt to 2 look at t h i s v a r i a b l e and determine i t s e f f e c t s on the Easton treatment environment as perceived by the Easton s t a f f and c l i e n t s . The purposes of such a study are: to provide process evaluation to the Easton un i t , which w i l l serve as a basis for future planning and p r i o r i t y s e t t i n g ; to lay the foundation for a meaningful outcome evaluation of such a treatment centre; and to add to the general theory of r e s i d e n t i a l treatment, by c l a r i f y i n g r e l a t i o n s h i p s between the s i g n i f i c a n t v a r i a b l e s operating i n such a s e t t i n g . This study consists of an overview of r e s i d e n t i a l treatment and an examination of the group cohesion factor, a d e s c r i p t i o n of the Easton pro-gram, an o u t l i n e of the study i t s e l f , and an analysis and discussion of r e s u l t s . 3 CHAPTER I BACKGROUND OF THE STUDY Section 1 — Residential Treatment Introduction This section consists of a discussion of r e s i d e n t i a l treatment. I t begins with some d e f i n i t i o n s of r e s i d e n t i a l treatment, followed by a short h i s t o r y , continuing with an overview of the general models of treatment, the structure of residence and treatment methods. Res i d e n t i a l treatment as i t pertains p a r t i c u l a r l y to adolescents i s then reviewed, and f i n a l l y there i s a synopsis of evaluations and evaluative techniques i n t h i s area. Some D e f i n i t i o n s of Residential Treatment Res i d e n t i a l treatment, as employed i n t h i s study, r e f e r s to a complex, f u l l time, twenty-four hours a day therapeutic process provided within a set-ting s p e c i a l i z e d f o r , and adapted to, the needs of c l i e n t s i n the early and middle periods of adolescence (ages 12 through 17 years). The therapeutic process i n such a se t t i n g i s designed to be comprehensive and addressed to the adolescent whose problems are of such a degree that they warrant removal from h i s family and s o c i a l environments and admission into f u l l time r e s i d e n t i a l care. Rinsley (1965) states that i n such treatment there are two basic ingredients: f i r s t , understanding and treatment of the c l i e n t ' s problem; and, secondly, cognitive and emotional growth experiences appropriate for the c l i e n t ' s age and development. Both of these, "curing" and " r a i s i n g , " exploring the disorder and s o c i a l i z i n g or educating the c l i e n t through the 4 i n t a c t aspects of h i s functioning, are necessary for a program to be j u s t l y e n t i t l e d r e s i d e n t i a l treatment. In a more general context, although there i s no accepted d e f i n i t i o n of r e s i d e n t i a l treatment, i t has some general c h a r a c t e r i s t i c s which have been defined by Adler (1968) as: 1. Structured, planned l i v i n g . 2. Authority and opportunities for c l i e n t s to work out t h e i r f e e l i n g s about i t . 3. Focus on health rather than pathology of p e r s o n a l i t y . 4. Group l i v i n g . 5. I n d i v i d u a l i z a t i o n of treatment. 6. I d e n t i f i c a t i o n , through opportunities for s i g n i f i c a n t r e l a t i o n s h i p s . 7. C h i l d - s t a f f i n t e r a c t i o n . 8. A sense of community. 9. Integration, j o i n t planning of treatment programs by a l l s t a f f . Lourie (1952) has described r e s i d e n t i a l treatment as follows: We would define r e s i d e n t i a l treatment as t h e r a p e u t i c a l l y directed i n s t i t u t i o n a l or group care for emotionally disturbed c h i l d r e n i n which a l l possible ways of helping — casework, education, recreation, planned group l i f e , and psychotherapy, are u t i l i z e d and integrated into a c l i n i c a l l y oriented and directed treatment plan for the i n d i v i d u a l c h i l d . I t i s not merely the removal of the c h i l d to a benign.environment where he i s a v a i l a b l e for psychotherapeutic interviews. The essence of r e s i d e n t i a l treatment l i e s i n the m i l i e u ~ i n the complement of a d u l t - c h i l d r e l a t i o n s h i p s and experiences which can be c l i n i c a l l y manipulated and c o n t r o l l e d i n the i n t e r e s t s of therapy (p. 801). A l l facets of the c l i e n t ' s l i f e i n residence are seen as providing opportunities for learning and growth. The m i l i e u i t s e l f i s seen as the primary and most powerful method of intervention. 5 Mayer (1955) makes the point that r e s i d e n t i a l treatment i s not an e n t i t y i n i t s e l f but a l i n k i n a t o t a l treatment process which includes pre-i n s t i t u t i o n a l and p o s t - i n s t i t u t i o n a l care. The fact that i n r e a l i t y t h i s i s not always so, but that there i s a need for such continuity of care, i s a common theme i n the l i t e r a t u r e (Whittaker, 1979; Children i n Canada i n Re s i d e n t i a l Care Report 1971; Celdic Report 1970). Such l i t e r a t u r e em-phasizes the dangers inherent i n the i s o l a t i o n of r e s i d e n t i a l treatment from the community, and the need f o r a comprehensive, coordinated community based network of treatment resources that w i l l meet the varied needs of disturbed chil d r e n . History of R e s i d e n t i a l Treatment Before 1900, r e s i d e n t i a l treatment consisted of orphanage type i n s t i t u t i o n s , mostly r e l i g i o u s i n s t i t u t i o n s , o f f e r i n g c u s t o d i a l care. A f t e r t h i s date,., however, group l i v i n g experiences, education, and psychotherapy for the c h i l d or adolescent began to replace custodial care. Shelter and t r a i n i n g began to give way to treatment. The outstanding pioneers i n t h i s f i e l d have been Aichhorn (1954), Bettleheim (1950), and Redl (1952) . The number of r e s i d e n t i a l treatment units grew slowly over the years, but a marked increase occured, i n the United States at l e a s t , between 1945 and 1965 (Pappenfort and Dinwoodie, 1970). Pappenfort and Dinwoodie also note that those i n s t i t u t i o n s e x i s t i n g i n 1966 were deluged with applicants, whether t h i s i s due to an increased incidence of psychological disturbance i n young people, improved diagnostic systems, or a tendency to redefine many types of deviant behaviour i n a mental health context i s not known. Hylton (1964) states that i n the United States, for every 100,000 people under age 18, 135 are i n inpatient care, and 355 i n outpatient care. In recent epidemiological studies (Langer et a l . , 1969), large numbers of 6 chi l d r e n were found i n the community showing marked p s y c h i a t r i c impairment, with disproportionate numbers coming from f a m i l i e s on welfare and from low income groups. Where i n the network of s o c i a l services do these c h i l d r e n go? Some are l i k e l y to be placed as delinquents i n t r a i n i n g schools, some i n homes for the retarded, some i n p s y c h i a t r i c wards i n state h o s p i t a l s , some i n multiple foster homes, and some i n r e s i d e n t i a l treatment f a c i l i t i e s , the need for which seems to be c r i t i c a l and increasing. Models of R e s i d e n t i a l Treatment The f i e l d of r e s i d e n t i a l treatment has now developed i n a v a r i e t y of d i r e c t i o n s , the main models r e f l e c t i n g d i f f e r e n t theories of c h i l d develop-ment. Psychoanalysis and learning theory provide s i g n i f i c a n t foundations for two p o l a r i t i e s of treatment approaches between which various mixtures are to be found. Lewis and S o l n i t (1975) break down the recent h i s t o r y of r e s i d e n t i a l treatment into three parts. F i r s t , the early view described by Nospitz (1962) that the goal of residence was simply to make the c h i l d a v a i l a b l e for i n d i v i d u a l psychotherapy, t h i s therapy being i s o l a t e d from the rest of the c l i e n t ' s environment. The therapist did not reveal h i s work with the c l i e n t to other s t a f f , who were reduced to the r o l e of custodians. In more recent v a r i a t i o n s of t h i s model, the power of the m i l i e u may be recognized as a context or integ r a t i n g force, but i n d i v i d u a l psychotherapy, which attempts to resolve intrapsychic c o n f l i c t s , i s seen as the core of treatment. Another view regarded the experience of l i v i n g i n a structured environment with healthy r o l e models as a l l the c l i e n t needed. The group l i v i n g experience was regarded as a c o r r e c t i v e emotional experience. This view culminated i n the behaviour modification and educationally focussed approaches using such techniques as token economy. In t h i s model, the focus 7 i s on behaviour, not inner personality t r a i t s . The "symptom" i s seen as the ent i r e problem to be treated by creating a systematic environment which reinforces desired responses and extinguishes negative responses. Achieve-, ment Place, i n Kansas,(Phillips and P h i l l i p s , 1973) i s an example of t h i s model. Hobbs' Project Re-ed (Hobbs, 1967), i s also s i g n i f i c a n t here. The t h i r d view of r e s i d e n t i a l treatment regards the whole r e s i d e n t i a l experience, group l i v i n g , i n d i v i d u a l counselling and psychotherapy, the power of the environment and the c l i e n t ' s i n t e r a c t i o n with i t as c o n s t i t u t i n g the c l i e n t ' s therapy. Whittaker (1979) states that the major ingredients of a therapeutic m i l i e u are: rules which create a helping culture, routines, program a c t i v i t i e s , group sessions, i n d i v i d u a l psychotherapy for c l i e n t s who can develop and act on the basis of i n s i g h t , l i f e space interviews (Redl and Wineman, 1952), incentive systems, s p e c i a l education, conjoint family t r e a t -ment, parent education groups, and i n d i v i d u a l behaviour modification programs. In t h i s view, s t a f f communication i s emphasized as they deal i n a consistent therapeutic way with the c l i e n t , h i s treatment environment, and h i s family. Here, combined treatment methods are used, including i n d i v i d u a l psychotherapy, behaviour modification, m i l i e u therapy, and s p e c i a l education. The Therapeutic Community Model (Jones, 1968) and the e c o l o g i c a l model of emotion-a l disturbance have contributed to t h i s t h i r d and most recent model for r e s i d e n t i a l treatment. The e c o l o g i c a l model (Rhodes and Tracy, 1977) has augmented and validated t h i s t h i r d approach to r e s i d e n t i a l treatment. Ecology i s the study of the i n t e r a c t i o n between organism and environment. In t h i s model, emotional disturbance i s seen as a dysfunction i n t e r a c t i o n between the i n d i v i d u a l and his unique environment. Key concepts i n t h i s model are: the necessity of taking into account the whole "eco-system" of a c l i e n t , 8 that i s h i s home, school, community and treatment environment; treating behaviour i n the here and now, i n i t s natural context; and the " f i t " and i n t e r a c t i o n of environment and c l i e n t . E c o l o g i c a l concepts such as " l i f e -space" (Lewin, 1951) are r e f l e c t e d i n the writings of r e s i d e n t i a l treatment p r a c t i t i o n e r s . F r i t z Redl (Redl and Wineman, 1952), for example, named one of h i s intervention techniques, l i f e - s p a c e interview. This model tends to foster an e c l e c t i c and m u l t i d i s c i p l i n a r y approach to treatment. The Therapeutic Community Model (Jones, 1953) i s also one of the more s i g n i f i c a n t i n r e l a t i o n to t h i s t h i r d view of r e s i d e n t i a l treatment. The words "therapeutic community" appear frequently i n the l i t e r a t u r e of r e s i d e n t i a l treatment. This model i s the basis for the idea that the t o t a l s o c i a l structure of the treatment unit i s involved as part of the helping process; a l l of the s o c i a l and interpersonal processes are seen as relevant to the treatment of the i n d i v i d u a l . The model grew from the psychoanalytic approach but was also a reaction to that approach. The i d e a l of such a com-munity i s to create an environment which heals (the Greek word therapeuein means to heal) and nourishes. The basic p r i n c i p l e s of the Therapeutic Community (Jones, 1953) are: f i r s t , the c l i e n t assumes as much respon-s i b i l i t y as possible for h i s own, h i s peers and the community's growth. Second, the s t a f f are u n i f i e d into a team rather than separated i n t o d i s -t i n c t r o l e s , and authority i s shared. Third, there i s open communication between s t a f f and c l i e n t , s t a f f and s t a f f , and c l i e n t and c l i e n t , enhancing the r e l a t i o n s h i p s which are the "primary source of therapeutic change." Fourth, the s o c i a l environment i s as normal as possible. F i f t h , there i s considerable emphasis placed on "group i n t e r a c t i o n , " the process of i n t e r -action as well as content i s stressed. Sixth, a l l facets of l i f e are opportunities for l i v i n g - l e a r n i n g experiences. And seventh, an emotional climate of warmth and acceptance i s desirable. The most powerful factor 9 i n the creation of such a community i s the s t a f f who, according to Jones, must be constantly examining t h e i r r o l e r e l a t i o n s h i p s and must remain open to c r i t i c i s m and feedback, thus forming a therapeutic culture which mani-fests a consistent a t t i t u d e towards c l i e n t s . This f i n a l view of r e s i d e n t i a l treatment, influenced as i t i s by the e c o l o g i c a l and therapeutic community models, i s the view favoured by most modern writers on t h i s subject. Whittaker (1979) states, "Psycho-a n a l y t i c a l l y oriented therapy as the treatment of choice i s slowly giving way to therapeutic intervention i n the l i f e - s p a c e . " (p. 11) Even programs which focussed on behaviour modification as the prime treatment modality are becoming aware of the power of in t e r a c t i o n s between s t a f f and c l i e n t and the ef f e c t of the peer culture ( P h i l l i p s and P h i l l i p s , 1973). These models of r e s i d e n t i a l care also tend to lose t h e i r c l a r i t y i n the process of implementation. Some writers speak of the psychoanalytic model i n t h i s f i e l d but, i n f a c t , c l a s s i c a l psychoanalysis with i t s focus on regression does not seem, at present, to be widely applied to the t r e a t -ment of disturbed c h i l d r e n or adolescents. Psychotherapy, grounded i n interpersonal theory and ego psychology, however, i s used. I t i s d i f f i c u l t as f a r as concrete implementation i s concerned to separate the psychotherapy practices of b u i l d i n g r e l a t i o n s h i p s and learning new ways of coping or ego strengths from more behaviourally orientated models which also emphasize these elements, but with a d i f f e r e n t t h e o r e t i c a l j u s t i f i c a t i o n . The behaviour therapists often also focus on the c l i e n t and therapist r e l a t i o n -ship, but for i t s r e i n f o r c i n g and modelling p o t e n t i a l i t i e s . Mayer (1977) makes the point that there are more s i m i l a r i t i e s than differences between the d i f f e r e n t approaches. He compares the twelve concepts Hobbs stresses as underlying Project Re-ed and the twelve items that Redl suggests i n h i s a r t i c l e on the therapeutic m i l i e u . In many ways these concepts overlap. 10 Redl's "The Impact of the Group Process" and Hobbs' "The Group i s Important," are j u s t one example. Most p r a c t i t i o n e r s , no matter what t h e i r t h e o r e t i c a l background, also speak of the importance of ego development and i t s growth through a graded set of expectations and r e s p o n s i b i l i t i e s . Appendix F contains a de s c r i p t i o n of some of the terms used i n these models of r e s i d e n t i a l treatment. Organizational Structure of Residential Treatment The s t a f f i n g pattern includes various combinations of c h i l d care workers, teachers, s o c i a l workers, nurses, psychologists and p e d i a t r i c i a n s , making the cost of r e s i d e n t i a l treatment very high (Hylton, 1964) . The rol e s and l e v e l s of t r a i n i n g of these professionals w i l l vary from unit to u n i t . In some centres the c h i l d care s t a f f are the primary therapists, teachers and custodians, while i n others these functions may be broken up and assigned to d i f f e r e n t professionals. The present trend (Mayer, 1977) seems to be to recognize more and more the c r u c i a l r o l e of the c h i l d care s t a f f . In recent years the French model of t r a i n i n g for the "educateur" has been advocated as a model for c h i l d care t r a i n i n g i n the United States and Canada. The emphasis i n t h i s model i s on a t o t a l l i f e education and on helping the c h i l d to manage and integrate d a i l y l i v i n g and learning experiences i n a l l areas, cognitive, emotional and interpersonal. The r a t i o of s t a f f to c l i e n t i n r e s i d e n t i a l care i s usually very high. Hylton reports a rate of s l i g h t l y l e s s than one for one to be most common, and the average turnover among s t a f f to be very high, two-thirds of the l i n e s t a f f i n some i n s t i t u t i o n s leaving every year. Increased profes-s i o n a l i z a t i o n of the c h i l d care s t a f f i s noted, but t r a i n i n g w i l l vary considerably from i n s t i t u t i o n to i n s t i t u t i o n , as w i l l administrative structures. 11 The J o i n t Commission on the Mental Health of Children (1970) made the recommendation that r e s i d e n t i a l f a c i l i t i e s be small, allowing ch i l d r e n and adolescents to l i v e i n small groups, and the i n s t i t u t i o n s should be open, locked buildings or rooms being only r a r e l y required. Also, the guiding p r i n c i p l e should be that ch i l d r e n be removed as l i t t l e as possible i n space, time and l i f e experience, from t h e i r normal s e t t i n g . This general theme, that the i n s t i t u t i o n should be as "normalizing" as possible i s consistent with recent developments i n the i n s t i t u t i o n a l care of other groups such as the retarded and the p h y s i c a l l y handicapped. Wolfensberger's book (1972) expounds the r a t i o n a l e surrounding t h i s concept which i s that treatment should be i n the " l e a s t r e s t r i c t i v e environment poss i b l e . " F r i t z Redl (Redl and Wineman, 1952) also speaks of the need for "a house that smiles, props which i n v i t e , and space which allows," meaning that the ph y s i c a l s e t t i n g and emotional climate must be one where the c l i e n t ' s acting out problems and behaviours can emerge and be sa f e l y dealt with. Bettleheim (1974), t a l k i n g of h i s Orthogenic School, states that the com-munity should be l i k e a "well appointed home." Cl i e n t Population The c l i e n t s for whom r e s i d e n t i a l treatment i s designed are ch i l d r e n or adolescents e x h i b i t i n g a v a r i e t y of problems such as aggressive impulse disorders, depressed or s u i c i d a l behaviours, or various forms of b i z a r r e or psychotic behaviour. The c l i e n t s w i l l vary according to the focus of the treatment centre. Some centres s p e c i a l i z e , for example Pioneer House i n Detroit (Redl and Wineman, 1952) which focussed p r i m a r i l y on aggressive impulse disorders. Others have a more general admissions p o l i c y . Whittaker (1979) suggests that c l i e n t s recommended for r e s i d e n t i a l 12 treatment commonly share the following t r a i t s : poor impulse control as a r e s u l t of f a u l t y ego development (that i s , an i n a b i l i t y to channel i n s t i n c -t u a l impulses into s o c i a l l y acceptable forms of expression); low self-image; poorly developed modulation of emotion; r e l a t i o n s h i p d e f i c i t s r e s u l t i n g i n i s o l a t e d a u t i s t i c - l i k e behaviour or c l i n g i n g over-dependence; family pain and s t r a i n ; l i m i t e d play s k i l l s ; and s p e c i a l learning d i s a b i l i t i e s . Whittaker then sees the r e s i d e n t i a l environment as consisting of a series of "teaching formats" to teach competence i n these basic l i f e s k i l l s . I n s t i t u t i o n s seeking to help the emotionally disturbed c l i e n t d i f f e r -entiate between these emotionally disturbed c l i e n t s , hard-core delinquent, chronic psychotic, and retarded c l i e n t s . In f a c t , when confronted with the i n d i v i d u a l these l i n e s may be d i f f i c u l t to draw. The causes of emotional disturbance are varied and include possible genetic factors (such as epilepsy and a re l a t e d emotional or behavioral di s o r d e r ) , disruptions i n the l i f e pro-cess which impede normal development (such as multiple f o s t e r home placements), developmental delay or traumatic experiences (such as ph y s i c a l abuse, in c e s t , parental psychosis, maternal deprivation and l o s s ) , or dysfunctional f a m i l i e s which produce b i z a r r e or inappropriate coping mechanisms i n the c h i l d or adolescent. C l i e n t s are generally referred by mental health p r o f e s s i o n a l s , such as school psychologists or state welfare agency workers; and previous attempts at treatment, such as f o s t e r home placement, usually precede r e s i d e n t i a l placement. The age range varies from i n s t i t u t i o n to i n s t i t u t i o n , but boys are generally referred more frequently than g i r l s . The needs of the c l i e n t , s k i l l s of the s t a f f , l i m i t a t i o n s of the s e t t i n g , balance of the patient population and estimates of prognosis are some of the v a r i a b l e s to be weighed when a c l i e n t i s being considered f o r admission (Lewis and S o l n i t , 1975). 13 Elements of Treatment The implementation of treatment displays some general c h a r a c t e r i s t i c s which are common to most i n s t i t u t i o n s . Most i n s t i t u t i o n s focus on the group i n t e r a c t i o n aspect of r e s i d e n t i a l treatment as a powerful therapeutic force. Polsky and Claster (1968) i n t h e i r studies of residence emphasized the power of the peer group i n residence to undermine or create a therapeutic environment. Redl (1966) states, "Residen-t i a l treatment i n a therapeutic m i l i e u means group therapy." The therapeutic e f f e c t of a structured environment with i t s r u l e s , routines, expectations, sanctions and incentives, a l l implemented i n a clear and consistent way, i s emphasized by most r e s i d e n t i a l treatment f a c i l i t i e s (Redl, 1959; Bettleheim, 1974; Trieschman, 1969). Easson (1969) states that the teenager's d a i l y l i v i n g i n the residence i s the main treatment t o o l . In addition, the c h i l d or adolescent's r e l a t i o n s h i p with key s t a f f members who are h i s chief therapists i s recognized, whether t h i s i s through the medium of a transference reaction (psychoanalytic model) where the c h i l d expresses h i s f e e l i n g s towards h i s parents through t h i s r e l a t i o n s h i p , or through a l i f e - s p a c e interview (Redl, 1959) where the working through of d a i l y c o n f l i c t s and problems i s used to b u i l d i n s i g h t and new coping mec-hanisms. Whittaker (1979) attempts to define the therapeutic r e l a t i o n s h i p between c l i e n t and s t a f f as containing the elements of s o c i a l r e i n f o r c e -ment, communication, and modelling, each of these elements f o s t e r i n g a d i f f e r e n t kind of learning, reward and punishment, i n s i g h t and i d e n t i f i c a t i o n -i m i t a t i o n learning, r e s p e c t i v e l y . Treatment i s i n d i v i d u a l i z e d , requiring generally high c l i e n t to s t a f f r a t i o and most r e s i d e n t i a l centres emphasize the need for free and regular s t a f f communication and team work. Bettleheim (1974) speaks of 14 the " s o c i a l s o l i d a r i t y " which i s necessary among the s t a f f to support them i n t h e i r r e l a t i o n s h i p s with t h e i r c l i e n t s . The importance of the personal q u a l i t i e s of the s t a f f , t h e i r i n t e r a c t i o n with each other and t h e i r a b i l i t y to form a therapeutic culture i s accepted as a basic b u i l d i n g block i n r e s i d e n t i a l treatment. I t i s Easson's (1969) view, echoed by many others such as Bettleheim, and Redl, that the f i n a l therapeutic e f f e c t of a r e s i d e n t i a l treatment unit i s t o t a l l y dependent on the q u a l i t y and the e f f e c -tiveness of the treatment personnel who must be able to l i v e c o n s t r u c t i v e l y with t h e i r own emotional p o t e n t i a l s and t h e i r own personal l i m i t a t i o n s . (p. 28) Education and recreation seem to be given a high p r i o r i t y i n most r e s i d e n t i a l units, as providing age-appropriate tasks through which the c h i l d or adolescent can learn competence i n l i f e s k i l l s . T r a d i t i o n a l modes of psychotherapy are used i n most r e s i d e n t i a l f a c i l i t i e s , except those operating under s t r i c t behaviour modification, token economy systems. Such modes include i n d i v i d u a l and group psycho-therapy and, i n some cases, family therapy. The general use of these techniques, however, and of others such as medication, w i l l vary not only from centre to centre, but also from i n d i v i d u a l to i n d i v i d u a l . There has been a general recognition that stages of treatment are i d e n t i f i a b l e i n such settings (Masterson, 1972; Rinsley, 1965). In the f i r s t stage, the c l i e n t displays anxiety which i s followed by a honeymoon period where the c l i e n t i s anxious to please, f i n a l l y lapsing, however, into h i s c h a r a c t e r i s t i c behaviour patterns and r e s i s t i n g treatment. This resistance takes the form of frequent l i m i t t e s t i n g . The second stage i s where the c l i e n t has formed r e l a t i o n s h i p s i n the community and begins to work through h i s or her problems and learn new coping mechanisms. The t h i r d , or f i n a l stage, i s discharge and termination, which often involves 15 feelings of loss i n the c l i e n t , creating a temporary regression i n behaviour. Length of treatment varies from f i v e years (Rinsley, 1965) to f i v e or s i x months (Hobbs, 1967). Treatment goals The goals of r e s i d e n t i a l treatment are stated i n terms of the p h i l -osophy and t h e o r e t i c a l o r i e n t a t i o n of each u n i t . However, i n general, the goals can be stated as: f i r s t , the control of problem behavioural patterns, hopefully at the end of treatment, by means of s e l f control on the part of the c l i e n t ; second, the maximizing of the c l i n e t ' s p o t e n t i a l f o r a normal and f u l f i l l i n g l i f e i n the outside community. Whittaker (1979) states the goal of r e s i d e n t i a l treatment to be "education f o r l i v i n g . " Bettleheim (1974) defines the goal of treatment to be " s e l f esteem" for the c l i e n t , and that a pr e r e q u i s i t e to t h i s i s for the c l i e n t to be backed i n h i s attempts to form s a t i s f y i n g human r e l a t i o n s h i p s , and gain "mastery over inner and outer f o r c e s . " The m i l i e u must, therefore, be structured so that the c l i e n t can master i t , be competent i n i t , and thereby l e a r n the tools to master the r e a l i t y of society. The goals of r e s i d e n t i a l treatment are also often stated i n terms of ego strength. Some of the s p e c i f i c ego strengths that are mentioned again and again are impulse c o n t r o l , the a b i l -i t y to cope with emotions p o s i t i v e l y , the a b i l i t y to see r e a l i t y without projection or d i s t o r t i o n , and the a b i l i t y to form t r u s t i n g r e l a t i o n s h i p s with others. The R e s i d e n t i a l Treatment of Adolescents How i s the r e s i d e n t i a l treatment of adolescents d i f f e r e n t from the r e s i d e n t i a l treatment of ch i l d r e n and adults? What are the s p e c i a l needs of adolescents to which such treatment must respond? The adolescent c l i e n t i s i n a t r a n s i t i o n a l stage of l i f e psycho-16 l o g i c a l l y , p s y s i o l o g i c a l l y and s o c i a l l y . The issues and objectives of therapy w i l l n a t u r a l l y r e f l e c t the themes and tasks of these years. Tanner (1962) and Young (1971) have reviewed the p h y s i c a l changes associated with puberty. Cognitive changes emerge i n the form of what Piaget c a l l e d the beginning of formal operational thinking (Elkind, 1968). Here chil d r e n become incr e a s i n g l y able to generate and explore hypotheses, make deductions and derive higher l e v e l abstractions. They now have an awareness of how things might be as opposed to how they are, and t h i s becomes increas-in g l y s i g n i f i c a n t i n the formation of t h e i r s e l f concept. Erikson (1965) described adolescence as the period i n which the main psychological task i s to e s t a b l i s h a personal i d e n t i t y , and t h i s i s t i e d to separating from parents. It i s possible to view a l l adolescent problems as b a s i c a l l y those of separation-individuation (Masterson, 1971). Bios (1970) speaks of adoles-cence as "a second stage i n i n d i v i d u a t i o n " , the f i r s t one having occurred toward the end of the second year when the c h i l d experiences the d i s t i n c t i o n between " s e l f " and "non-self". The leaving of elementary school for high school also underlines a new s o c i a l r o l e , one i n which performance and peer approval becomes incr e a s i n g l y important. In summary, the tasks of adolescence, as defined by Shields (1973) are: (1) the establishment of healthy sexuality; (2) the achievement of adult intimate r e l a t i o n s h i p s ; and (3) a firm sense of s e l f and independence. When does the adolescent require r e s i d e n t i a l treatment? Easson (1969) states that only when the disturbed adolescent shows "a profound d e f i c i t i n ego strength", therefore not being able to handle h i s inner drives, and a " d e f i c i t i n r e l a t i o n s h i p a b i l i t y " , therefore not being able to form meaningful, stable r e l a t i o n s h i p s to use as a support system, should the adolescent be admitted to residence. In r e s i d e n t i a l treatment, the adolescent receives the maximal environmental support and c o n t r o l as he 17 reveals h i s problematic behaviour patterns and i s taught new methods of coping. The treatment goals, then, that e s p e c i a l l y r e l a t e to the adolescent c l i e n t are: 1. Promoting an understanding of, and a b i l i t y to cope with, emerging sexuality. 2. Improving s o c i a l s k i l l s and the a b i l i t y to form peer r e l a t i o n s h i p s and re l a t i o n s h i p s with adults. 3. Increasing s e l f esteem by teaching new coping s k i l l s through graded tasks, duties and r e s p o n s i b i l i t i e s . 4. Helping the adolescent separate from h i s family and become independent; aiding the emancipatory process. 5. Reinforcing of any i n d i v i d u a l strengths and confidence the c l i e n t possesses by making the c l i e n t ' s behaviour his r e s p o n s i b i l i t y and struggle (Easson, 1969). Easson (1969) states that the t o t a l treatment program for the disturbed adolescent must be geared towards promoting " t r u s t , self-awareness, s e l f -c o n t r o l , and self-confidence." The implications for the implementation of treatment are many. Meeks (1975) states that adequate treatment of many adolescent problems requires "the f l e x i b l e a p p l i c a t i o n of a v a r i e t y of approaches," which are designed to match the i n d i v i d u a l ' s needs and a b i l i t i e s . This requires consistency i n approach and p a r t i c u l a r l y close c o l l a b o r a t i o n and communication between therapists, what Bettleheim (1948) c a l l s an "inner cohesiveness" or the necessary i n t e g r a t i o n of co n t r o l , support, d i r e c t i o n and g r a t i f i c a t i o n for each c l i e n t . Most r e s i d e n t i a l treatment f a c i l i t i e s f o r adolescents recognize a 18 p a r t i c u l a r need to develop a "protherapy" group culture among the adoles-cents who tend to be p a r t i c u l a r l y peer orientated, as well as an e s p e c i a l l y c l e a r system of l i m i t a t i o n s and p r i v i l e g e s designed to c o n t r o l the adoles-cent tendency to l i v e out problems rather than discuss them (Holmes, 1964). Easson (1969) emphasizes that these controls must be "human based", happening i n the context of a therapeutic r e l a t i o n s h i p . Most programs also recognize the importance of parental involvement, and o f f e r parents groups and family therapy as a part of t h e i r program. Forming a r e l a t i o n s h i p with an adolescent c l i e n t i s a d i f f e r e n t pro-cess from engaging a c h i l d or adult c l i e n t . The therapist may be seen as a authority f i g u r e , or a surrogate parent. Interpretation and i n s i g h t may not be relevant or acceptable to the c l i e n t , and the main influence that the therapist has on the c l i e n t may be that of a healthy r o l e model. Easson talks of "acceptance and a l l i a n c e " as the key words i n the therapeutic r e l a t i o n s h i p between s t a f f and c l i e n t . The treatment team has "to be r e s -pected as secure, meaningful, dependable adults who can then be used as consistent i d e n t i f i c a t i o n models" (p. 71). Authors such as Easson also t a l k of the need for space and safety i n the environment f o r the adolescent to express himself and h i s f e e l i n g s , and to take a more and more responsible r o l e i n h i s own treatment, and i n the community i n general. The c l i e n t has to be allowed to move from dependence to independence. Many authors emphasize the need for c l a r i t y and consistency i n d a i l y routines and expectations, since the adolescent w i l l need to t e s t and r e t e s t these structures to discover i f they are c e r t a i n and dependable. Acceptable and unacceptable patterns of i n t e r a c t i n g must be d e f i n i t e l y delineated, the focus of treatment being the day to day l i v i n g and the problem of coping with t h i s present r e a l i t y . 19 The use of various treatment modalities must be adapted to the needs and l i m i t s of the adolescent Most disturbed adolescents, as Easson points out, f i n d close r e l a t i o n s h i p s very threatening and do not have the ego strength necessary to benefit from a c l a s s i c a l uncovering a n a l y t i c psycho-therapy process. Instead, the need i s to strengthen the emotional defenses the c l i e n t already has, while attempting to make h i s reaction patterns l e s s maladaptive. Often the use of group counselling, i f a pro-treatment culture can be created, i s one of the more acceptable treatment modalities for the adolescent c l i e n t . The Evaluation of Res i d e n t i a l Treatment Numerous serious methodological problems plague research i n t h i s area. C r i t e r i a for diagnosis, treatment and outcome are not s u f f i c i e n t l y well defined f o r research purposes, and the intervening v a r i a b l e s make con-t r o l l e d studies v i r t u a l l y impossible. C l i e n t groups also tend to be small and heterogeneous so i t becomes d i f f i c u l t to compare them. Many studies are conducted without benefit of controls, so although a change i n the dependent va r i a b l e may occur, the precise nature of independent v a r i a b l e s responsible for the change cannot be s p e c i f i e d . The importance of evaluation i s emphasized f i r s t l y by the powerful nature of r e s i d e n t i a l treatment which may a c t u a l l y be harmful to the disturbed c l i e n t . Easson stresses t h i s point by sta t i n g that the firm external imposition of such st r u c t u r i n g as occurs i n the r e s i d e n t i a l s e t t i n g can act d i r e c t l y counter to the adolescent emancipation-individuation process... and perpetuate emotional dependence... (p. 6). The f i r s t e f f e c t of admission, i n f a c t , i s usually to further undermine the teenager's emotional competence since i t can be seen as a judgement by society and family. In t h i s case the adolescent may see admission to residence as a confirmation of h i s "craziness" or "badness". Writers such as Goffman (1961) 20 have also s p e c i f i e d the dangers of i n s t i t u t i o n a l l i f e , such as depersonal-i z a t i o n and iatrogenic disturbance (where disturbance i s an adaption to the culture of the h o s p i t a l ) , and these dangers could be seen as even more c r i t i c a l i n r e l a t i o n to adolescent c l i e n t s . The report, "Children i n Residential Care," (1971) states that often there i s a lack of continuity of care, such as l i t t l e s p e c i f i c discharge planning, and thus there i s a danger that the c h i l d w i l l adapt to the needs of the i n s t i t u t i o n while t i e s i n the outside community are allowed to wither. This then r e s u l t s i n a traumatic separation at discharge and the creation, since the c l i e n t has great d i f f i c u l t y adapting now to the general community, of another f a i l u r e experience. This danger i s increased further i f the values and expectations of the r e s i d e n t i a l unit deviate dramatically from those of society i n general or the c l i e n t ' s family i n p a r t i c u l a r . The second factor that emphasizes the importance of evaluation i s the complexity and expensive nature of r e s i d e n t i a l treatment. "The Children i n Canada, Res i d e n t i a l Care Report" (1971) makes the point that r e s i d e n t i a l programs are c a n n i b a l i s t i c of scarce professional s t a f f , e s p e c i a l l y since they give great amounts of time and energy to very small numbers of i n d i v i d -uals. In 1978/79 the cost of keeping a c l i e n t at Easton, the unit that i s the subject of t h i s study, was approximately one hundred and twenty-five d o l l a r s per day. Such questions as the effectiveness of treatment as a whole, the d i f f e r e n t i a l e f f e c t s (what works best, when, and for whom), and the trans-f e r a b i l i t y of learning to the outside environment, are therefore very p e r t i n -ent. The question of t r a n s f e r a b i l i t y i s p a r t i c u l a r l y so, since studies such as the " B e l l e f a i r e Follow-up Study" (Allerhand et a l , 1966) and the Taylor and Alpert study (1973) suggest that p o s i t i v e adaption to the i n s t i t u t i o n does not forecast adequacy i n the post-treatment environment. 21 Durkin and Durkin (1975) i d e n t i f y four d i f f e r e n t types of research i n t h i s area: d e s c r i p t i v e studies; follow-up and outcome studies; process evaluations; and system analyses. Of the d e s c r i p t i v e studies that have been done, most are extremely subjective. For example, Easson's "impressions" (1969) that four out of f i v e severely neurotic teenagers at the Menninger Foundation grow i n the treatment process to "some l e v e l of acceptable s o c i a l adaptation." The c l e a r e s t point i n h i s evaluation i s the judgement, shared by other c l i n i c i a n s , that the more psychotic the c l i e n t ' s behaviour pattern, the worse the prognosis. Redl and Wineman (1952) attempted a follow-up study of the c l i e n t s who were i n treatment at Pioneer House, but again there i s a lack of empirical data. He states only that he observed a diminution of major symptomatology and an increased a b i l i t y to r e l a t e to adults and cope with r u l e s , i n the eight months following the c l o s i n g of the school. However, he also states that many c l i e n t s l a t e r regressed, but suggests that t h i s may be the r e s u l t of re-exposure to traumatic l i f e s i t u a t i o n s . Most follow-up studies display the methodological problems common to t h i s area. T r e f f e r t (1969) estimated that forty-eight percent of the c l i e n t s admitted improved. However, i t i s not clear how much of t h i s improvement was due to treatment, and how much due to maturation, spontaneous recovery or other f a c t o r s . It i s also not clear i n t h i s study exactly what "treatment" consisted of. The main conclusion drawn from studies of t h i s type seem to be that poor outcome i s associated with a psychotic diagnosis, the early onset of problems (King, 1970) or low I.Q. (Levy, 1969). Not s u r p r i s i n g l y , h e a l t h i e r c l i e n t s do better a f t e r discharge. Most follow-up studies also emphasize the c r u c i a l importance of after-care and discharge planning (Mora et a l . , 1969). In general, outcome or follow-up studies, as Durkin and Durkin (1975) point out, usually disregard the intramural functioning 22 of the program, provide very delayed feedback, do not delineate the r e l a t i v e contributions of the various components of the program, and do not d i f f e r -entiate between formal and informal, or unrecognized goals. An example of process evaluation i s the book, "A M i l i e u Therapy Program for Behaviourally Disturbed Children" (Monkman, 1972). Here a thor-ough going a p p l i c a t i o n of behaviourist p r i n c i p l e s lead to meaningful compar-isons over time of behaviour c h e c k l i s t s , punishment records, a d a i l y mark sheet and samples of the c l i e n t ' s behaviour. This kind of process evalu-ation would only be possible, however, i n a centre organized on behaviourist p r i n c i p l e s , and does not address i t s e l f to long term outcome. One of the newest approaches to evaluating such treatment programs i s goal attainment s c a l i n g . Austin (1976) used t h i s approach to compare two day h o s p i t a l s , one using behaviour therapy and one implementing m i l i e u therapy based on group i n t e r a c t i o n . The subjects were randomly d i s t r i b u t e d to treatment u n i t s . In a s i x month follow-up, s i g n i f i c a n t l y more subjects who had received the behavioural therapy had attained t h e i r treatment goals (93% versus 79%). Another goal attainment study by Goldenburg (1971) analyzed changes i n a t t i t u d e (such as a l i e n a t i o n , authoritarianism, t r u s t for others, and positiveness of world view) and changes i n arrests and work performance of an experimental group of delinquent boys i n r e s i d e n t i a l treatment and a control group. Pre and post measure of a t t i t u d e s and behaviour were taken. Randomization was not possible, but the most d i f f i c u l t twenty-five boys were taken into the experimental group, and the next most d i f f i c u l t were taken into the control group. This sampling poses obvious problems. The r e s u l t s , favouring s i g n i f i c a n t l y the experimental group, may have been the r e s u l t of a Hawthorne e f f e c t or a regression-from-the-mean phenomenon (the most troublesome boys could only improve). The authors did r e l a t e a t t i t u -d i n a l measures to behavioural ones however. This approach to evaluation 23 seems to have considerable p o t e n t i a l , as well as problems. The l a s t type of evaluation i s the analysis of the r e s i d e n t i a l centre as a s o c i a l system. System analyses are evaluative i n the sense that they examine functional and dysfunctional aspects of programs. The Polsky and C l a s t e r study (1968) i s such a study. In t h i s study, the authors use the concept of r o l e to examine s t a f f and peer group structures, and to analyze the s o c i a l and c u l t u r a l processes i n r e s i d e n t i a l treatment cottages. Unfortunately, the lack of r e l i a b i l i t y i n the c o l l e c t i n g of the data mars the study. Henry (1957) employs a systems approach to contrast two types of s o c i a l structures c h a r a c t e r i s t i c of r e s i d e n t i a l treatment centres. He con-t r a s t s the structure c h a r a c t e r i s t i c of the Sonia Shankman Orthogenic School with a more t r a d i t i o n a l p s y c h i a t r i c model. The Orthogenic School i s seen as an example of simple, u n d i f f e r e n t i a t e d subordination. There i s one d i r e c t o r with a s t a f f that i s responsible for a l l phases of the operation. The s t a f f are responsible for the c h i l d care and i n d i v i d u a l psychotherapy, and have an intense involvement i n a l l phases of the c h i l d ' s l i f e . Contrasted with t h i s i s a system of multiple d i f f e r e n t i a t e d subordination. In t h i s system, thera-peutic tasks are broken down into c h i l d care custodians, teachers, t h e r a p i s t s , r e c r e a t i o n a l s t a f f , and so on. Henry suggests the f i r s t model i s much more e f f i c i e n t i n achieving the organizational goals of r e s i d e n t i a l treatment. P i l i v i a n (1963) examined the r e l a t i o n s h i p s between c h i l d care s t a f f who were given the r o l e of " r a i s i n g " the c l i e n t s , and caseworkers who were " t r e a t i n g " the c l i e n t s , and suggested that the i n t e g r a t i o n of such functions was c r u c i a l . There are also many studies which attempt to examine the i n t e r -relationship between process variables i n mental h o s p i t a l s and r e s i d e n t i a l treatment s e t t i n g s . These variables are usually grouped under the heading "environment" (Jackson, 1964; Moos, 1974; Rice et a l . , 1963; Ellsworth et a l . , 1969). These studies ask questions such as: Which s e t t i n g c h a r a c t e r i s t i c s 24 r e l a t e to which indices of treatment outcome? or What type of m i l i e u program i s best for what type of patient? Moos (1972), for example, found large s i z e was associated with low scores on such factors as Spontaneity, Personal Problem Orientation and Anger shown i n the environment, and high scores i n Staff Control as perceived by patients. Moos (1974) also found a c o r r e l a t i o n between high dropout rates i n a p s y c h i a t r i c h o s p i t a l program, and factors s.uch as low Involvement Support, Order and Organization, and Program C l a r i t y . Wards that were successful at keeping patients out of the h o s p i t a l emphasized Autonomy, P r a c t i c a l Orientation, Order and Organization, and a reasonable degree of S t a f f Control. Durkin and Durkin (1975) emphasize the v i r t u e s of t h i s l a s t model of evaluation i n r e s i d e n t i a l treatment over the other models mentioned. They suggest examining goals i n r e l a t i o n to inputs, sub and supra systems, and the functional processes of residence such as communication patterns, account-a b i l i t y , decision-making, coordination, and s t a f f support. Outcome v a r i a b l e s can then be re l a t e d to i n s t i t u t i o n a l c h a r a c t e r i s t i c s and processes which are amenable to change, such as the composition of s t a f f . The evaluation of r e s i d e n t i a l treatment remains, however, a d i f f i c u l t but i n c r e a s i n g l y necessary task. Section 2 — Role of S t a f f Cohesion i n Residential Treatment This section consists of a discussion of the s i g n i f i c a n c e of s t a f f r e l a t i o n s h i p s i n r e s i d e n t i a l treatment, and the perspective of the Easton r e s i d e n t i a l centre concerning t h i s v a r i a b l e . A general discussion of the group cohesion concept i s then followed by a statement of hypotheses. In the l i t e r a t u r e of r e s i d e n t i a l treatment the s i g n i f i c a n c e of the q u a l i t y of the m i l i e u i s emphasized continually. Moos (1974) makes the point that, . 25 various authors have d i f f e r e d i n t h e i r f e e l i n g s about the effectiveness of p s y c h i a t r i c treatment, but they a l l agree on one point: that the immediate psychosocial environment i n which patients function determines t h e i r a t t i t u d e s , behaviour, and symptoms, and that t h i s environment can be the most c r i t i c a l factor i n determining the outcome of the treatment, (p. 8) The Sig n i f i c a n c e of Staff Relationships What are the factors that f a c i l i t a t e the creation of an e f f e c t i v e therapeutic milieu? The consensus appears to be that the main factor here i s the r e s i d e n t i a l s t a f f , t h e i r i n d i v i d u a l c h a r a c t e r i s t i c s , and how that s t a f f operates as a group. The s t a f f must form a cohesive team i f they are to create an e f f e c t i v e treatment environment. Staton and Schwartz (1954) c l e a r l y i l l u s -t r a t e the r e l a t i o n s h i p between c l i e n t symptoms and the s o c i a l environment, s p e c i f i c a l l y between the c o l l e c t i v e disturbance of a p s y c h i a t r i c ward and low s t a f f morale occuring as a r e s u l t of c o n f l i c t and lack of communication. Matsishima (1972) states, any c o l l e c t i o n of i n d i v i d u a l s l i v i n g together develops r e l a t i o n s h i p s of influence toward one another, cliques spring into being, unstated expectations of sanctioned and unsanctioned behaviour a r i s e , subtle power r e l a t i o n -ships become apparent, a l l quite apart from the formal i n s t i t u t i o n a l organization, functioning for or against i t s treatment purposes. The s t a f f i s part of t h i s net-work of r e l a t i o n s h i p s , so that tensions i n one element i n e v i t a b l y a f f e c t the others. (p. 17.6). Wessen (1961) also stresses that s t a f f c o n f l i c t undermines treatment goals, where misperceptions, disagreement and c o n f l i c t about authority r e l a t i o n s among s t a f f create b a r r i e r s to communication and a u t i s t i c h o s t i l i t y , the t o t a l amount of s t a f f time and energy a l l o c a t e d to maintenance or the s o l u t i o n of the expressive-integrative problem of the system w i l l be disproportionately large, and r e l a t i v e l y l i t t l e s t a f f time and energy w i l l be a v a i l -able for accomplishment (p. 42). The l i t e r a t u r e further emphasizes the necessity of an integrated team approach to treatment so that a health promoting consistent culture 26 or network of norms and values w i l l form the basis for a therapeutic culture set up among the c l i e n t peer group. Weber (1972) emphasizes that adolescents i n p a r t i c u l a r , know about c o n f l i c t and inconsistency i n t h e i r homes, and develop devious means of s a t i s f y i n g t h e i r needs. They evaluate s o c i a l s i t u a t i o n s very well and e x p l o i t and manipulate any weak-ness i n the s t a f f group (p. 283). To create a therapeutic culture, capable of dealing with such adolescents requires "consensus" and "cooperation" (Dean, 1976) . The l i t e r a t u r e also emphasizes the importance of the s t a f f as r o l e models for the c l i e n t s , modelling e f f e c t i v e p o s i t i v e ways of i n t e r a c t i n g with others. Dean states that the therapeutic s o c i a l system teaches r e l a t i o n s h i p s k i l l s by making a wide v a r i e t y of r e l a t i o n s h i p s a v a i l a b l e , and by examining the processes of the r e l a t i o n s h i p s as they take place. Also that the q u a l i t y of the interpersonal r e l a t i o n s h i p s among s t a f f shapes the work output by influencing the process of communication and i n d i v i d u a l commitment to the task. Maxwell Jones (1968) stresses that i n a therapeutic community, open communication, feedback and free expression of f e e l i n g i n the s t a f f group i s a p r e r e q u i s i t e to the creation of a therapeutic community cons i s t i n g of c l i e n t s and s t a f f . This p a r a l l e l s Bettleheim's concept (1974) of s t a f f s o l i d a r i t y , which he sees as e s s e n t i a l to provide the s t a f f with the reassurance and security necessary to cope with the personal r i s k s and s t r a i n s involved i n t h e i r r o l e . He also emphasizes that the s t a f f group must have a common com-mittment to a clear treatment philosophy. His concept of i n t e g r a t i o n perhaps sums up hi s view of the s i g n i f i c a n c e of s t a f f i n t e r a c t i o n i n r e s i d e n t i a l treatment. He sees inner i n t e g r a t i o n as the goal of therapy, the achieve-ment of t h i s goal being dependent i n turn on the i n t e g r a t i o n of a l l features of :the environment, routines, groups, r u l e s , etc., which i s i n turn dependent on the inner i n t e g r a t i o n of the s t a f f themselves, and t h e i r i n t e g r a t i o n into 27 a supportive s t a f f team. He states, a therapeutic m i l i e u must provide the r i g h t emotional climate for i t s patients so that they can regain mental health. I t w i l l succeed i n doing t h i s to the extent that i t i s able to create a human and s o c i a l environ-ment which promotes the s o c i a l s o l i d a r i t y of the s t a f f (p. 320). Staff Relationships at Easton This concept that s t a f f i n t e r a c t i o n and teamwork i s one of the most i f not the most s i g n i f i c a n t b u i l d i n g block i n the implementation of residen-t i a l treatment i s a clear and generally accepted assumption at Easton, the r e s i d e n t i a l treatment centre described i n t h i s study. A close and supportive s t a f f group has always, since the units inception, been seen as a p r e r e q u i s i t e for the creation of the desired therapeutic community. The assumption i s that only when a s t a f f has close, open, and p o s i t i v e r e l a t i o n s h i p s with h i s peers w i l l he then be secure and confident enough to be honest, authentic and com-municative with residents. In the unit's early years, t h i s b e l i e f i n the importance of the rel a t i o n s h i p s between s t a f f was r e f l e c t e d i n the emphasis placed on s t a f f "process", which i s the ongoing examination of f e e l i n g s , r e l a t i o n s h i p s , and int e r a c t i o n s between s t a f f as they are i n the process of developing. This p r i o r i t y was r e f l e c t e d i n the content of t r a i n i n g days and marathon group sessions. Here the s t a f f engaged i n extensive s e n s i t i v i t y t r a i n i n g , encounter groups, and general group therapy techniques as suggested by Polsky and Claster (1968). For the l a s t few years, the value placed on s t a f f r e l a t i o n s h i p s has been further formalized i n that the f i r s t half of the d a i l y cottage s h i f t change meeting i s set aside f o r such "process". During t h i s time, the focus i s on " f e e l i n g s " rather than "business" or "issues", that i s , on c l a r i f y i n g 28 the r e l a t i o n s h i p s and i n t e r a c t i o n patterns between s t a f f and s t a f f , s t a f f and c l i e n t s , and s t a f f and job expectations or tensions. A f a m i l i a r pattern i s to discuss the events of the day and t h e i r e f f e c t on the s h i f t team, also to give resentments, appreciations and demands to other members of the team. Staff may share t h e i r personal f e e l i n g state, and examine how t h i s i s l i k e l y to a f f e c t t h e i r i n t e r a c t i o n with s t a f f and c l i e n t s at t h i s p a r t i c u l a r time. C o n f l i c t around treatment issues i s also examined. The goals here are to pro-mote the personal and professional growth of s t a f f and to create a cohesive and supportive s t a f f team. The assumption i s that t h i s w i l l then f a c i l i t a t e the completion of tasks and enable the counsellors to r e l a t e c o n s i s t e n t l y and a u t h e n t i c a l l y with t h e i r c l i e n t s , thus creating a healing culture i n the cot-tages. If the exposure and r e s o l u t i o n of tension and c o n f l i c t i s the basic dynamic i n a therapeutic community, then t h i s process must l o g i c a l l y begin with the s t a f f group. To summarize, one of the chief assumptions a f f e c t i n g the implementation of r e s i d e n t i a l treatment at Easton i s that the cohesiveness of the s t a f f group exerts a powerful influence on the treatment environment, and thus on c l i e n t behaviour and treatment outcome. F r i t z Redl (1959) has stated that an exam-in a t i o n of the impact of v a r i a b l e s , assumed to be c r i t i c a l i n r e s i d e n t i a l treatment, i s an "urgent job". In order to further examine the s i g n i f i c a n c e of the v a r i a b l e , s t a f f cohesion, i t i s necessary to further define and examine t h i s concept. The Concept of Cohesiveness: Some D e f i n i t i o n s A number of authors have emphasized the t h e o r e t i c a l and p r a c t i c a l importance of the concept of group cohesion. For example, Golembiewski (1962); states, 29 The concept of cohesiveness occupies a p a r t i c u l a r l y prominent place i n small group a n a l y s i s . This pro-minence i s a r e s u l t of several contributing f a c t o r s , t h e o r e t i c a l , experimental, and p r a c t i c a l . T h e o r e t i c a l l y , cohesiveness i s the e s s e n t i a l small-group c h a r a c t e r i s t i c . This "stick-togetherness" or member a t t r a c t i o n at once characterizes a small group and d i f f e r e n t i a t e s i t from other s o c i a l u n i t s . Further, cohesiveness can be induced i n laboratory s i t u a t i o n s by straightforward means. Moreover, early small group studies of pr o d u c t i v i t y and opinion formation demonstrated the importance of the con-cept. The simultaneous impact of these factors led to the frequent use of the concept, to i t s conceptual and operational development and to a growing l i t e r a t u r e . In a r e a l sense then, the study of cohesiveness i s small group analysis at i t s best (pp. 149-50). What, then, i s group cohesion? Seashore (1954) makes the point that i n common parlance the term encompasses such ideas as "group pride", "group s o l i d a r i t y " , "group l o y a l t y " , " i n t e g r a t i o n " , "team s p i r i t " , and "teamwork". Several operational d e f i n i t i o n s have been used, such as the r e l a t i v e frequency of friendship choices within and outside the group, the frequency of "we" versus " I " references i n conversation, the degree to which norms are shared, the strength of desire to continue r e l a t i o n s as a group, and the perception of the group as being better than others i n various respects. Cartwright and Zander (1960) d i s t i n g u i s h three d i f f e r e n t commonly used meanings of the term: a t t r a c t i o n to the group, including resistance to leaving i t ; morale, or the l e v e l of motivation of the members to attack t h e i r tasks with zeal; and, the coordination of the e f f o r t s of members. For the purposes of t h i s study, group cohesiveness i s defined as a t t r a c t i o n to the group and resistance to leaving, and t h i s i s the most common d e f i n i t i o n used i n recent research studies. There have been several attempts to further delineate t h i s a t t r a c t i o n to group. Mikalachki (1969) i n hi s study defined group attractiveness as consisting of members' i d e n t i f i c a t i o n with t h e i r group; members' p o s i t i v e evaluation of t h e i r group as compared to others; high within group friendship choices; few expressions of open c o n f l i c t or antagonisms among members; and 30 r e f u s a l s of transfers to other groups. Golembiewski (1962) states that i n d i v i d u a l s ' attraction-to-group i s a function of two classes of f a c t o r s : group properties and the properties of group members, such as the motivational states of the persons involved, which are a function of personal needs and c h a r a c t e r i s t i c s . Newcomb (1960) divided interpersonal a t t r a c t i o n into f i v e subclasses: respect, admiration, r e c i p r o c a t i o n (judged f a v o r a b i l i t y of another toward s e l f ) , r o l e support, and value support. Of these, a combination of the l a s t three forms of a t t r a c t i o n was found to be the most stable. Mikalachki (1969) also s p e c i f i e d some of the behaviours and f e e l i n g s c h a r a c t e r i s t i c of the highly cohesive groups i n h i s study. The d e f i n i t i o n of cohesion was, as above, a t t r a c t i o n to group. He found that the high cohesive group members joined i n more voluntary j o i n t a c t i v i t i e s , were distinguished by t h e i r cooperative behaviour, lack of i n t e r a c t i o n a l sub-grouping, and a s t a b i l i t y of i n t e r a c t i o n a l patterns when newcomers entered the group, as well as more e g a l i t a r i a n mode of i n t e r a c t i n g . Conditions F a c i l i t a t i n g Group Cohesion The f i r s t condition that has been noted as l i k e l y to f a c i l i t a t e high l e v e l s of cohesion i s the opportunity f o r i n t e r a c t i o n . Homans (1950) contends that a high frequency of i n t e r a c t i o n between i n d i v i d u a l s w i l l r e s u l t i n a high degree of a t t r a c t i o n or p o s i t i v e sentiments between these i n d i v i d u a l s . I t seems self-evident that the rewards and deprivations associated with group membership are determined and r e a l i s e d through i n t e r a c t i o n . For example, consensual v a l i d a t i o n of attitudes occurs through i n t e r a c t i o n . Studies have also generally shown that i n t e r a c t i o n i s more equal and more intense i n highly cohesive groups. Certain kinds of s i m i l a r i t y among members may also strengthen the cohesiveness of a group. In an experimental study, Zander and Havelin (1960) 31 observed that persons preferred to associate with those close to them i n a b i l i t y . The r e s u l t of the tendency f o r l i k e to j o i n l i k e i n group a s s o c i -ation, as Cartwright (1960) points out, i s an eventual increase i n s i m i l a r i t y among members. Deutsch (1960) i n h i s study found that a s i t u a t i o n i n which group members are i n a cooperative r e l a t i o n s h i p i s more a t t r a c t i v e than one i n which they are competing. Raven and Rietsema (1957) reveal that a member i s more strongly attracted to his group when he i s clear as to the goal of the group, and the path i t i s following toward the goal, as well as how h i s own task f i t s into the goal and path, than when he i s not clear about these matters. Mikalachki (1969) suggests that interdependent rol e s and a climate of concern for each other foster high cohesion. He also adds that a high degree of i d e n t i f i c a t i o n with formal group goals, as well as a high degree of success i n a t t a i n i n g these goals, f a c i l i t a t e s cohesion. The absence of the l a s t two conditions concerning goals tends to s h i f t a cohesive group from a task o r i e n -t a t i o n to a s o c i a l one. Cartwright and Zander (1960) also emphasize success i n goal attainment as a factor which increases cohesion, suggesting that t h i s r e s u l t s from the r e a l i z a t i o n that membership i n the group enhances personal prestige. When a group i s attacked, an increase of cohesiveness can occur, i f the group i s seen to be a source of se c u r i t y . Cartwright and Zander (1960) sum up the conditions which f a c i l i t a t e cohesion thus, the attractiveness of a group may be increased by making i t better serve the needs of people. A group w i l l be more a t t r a c t i v e the more i t provides status and recognition, the more cooperative the r e l a t i o n s , the freer the i n t e r a c t i o n , and the greater security i t provides f o r members (p. 83). The main condition Cartwright and Zander i d e n t i f y as damaging to cohesion i s members' disagreement over the way to solve a problem. 32 Consequences of Group Cohesion Back (1951) attempted to answer the question, Does the source of a t t r a c t i o n create d i f f e r e n t i a l effects? In h i s study, groups were established on three bases: personal a t t r a c t i o n , task a t t r a c t i o n , and possible prestige gains from membership. The conclusions were that the s t y l e of communication and influence was d i f f e r e n t for each source of a t t r a c t i o n , but a s i m i l a r increase of a t t r a c t i o n on each of the bases led to a s i m i l a r increase i n the power of the group to influence i t s members. With respect to power to influence, then, i t appears probable that d i f f e r e n t sources of a t t r a c t i o n have the same e f f e c t . This power of the group to influence i t s members, or members' willingness to accept influence, has been i d e n t i f i e d as one of the main r e s u l t s of group cohesion. Cartwright and Zander (1960) state that the power of a group over i t s members i s proportional to the cohesiveness of that group, and that pressures toward uniformity are stronger i n a more cohesive group because of the value attached to the group. Schachter (1951) also found that members of a cohesive group more r e a d i l y t r y to influence others, perhaps because members who are strongly attracted to a group place greater value on the group goals, and ad-here more c l o s e l y to ; the group's standards. In summary, the research suggests that i n a highly cohesive group there i s more interpersonal influence and, thus, usually a greater s i m i l a r i t y i n values and conformity i n behaviour (Lott, and L o t t , 1961). Another consequence of high cohesion that has been i d e n t i f i e d i s a lack of anxiety, or sense of security among members. Seashore (1954) suggests that t h i s a r i s e s because being an accepted member of such a group gives the i n d i v i d u a l added control over his environment and a defense against any threat a r i s i n g i n h i s environment. In addition to t h i s support, the d i r e c t s a t i s -f a c t i o n of being a member of a cohesive group can also be surmised to be 33 anxiety reducing. Mikalachki (1969) suggests that the tension character-i s t i c of uncohesive groups i s a r e s u l t of the disconcerting interpersonal r e l a t i o n s found i n such a group. The main thrust of research concerning the consequences of group cohesion, however, has been towards the r e l a t i o n s h i p between t h i s v a r i a b l e and p r o d u c t i v i t y or goal attainment. The r e l a t i o n s h i p between these two v a r i -ables has been shown to be a complex one. Seashore (1954) found that highly cohesive groups show les s v a r i a t i o n i n p r o d u c t i v i t y (more e f f e c t i v e group standards), but the d i r e c t i o n of p r o d u c i t v i t y , up or down, depends on the norms of the group which are influenced by the support and reward structure set up by the larger organization. Shaw (1976) states that, i t seems evident that the empirical data supports the hypothesis that high-cohesive groups are more e f f e c t i v e than low-cohesive groups i n achieving t h e i r goals. The cohesive group does whatever i t t r i e s to do better than the noncohesive group (p. 207). Thus, i f the cohesive group's p r i o r i t y i s production, then i t tends to be more e f f i c i e n t , but i f , for example, s o c i a l i n t e r a c t i o n i s the p r i o r i t y , then t h i s may c o n f l i c t with task orientated production goals. There i s also evidence that the members of highly cohesive groups more often take on r e s p o n s i b i l i t i e s f or the organization, p a r t i c i p a t e more r e a d i l y i n meetings (Back, 1951), p e r s i s t longer i n working towards d i f f i c u l t goals (Horwitz, 1953), attend meetings more f a i t h f u l l y (Libo, 1953), and remain members longer (Sagi et a l . , 1955). Also, because there i s a higher degree of interpersonal influence i n a cohesive group, i f the group attempts to influence i t s members towards increased pro-duction, a cohesive group should be more successful i n t h i s respect (Berkowitz, 1954). There has been no d i r e c t study examining the " p r o d u c t i v i t y " or success of r e s i d e n t i a l treatment units i n r e l a t i o n to group cohesion. However, some research has been done on the d e s i r a b i l i t y of cohesion i n therapy groups. 34 Truax (1961) found s i g n i f i c a n t r e l a t i o n s h i p s between group cohesiveness and both the degree of patient s e l f - e x p l o r a t i o n and the degree of patient i n s i g h t . Bettleheim (1974) sees both s e l f - e x p l o r a t i o n and i n s i g h t into s e l f as necessary processes for r e s i d e n t i a l treatment s t a f f . The research of Truax suggests that t h i s process w i l l be more e f f e c t i v e i n a highly cohesive s t a f f group. Yalom (1975) states, "Members of cohesive groups are more accepting of one another, more supportive, and more i n c l i n e d to form meaningful r e l a t i o n s h i p s i n the group!' (p. 67). This would suggest that members of a cohesive s t a f f team would be more therapeutic as r o l e models than members of a le s s cohesive s t a f f team. The Measurement of Group Cohesion One very prevalent method i s to use a sociometric status measurement. The main objections here are that such an instrument measures only each i n d i v i d u a l ' s a t t r a c t i o n to the group, one part of the group, and the precise r e l a t i o n to the cohesiveness of a t o t a l group i s unclear, and that such i n s t r u -ments are often d i f f i c u l t to i n t e r p r e t (Golembiewski, 1962) . A second kind of measure i s an operational measure sometimes c a l l e d a "locomotion measure". Libo (1953), for example, allowed people to vote with t h e i r feet concerning the attractiveness of t h e i r group. His subjects were given a choice: they could enter one door and thus remain i n the group; or enter another and leave. Libo also devised a p r o j e c t i v e t e s t , a Group Picture Impressions Test, which correlated s i g n i f i c a n t l y with the locomotion measure. A t h i r d kind of measure i s a questionnaire, perhaps c o n s i s t i n g of only one question, Do you wish to remain i n t h i s group? or a scale, such as the Seashore Cohesion Index (1954) which was the instrument used i n t h i s study and which w i l l be discussed i n the next chapter. 35 Summary Cartwright and Zander (1960) state that "the t h e o r e t i c a l and p r a c t i c a l importance of cohesiveness as a determinant of other group properties i s now well established" (p. 91). I t seems then an e s p e c i a l l y s i g n i f i c a n t v a r i a b l e to examine i n a m i l i e u such as a r e s i d e n t i a l treatment centre, which purports to be a therapeutic community, where the group r e l a t i o n s h i p s and l i v i n g s i t u a t i o n are the basis of treatment. Yalom (1975) suggests that cohesiveness i n group therapy i s the analogue of r e l a t i o n s h i p i n i n d i v i d u a l therapy. Here r e l a t i o n -ship i s valued for i t s curative powers and i s seen as a goal i n i t s e l f . In t h i s s e t t i n g then, group cohesion i s not only deemed a necessary condition f or goal attainment, i t can be seen as part of the treatment goal i t s e l f . The cohesiveness of s t a f f being viewed as a p e r q u i s i t e for the i n t e g r a t i o n , or cohesiveness, of the whole community of s t a f f and c l i e n t s . The hypothesis of t h i s thesis i s that as the s t a f f cohesion i n the r e s i d e n t i a l cottages at the Easton r e s i d e n t i a l treatment centre varies so the treatment environment, or atmosphere, as perceived by c l i e n t s and s t a f f w i l l vary. S p e c i f i c a l l y , as s t a f f cohesion increases, the gap between the perceived r e a l treatment environment and the s t a f f ' s conception of an i d e a l treatment environment w i l l decrease. Also, as s t a f f cohesiveness increases, the c l i e n t s ' perception of cottage atmosphere w i l l become more p o s i t i v e , and t h i s w i l l be r e f l e c t e d i n l e s s c l i e n t runaways and acting-out n e c e s s i t a t i n g confinement to a locked room. 36 CHAPTER II SETTING: EASTON RESIDENTIAL TREATMENT CENTRE This section consists of a p h y s i c a l d e s c r i p t i o n of the r e s i d e n t i a l treatment centre, Easton, together with a short h i s t o r y and synopsis of the unit's s o c i a l organization. A d e s c r i p t i o n of the unit's design and intent, c l i e n t population, s t a f f , and c l i e n t organization w i l l follow. L a s t l y , there w i l l be a discussion of the general philosophy of r e s i d e n t i a l treatment operat-ing at Easton, and how t h i s philosophy f i t s i nto the general context of r e s -i d e n t i a l treatment, followed by an overview of the program and i t s implemen-t a t i o n . Physical Description The r e s i d e n t i a l treatment centre for emotionally disturbed adolescents, known as Easton i n t h i s study, has been i n operation since August, 1969. The •' unit i s part of a larger Mental Health Centre which includes a Psychological Education C l i n i c and a Family and Children's C l i n i c . The adolescent treatment centre also includes a day centre program for adolescents not requiring residen-t i a l treatment. This study, however, i s concerned only with the r e s i d e n t i a l u n i t . Easton i s a P r o v i n c i a l Government Mental Health I n s t i t u t i o n situated i n a mixed commercial-residential area of a major Canadian c i t y . The Easton r e s i d e n t i a l unit consists of three cottages, each accom-modating up to twelve "emotionally disturbed adolescents, boys and g i r l s . " The age of the c l i e n t s ranges from twelve to seventeen years. The r e s i d e n t i a l unit has access to a swimming pool, gymnasium, tennis courts, an outdoor sports 37 and play area, an arts and c r a f t s centre, and a schoolroom i n the school com-plex. The administration b u i l d i n g for the residence i s separate from the cottages, located i n the centre of the complex (see Figure 1). The unit grounds are landscaped with well maintained lawns, shrubs, and trees. For an urban area i t i s r e l a t i v e l y quiet and peaceful. The r e s i d e n t i a l cottages were designed i n the i n t e r e s t s of i n d e s t r u c t -i b i l i t y , being made of brown b r i c k and f u r n i t u r e b u i l t into the walls. Any movable f u r n i t u r e i s made of very heavy materials. The l i v i n g room f l o o r s are carpeted and l i g h t i n g i s i n d i r e c t , behind i n a c c e s s i b l e valances. The walls, however, are brightened considerably by painted, coloured geometric designs and an occasional a r t p r i n t . The woodwork i s also painted bright colours and t h i s , with the general l i g h t i n g , including big windows and s k y l i g h t s , creates a cheerful i n t e r i o r . The l i v i n g rooms have f i r e p l a c e s and contain plants and art work which have been donated by the s t a f f and previous residents. There are c e r t a i n features necessary to s a t i s f y the health and safety requirements of an i n s t i t u t i o n , such as e x i t l i g h t s , f i r e alarms, f i r e e x t i n -guishers, etc. Each cottage also has a room e s p e c i a l l y designed for the safe containment of adolescents. Such a room i s n e c e s s a r i l y ra.ther bare, has immovable windows and elaborate locks on the door. Each cottage contains eight bedrooms (six double rooms and two s i n g l e rooms); four double rooms i n one wing accommodating boys, and the rest i n another wing accommodating g i r l s . The main s t a f f o f f i c e i s c e n t r a l l y located near the front door, with the walls consisting mostly of glass to f a c i l i t a t e the s t a f f being able to see out into the cottage community. Design arid Intent Easton was designed to f i l l the needs p r i m a r i l y of non-delinquent and non-psychotic adolescents who did not require a closed i n s t i t u t i o n . However, L A W N PLAY AREA O o 0° BLACK TOO PLAY AREA 8°o<b°o T E N N I S COURTS o ^ o O °o° o P A R K I N S C D O O M * ADMINISTRATIVE OFFiCtSJ //J////7K EASTON ComPLEX SCALE l"« '00' o _ o f//J o°^o° O o WOODED A R E A o 9^  o o o o ao°o2 0, o o°. 39 small numbers of psychotic or delinquent youths could be admitted. The "open door" character of t h i s i n s t i t u t i o n was, and i s , consistent with a therapeutic community model which forms one of the basic t h e o r e t i c a l frameworks for the implementation of treatment at Easton, although t h i s model and other s i g n i f i -cant concepts have necess a r i l y been adapted to the needs of adolescent c l i e n t s and the bureaucratic structure imposed by the P r o v i n c i a l Government Mental Health Branch. C l i e n t Population Each cottage at Easton can contain as many as twelve adolescents, but the numbers flu c t u a t e because of discharge and admission timing and the c l i e n t runaways or " s p l i t s " . At the time of t h i s study, July, 1979, there were ten residents i n cottage one, ten i n cottage two with an impending ad-mission, and eleven i n cottage three. The age range of the residents varies from twelve to seventeen years. The average age of Easton residents at the time of t h i s study was f i f t e e n years and three months. The number of boys and g i r l s i n a cottage at any one time can vary s l i g h t l y . At the time of the study there were s i x boys and four g i r l s i n cottage one, f i v e boys and f i v e g i r l s i n cottage two, and f i v e boys and six g i r l s i n cottage three. I t i s reasonable to assume that the Easton c l i e n t s would f a l l i n the average range as far as I.Q. i s concerned, since part of the admission c r i t e r i a i s that the c l i e n t has been tested and found to be at least i n the normal or dull-normal range. The adolescents are referred by mental health teams, p s y c h i a t r i s t s , physicians, counsellors, probation o f f i c e r s , s o c i a l workers, and assessed by the Easton assessment team. This assessment process consists of an interview 40 of the family by the s o c i a l worker, an interview of the c l i e n t by a c h i l d care counsellor and a p s y c h i a t r i c assessment followed byl.ia day v i s i t to one of the cottages. If admitted, the f i r s t month i s also an assessment period, during which the cottage assesses the nature of the c l i e n t ' s disturbance and the treatment goals to be achieved. Easton c l i e n t s come from a l l over the Province but by f a r the larges t proportion are admitted from the surrounding urban area. In 1978, Easton received 183 r e f e r r a l s . Of these r e f e r r a l s , 97 were recommended for admission a f t e r the assessment procedure; and of these, 57 were a c t u a l l y admitted i n that year. There are various reasons for the lower number ac t u a l l y admitted: the l i m i t e d number of beds a v a i l a b l e at Easton, c l i e n t s on the waiting l i s t (there are usually 30 to 40 on t h i s l i s t ) may f i n d a l t e r n a t i v e placement, or parents may refuse placement. The average length of stay at Easton i s approximately eight to nine months, although t h i s i s a somewhat a r t i f i c i a l l y low fi g u r e influenced by some c l i e n t s who repeatedly run away during the f i r s t months of treatment and are then discharged. A more r e a l i s t i c f i g u r e would perhaps be ten to eleven months. Staff (Figure 2) The importance of the q u a l i t y of the r e s i d e n t i a l s t a f f i s emphasized by most a u t h o r i t i e s on r e s i d e n t i a l treatment. Easson (1969) states, "The f i n a l therapeutic e f f e c t of a r e s i d e n t i a l treatment unit i s t o t a l l y dependent it on the q u a l i t y and effectiveness of the treatment personnel (p. 28). At Easton, the c h i l d care counsellors are considered the primary therapists for the Easton c l i e n t s . They are supported i n each cottage by a s o c i a l worker, a ward aid (who sees to household d u t i e s ) , and a consultant p s y c h i a t r i s t . These counsellors have an intense involvement i n a l l phases of the c l i n e t ' s l i f e . This d i f f e r s from many other i n s t i t u t i o n s where tasks are usually 41 broken down and assigned to d i f f e r e n t s t a f f with d i f f e r e n t p r o f e s s i o n a l o r i e n t a t i o n s . At Easton, the counsellor i s responsible for basic c h i l d care, m i l i e u management, and the planning and implementation of i n d i v i d u a l , group, and family therapy for t h e i r p a r t i c u l a r c l i e n t or cottage. Thus, there i s no d i v i s i o n of s t a f f r o l e s between those who do "therapy" and those who put c h i l d -ren through d a i l y routines. Redl's l i f e - s p a c e interview technique (1959) was an attempt to break down such d i v i s i o n s which have proved problematic i n many i n s t i t u t i o n s ( P i l i v i a n , 1963) and encourage "the c l i n i c a l e x p l o i t a t i o n of l i f e events." This concept of the c h i l d care r o l e which integrates management and treatment i s s i m i l a r to the European concept of the "educateur" who i s a pro f e s s i o n a l mental health s p e c i a l i s t trained i n c h i l d care, education, and c l i n i c a l manage-ment. This model i s the one recommended for r e s i d e n t i a l unit s t a f f i n g i n "The Children i n Canada, Res i d e n t i a l Care Report," (1971). The s t a f f to c l i e n t r a t i o i s nec e s s a r i l y high i n r e s i d e n t i a l treatment, and at Easton there are f i f t e e n c h i l d care counsellors i n each cottage, c o n s i s t -ing of one cottage supervisor ( c h i l d care counsellor 4), four shiftheads ( c h i l d care counsellor 3), and ten c h i l d care counsellors ( c h i l d care counsellor 2). The p o l i c y of Easton i s to balance male and female s t a f f i n the cottages. However, at the time of t h i s study, the s t a f f i n g pattern as f a r as sex was con-cerned was that cottage one had eight men and seven women, cottage two and three had nine men and f i v e women. The s t a f f are a l l required to hold a B.A. degree i n Chi l d Care or the Behavioural Sciences. Most have had previous experience with disturbed young people and a l l , once hired, take part i n a two-year i n - s e r v i c e t r a i n i n g program consisting of two days t r a i n i n g per month. The t r a i n i n g program covers the following areas: the counsellor r o l e expectations, Easton philosophy of treatment, communication s k i l l s , human FIGURE 2 RESIDENTIAL UNIT ORGANIZATION 1978 Consulting Psychiatrists (Sessional) — 3 Training Coord. CCC 5 - 229948 Program Coord. CCC 3 - 229534 CCC 2 - 229559 CCC 2 - 229583 Day Care Unit CCC 4 - 230003 CCC 2 - 229369 CCC 2 - 229500 CCC 2 - 229807 W/Asst. 229799 Cottage No. 1 CCC 4 - 229831 CCC 3 - 220856 CCC 3 - 229666 CCC 3 - 229781 CCC 3 - 440156 CCC 2 - 229484 CCC 2 - 229609 CCC 2 - 229526 CCC 2 - 229930 CCC 2 - 229955 CCC 2 - 229542 CCC 2 - 229625 CCC 2 - 229443 CCC 2 - 229872 CCC 2 - 229658 W/Asst. 229849 VRT Director — Psychiatrist (Sessional) Psychologist CCC 6 — 22989 Chief CCC [Psychiatric Social Worker 4 - 229674 CCC 4 - 23001 Admin. Asst. Ck.St. 3 - 229708 Ck.Typ.2 - 229880 Ck.Typ.l - 229344 Education Program CCC 3 - 2220476 CCC 2 - 229393 CCC 2 - 229823 Psyc.Soc.Wkr. 3 - 229435 Psyc.Soc.Wkr. 3 - 229351 Psyc.Soc.Wkr. 3 - 229732 Psyc.Soc.Wkr. 3 - 229864 Cottage No. 2 CCC 4 - 229815 Cottage No. 3 CCC 4 - 229633 CCC 3 - 229724 CCC 3 - 229898 CCC 3 - 440149 CCC 3 - 229906 CCC 3 - 440131 CCC 3 - 229757 CCC 3 - 229740 CCC 3 - 229971 CCC 2 - 229690 CCC 2 - 229963 CCC 2 - 229682 CCC 2 - 229773 CCC 2 - 440164 CCC 2 - 229518 CCC 2 - 229419 CCC 2 - 229591 CCC 2 - 229997 CCC 2 - 229922 CCC 2 - 229427 CCC 2 - 229641 CCC 2 - 229575 CCC 2 - 229377 CCC 2 - 229567 CCC 2 - 229492 CCC 2 - 229385 CCC 2 - 229450 CCC 2 - 229468 CCC 2 - 229401 W/Asst. 229914 W/Asst. 229617 CCC = Child Care Counsellor 43 growth and development, basic c h i l d care s k i l l s , and an introduction to t r e a t -ment techniques. There i s also a supervisor t r a i n i n g program focussing on supervisory s k i l l s . The personal c h a r a c t e r i s t i c s that are sought by the Easton supervisory team when h i r i n g s t a f f are "genuineness", "openness", "energy", " f l e x i b i l i t y " , "warmth", "appropriate aggression", and a "desire to grow". These q u a l i t i e s then create the " a b i l i t y to form e f f e c t i v e interpersonal r e l a t i o n s with other s t a f f , " that i s , to help form a cohesive team. The presence of these q u a l i t i e s i s determined through the subjective judgement of the h i r i n g team during several interviews, and feedback from the cottage s t a f f observing the poten-t i a l employee on a t r i a l s h i f t . This high value placed on c e r t a i n personal c h a r a c t e r i s t i c s i n s t a f f and t h e i r general a b i l i t y to r e l a t e to each other and t h e i r c l i e n t s i s p a r a l l e l e d i n the writings of Bettleheim (1974), who stresses the psychological and s o c i a l development of s t a f f , s t a t i n g that such s t a f f must be "true to themselves" and have a b a s i c a l l y strong ego as well as a personal desire to grow and become more integrated. Easson (1969) also states, In the diagnostic and treatment process, therapeutic personnel are obliged to use t h e i r own reactions and i n t u i t i o n s as v a l i d diagnostic clues. Such t o t a l treatment involvement requires a high l e v e l of i n d i v i d u a l i n t e g r i t y and personal strength i n every member of the treatment personnel (p. 60). Also pertinent here are the three personal c h a r a c t e r i s t i c s which Traux and M i t c h e l l (1971) consider to be e s s e n t i a l i n any e f f e c t i v e t h e r a p i s t . These are genuineness, the a b i l i t y to accept the c l i e n t and so create t r u s t , and the a b i l i t y to empathize with the c l i e n t . The t o t a l cottage s t a f f are spread over three s h i f t s per day, with an hour overlap of day and evening s h i f t s to f a c i l i t a t e d a i l y group meetings. There are usually three to four s t a f f members on the day and evening s h i f t s , and one on the night s h i f t . 44 Each c h i l d care counsellor i s assigned a supervisor who conducts regular supervising sessions with the supervisee. The cottage supervisors are i n turn supervised by the chief c h i l d care counsellor who reports d i r e c t l y to the Director of the u n i t , a p o s i t i o n held by a p s y c h i a t r i s t . The super-v i s i o n of s t a f f at Easton has as i t s ultimate goal not j u s t the monitoring of s t a f f job performance i n task and interpersonal functioning, but the growth and t r a i n i n g of the s t a f f towards t h e i r highest p o t e n t i a l . The s t a f f at Easton have been r e l a t i v e l y constant for the l a s t few years. In July, 1979, the mean for Easton c h i l d care s t a f f , as f a r as length of stay at Easton was concerned, was approximately three and a h a l f years (See Table 21, Appendix C). The s h i f t workers at Easton work seven and a h a l f hour s h i f t s on a modified four day - f i v e day r o t a t i o n schedule (four days on, two days o f f , and f i v e on, and three o f f ) with some changes including four or f i v e days o f f a f t e r f i v e midnights. The cottage supervisor works a regular day s h i f t . This s h i f t pattern can r e s u l t i n treatment d i s r u p t i o n and incon-sistency due to absences of key s t a f f at c r u c i a l times. This factor makes the cohesion and teamwork of the s t a f f group and good communications patterns even more e s s e n t i a l . S t a f f are occasionally moved from cottage to cottage to com-plete s t a f f i n g l i n e s or balance team strengths and weaknesses. The administration and decision making process i n the unit operates on a h i e r a r c h i c a l a c c o u n t a b i l i t y model i n keeping with the bureaucratic demands of the c i v i l s ervice. However, the nature of the task obligates s t a f f to f i n d " e f f i c i e n t , e f f e c t i v e , and humane ways of r e l a t i n g i n the organization" (Clarke et a l . , 1977). As a r e s u l t , there i s a value placed on p a r t i c i p a t i o n , feedback and group consensus i n the decision making process at Easton. The creation of a therapeutic environment i s seen as the mutual r e s -p o n s i b i l i t y of a l l members of the s t a f f team, who engage i n peer supervision 45 and feedback. The underlying b e l i e f here i s that the use of a r b i t r a r y authority causes "resentment, r i g i d i t y , and undermining" (Clark et a l . , 1977). Thus, there i s a great emphasis at Easton on including a l l people affected by decisions i n the decision making process, and valuing peoples' personal f e e l -ings, ideas, and preferences. A decision such as a s t a f f move from one cottage to another (which happens f a i r l y r e g u l a r l y ) , for example, w i l l be discussed i n a meeting of a l l the unit supervisors, discussed with the s t a f f to be moved and the cottage shifthead group before being recommended to the administration group (consisting of area supervisors, the Director, and s o c i a l work super-visor) for r a t i f i c a t i o n . C l i e n t Organization: Admission C r i t e r i a The factors operating i n the decision to admit or not to admit an adolescent to Easton are l i s t e d below. I t should be understood that Easton i s a " l a s t r e s o r t " resource. Community resources such as mental health centres, therapeutic foster and group homes, and p s y c h i a t r i c consultation have f i r s t been t r i e d and found i n s u f f i c i e n t . A l l avenues possible are t r i e d before taking the serious step of placing the c l i e n t i n a r e s i d e n t i a l i n s t i t u t i o n . There are two general p r i n c i p l e s concerning admission to Easton. F i r s t , does the c l i e n t need the Easton program? S p e c i f i c a l l y , i s the c l i e n t at r i s k i n the community? Is he hurting others or himself, and have a l l the community resources been exhausted? Second, can the c l i e n t benefit from the Easton program? Such factors as I.Q. and motivation must be considered here. Easton i s a r e l a t i v e l y sophisticated program demanding a c e r t a i n verbal and conceptual a b i l i t y , and for t h i s reason Easton does not accept c l i e n t s below the dull-normal range of I.Q. (a score of at l e a s t 80 on the Weschler I n t e l -ligence Scale for Children) and prefers I.Q. to be i n the normal range. Environmental factors and possible deprivation that may lead to lowered I.Q. 46 scores are factors that are taken into account. The c l i e n t ' s motivation has to be at le a s t at the l e v e l where there i s some recognition of h i s or her problem. Some c l i e n t s do not complete the assessment due to t h e i r u n w i l l i n g -ness or that of t h e i r family. Other c l i e n t s c o ntinually run away i n the f i r s t month, making treatment impossible. It seems appropriate here to quote d i r e c t l y from the Easton r e f e r r a l form, which states that Easton i s "geared to treat severely emotionally disturbed adolescents, including those who are depressed, p o t e n t i a l l y s u i c i d a l , psychotic, borderline psychotic, s u f f e r s i g n i f i c a n t arrested emotional development, display confusion i n sexual i d e n t i t y , s u f f e r impaired interpersonal r e l a t i o n s h i p s , act out as a manifestation of an emotional disorder, or exhibit symptoms relat e d to s i t u a t i o n a l c r i s e s during adolescence. We do not treat those who suffe r gross i n t e l l e c t u a l impairment, are deemed hard-core delinquents or a n t i - s o c i a l characters, or those who have displayed repeated patterns of law breaking or running away. This i s due to the fac t that the t r e a t -ment cottages are open with l i t t l e f a c i l i t i e s for containment. P r i v i l e g e s , Rules, and Penalties i n the Cottage For a period of two weeks a f t e r admission the c l i e n t i s not allowed phone p r i v i l e g e s , outings, or contact with h i s or her family. The c l i e n t i s assigned a "treatment team" of two or three "key" workers who assess h i s needs and formulate a treatment program, which i s presented to the rest of the s t a f f group for discussion and approval (A sample treatment sheet i s included i n Appendix E). These key workers work with the c l i e n t i n one-to-one psycho-therapy, and with the family i n family counselling sessions. As the c l i e n t gradually progresses, he or she i s included into more group sessions, pro-gressing from planning groups (to plan the day) to asking groups (to ask for p r i v i l e g e s , feedback, etc.) to group therapy sessions. The c l i e n t can also lose or gain p r i v i l e g e s such as "on grounds" that i s being able to walk around the complex grounds unsupervised; " o f f 47 grounds", that i s being able to walk to a store, etc.; and " s i x hour walks" where the c l i e n t can leave the grounds unsupervised for s i x hours. Attending a c e r t a i n group can be a p r i v i l e g e , as can being able to leave your room during the d a i l y s t a f f meeting (3:00 p.m. to 4:00 p.m.). The d e t a i l s of t h i s p r i v i l e g e structure may vary s l i g h t l y from cottage to cottage, but the concept, that of the c l i e n t moving towards more s e l f - c o n t r o l , freedom and r e s p o n s i b i l i t y , i s the same. The basic rules of the cottage are: 1. No drugs or alcohol allowed on the premises. 2. No sexual a c t i v i t y to take place between residents. 3. Physical violence i s not acceptable i n the cottage, either to s e l f , others, or community property. 4. No admission to the wing of the b u i l d i n g designated for the opposite sex. 5. The residents are expected to complete regular clean-up and community maintenance duties. 6. No smoking i n the bedroom wings. 7. No running away (perhaps the most basic rule i n an "open door" s e t t i n g ) . The penalties employed i n the cottages are: 1. Room confinement for c e r t a i n periods of time. 2. Loss of p r i v i l e g e s or f i n e s from the c l i e n t ' s allowance. 3. Locked room placement. 4. Drugs (used as l i t t l e as p o s s i b l e ) . 5. Physical r e s t r a i n t (used b r i e f l y f o r c r i s i s management). 6. Discharge (for i n f r a c t i o n s such as constant running away). 48 The emphasis i n the program, however, i s on confrontation by the s t a f f and by the r e s t of the community rather than automatic consequences and rewards. The general focus i s on the c l i e n t taking more and more respon-s i b i l i t y as he moves towards discharge, for instance, p a r t i c i p a t i n g i n draw-ing up h i s own treatment proposals (which are r e g u l a r l y reviewed) and discharge planning. Generally, the c l i e n t i s seen by the Easton s t a f f as moving through three phases: resistance to treatment, working through of problems, and separ-ation from Easton. The use of drugs at Easton i s kept as minimal as possible, and used only to control v i o l e n t behaviour or very high anxiety. In J u l y , 1979, f i v e out of 30 c l i e n t s were being administered drugs as part of t h e i r treatment program. Four of the c l i e n t s were on major t r a n q u i l l i z e r s , and one on a n t i -psychotic medication. Two of these c l i e n t s were i n cottage one, two i n cottage three, and one i n cottage two (not included i n these figures are two c l i e n t s i n cottage one taking long-term medication to control e p i l e p s y ) . General Philosophy of Residential Treatment Operating at Easton The main threads i n the ideology of the Easton unit since the begin-ning has been the concept of the therapeutic community (Jones, 1953) and the b e l i e f as stated here by the f i r s t Director that "the basis of therapy i s good i n d i v i d u a l r e l a t i o n s h i p s between the counsellors and c h i l d r e n within a therapeutic m i l i e u which caters to adolescent needs" (Mental Health Branch Report, 1969). The influence of the therapeutic community model can be seen i n the emphasis on community, group process, and i n t e r a c t i o n among kids and s t a f f as the main therapeutic t o o l , and among s t a f f as a unit management modality; i n the focus on consensus and p a r t i c i p a t i o n i n the decision making process; i n the emphasis on "open communication" between s t a f f and c l i e n t , s t a f f and s t a f f , and c l i e n t and c l i e n t ; the focus on r e s p o n s i b i l i t y , both i n 49 c l i e n t s ' treatment and i n s t a f f development; the twenty-four hour a day nature of the Easton therapy program; and the constant attempt to create an emotional climate of warmth and acceptance. The therapeutic community model springs out of the psychoanalytic t r a d i t i o n . This can be seen i n the primary emphasis placed on r e l a t i o n s h i p as a therapeutic t o o l , i n the s i g n i f i c a n c e given to the dynamics underlying behavioural patterns, and i n the value attached to the gaining of i n s i g h t . However, t h i s model i s also a reaction to psychoanalytic t r a d i t i o n i n that i t focusses on the healthy functioning part of the c l i e n t , emphasizing the c l i e n t ' s r e s p o n s i b i l i t y for h i s behaviour patterns and the therapeutic s i g -n i f i c a n c e of h i s s o c i a l i n t e r a c t i o n s . Another o f f s p r i n g of the psychoanalytic t r a d i t i o n , ego psychology, i s s i g n i f i c a n t i n the whole f i e l d of r e s i d e n t i a l treatment and i s p a r t i c u l a r l y pertinent to adolescent c l i e n t s who can be viewed as engaging i n the process of trying to b u i l d an ego, that i s , a set of functions, coping mechanisms, and defenses to cope with inner drives and outer r e a l i t i e s . In discussing the l i f e - s p a c e interview, a technique used extensively at Easton, Wineman (1959) re f e r s constantly to the ego b u i l d i n g goal of such intervention. The treatment philosophy of Easton has also been influenced by l e a r n -ing theory with i t s emphasis on modelling and s o c i a l reinforcement, and by the e c o l o g i c a l model with i t s focus on the creation of a supportive m i l i e u , and treatment techniques such as family therapy. The treatment goals and d i r e c t i o n are encapsulated i n part of the introduction to the assessment form thus: "Treatment i s designed to reverse psychopathology, promote interpersonal r e l a t i o n s h i p s , personal growth, l i f e s k i l l s and r e s p o n s i b i l i t y . These goals are achieved by l i v i n g i n a consistent, supportive, and caring m i l i e u where s t a f f serve as healthy r o l e models and where adolescents are encouraged to p a r t i c i p a t e i n age appropriate a c t i t i v i e s . 50 The s t a f f work towards improved r e l a t i o n s h i p s between peers and involve the adolescents i n i n d i v i d u a l , group, and family therapy aimed at resolving the c l i e n t ' s underlying problems. Much emphasis i s placed on personal hygiene, d a i l y chores and other r e s p o n s i b i l i t i e s and s k i l l s necessary for the c l i e n t ' s return to the community. The key words here are "growth", "M i l i e u " , " r e l a t i o n s h i p s " , and "underlying problems". These concepts place Easton i n the context of Whittaker's (1979) t h i r d model of r e s i d e n t i a l treatment, which i s e s s e n t i a l l y a merging of the more modern ego-orientated psychotherapeutic t r a d i t i o n and learning theory, with some input from the e c o l o g i c a l and therapeutic community models. The strong emphasis on s t a f f , and the i n t e r a c t i o n between the s t a f f i s more unique to Easton, but r e f l e c t s s i m i l a r values found i n the work of Bettleheim (1974) and Jones (1968). The high p r i o r i t y given to the t r a i n i n g program r e f l e c t s the high value which the unit places on the personal growth and development of the s t a f f which-will then, i n the context of the Easton philosophy, be r e f l e c t e d i n and passed on to the c l i e n t s with which the s t a f f work. The focus on r e l a t i o n s h i p , i n t e r a c t i o n with peers, and personal r e s p o n s i b i l i t y begins with the s t a f f group. The chief c h i l d care counsellor gave her view of Easton's philosophy as, "treatment based on s t a f f growth and communication." The s h i f t change meeting, which i s held every day i n the cottages, i s divided into two sections. The f i r s t section i s dedicated to s t a f f emotive communication and feedback or "process", and the second section to business issues. This "process" i s seen as c r u c i a l to the forming of cohesive, supportive s t a f f teams which can then create a therapeutic environ-ment. One of the goals here i s , as the Child Welfare League of America (1972) suggests, to make sure issues are openly worked through among s t a f f , and not "worked out upon and through the p a t i e n t s . " Here the s t a f f attempt to p r a c t i s e s k i l l s which they hope to r o l e model for t h e i r c l i e n t s . These 51 include self-awareness, emotional honesty, the a b i l i t y to hear and give feedback openly, and to r e l a t e to others supportively, together with the taking of personal r e s p o n s i b i l i t y for one's l i f e - s t y l e and circumstances. Program and Daily Routines The primary therapeutic agents i n the unit are seen to be the following: a. R e s i d e n t i a l l i v i n g i t s e l f with i t s duties, problem sharing, c o n f l i c t r e s o l u t i o n s , and day to day i n t e r a c t i o n with adults and peers. b. Community meetings and therapy groups with t h e i r emphasis on interpersonal communication, s o c i a l i n t e r a c t i o n , and i n s i g h t s into the dynamics of behaviour. c. The one-to-one r e l a t i o n s h i p s with key s t a f f involved i n creating awareness of problem areas, working through c o n f l i c t r e s o l u t i o n , creating emotional catharsis and teaching alternate behaviours. d. The family counselling sessions which, hopefully, allow the c l i e n t to re-examine the family r e l a t i o n s h i p s and reassess his p o s i t i o n as part of the family. e. The learning experiences encountered i n the art s and c r a f t s , recreation, and school programs. During the f i v e weekdays, residents are awakened by one of t h e i r members (chosen by roster) and come to breakfast at 8:30 a.m., beds being made immediately a f t e r breakfast. The residents then meet for a planning group to set up the day's events. In the morning, there w i l l be eit h e r a group of some kind or an a c t i v i t y such as school, arts and c r a f t s time, pool or gym a c t i v i t i e s , etc. In addition, i n the afternoon, there may also 52 be family conferences or i n d i v i d u a l therapy sessions, as well as shopping t r i p s , etc. During the s h i f t meeting from 3:00 p.m. to 4:00 p.m., the adolescents are i n t h e i r rooms where they do homework, play games, etc. Supper i s at 5:00 p.m. and the evening time i f no group i s scheduled, i s free for r e l a x a t i o n , T.V., games, discussion, etc., except for one hour of school homework time supervised by the s t a f f . Bedtime i s set for 10:00 p.m. with l i g h t s out at 10:30 p.m. The weekends are more f l e x i b l e . Makeup and bedtimes are l a t e r . Some residents leave Easton for home v i s i t s , others go on outings with the s t a f f , or simply relax i n the cottage. The s t a f f are assigned to recreation and arts and c r a f t s programming. This includes i n d i v i d u a l gym programs, a s k i i n g program, summer camping pro-grams, arts and c r a f t s classes, and art therapy sessions once or twice a week for selected c l i e n t s . Three s t a f f are also assigned to the school program. U n t i l 1974, the basic p o l i c y of Easton concerning education was, to quote a report (1972) to the Mental Health Branch, that "the c h i l d i s so involved i n the process of therapy as to make cognitive achievement out of place." Since that time, the school program has grown to the point where a l l c l i e n t s at Easton are given an educational assessment and placed on an i n d i v i d u a l i z e d educational program. However the s t a f f to c l i e n t r a t i o , and thus the quantity of schooling given, i s s e r i o u s l y inadequate (for some c l i e n t s as l i t t l e as three hours per week) e s p e c i a l l y since most of the Easton c l i e n t s have experienced considerable d i f f i c u l t y i n school and are i n need of intensive i n d i v i d u a l i z e d , often one-to-one teaching. To be e f f e c t i v e , the school approach also has to be c l o s e l y integrated with the cottage's general treatment plan for a p a r t i c u l a r c l i e n t . As Whittaker (1979) points out, a low p r i o r i t y i s frequently given to formal education i n r e s i d e n t i a l treatment centres. The reasons for t h i s are complex. 53 Perhaps the most obvious i s that such centres usually come under the auspices of Health rather than Education. Professional d i v i s i o n s can also create very r e a l problems i n the i n t e g r a t i o n of such elements as formal education into a u n i f i e d treatment plan. If the c l i e n t i s to function adequately i n the com-munity a f t e r discharge, however, a f u l l creative educational program geared to the c l i e n t ' s i n d i v i d u a l i z e d learning s t y l e would appear to be e s s e n t i a l . A d d i t i o n a l therapeutic services at Easton include music therapy sessions once a week for a selected number of c l i e n t s , and an alumni group held once a week for discharged c l i e n t s or those close to discharge, to help these l a t t e r c l i e n t s deal with the problems of separating from Easton and re i n t e g r a t i n g back into the community. There i s also an aftercare program which i s extended to most c l i e n t s who complete t h e i r treatment at Easton, i f they are staying i n the surrounding area. This consists of a number of conferences with the c l i e n t and h i s guardians over a period of three months. They are conducted by the counsel-l o r s or s o c i a l worker with a view to helping the c l i e n t reintegrate success-f u l l y into the community. 5^ CHAPTER I I I THE STUDY D e f i n i t i o n of Terms Emotional Disturbance: William Rhodes (1977) points out that each theory i n the behavioural sciences defines "emotional disturbance" d i f f e r e n t l y . For example, i t can be seen as a d i s a b i l i t y , or as deviance, as a lack of f i t between i n d i v i d u a l and environment, or as a dysfunctional set of learned habits. He states, however, that a l l the models speak of "a human system i n d i s t r e s s " and a "disrupted pattern of human-environmental exchanges." The C a l i f o r n i a Department of Education (1959) state that c h i l d r e n may be considered emotionally disturbed when they usually e x h i b i t such primary symptoms as: 1. I n a b i l i t y to have e f f e c t i v e r e l a t i o n s h i p s with peers and adults. 2. Inappropriate behaviour or fe e l i n g s under ordinary conditions. 3. A general pervasive mood of unhappiness or depression. 4. A very poor self-concept. 5. I n a b i l i t y to face r e a l i t y . 6. I n a b i l i t y to cope with the learning s i t u a t i o n i n sp i t e of educational remedial measures. 7. A tendency to develop physical symptoms, speech problems, pains or fears associated with personal problems. In addition, Kirk (197 2) states that emotional disturbance i s a "deviation from age appropriate behaviour which s i g n i f i c a n t l y i n t e r f e r s 55 with the c h i l d ' s growth and development and/or the l i v e s of others" (p. 389). These d e f i n i t i o n s are a l l congruent with the concept of emotional disturbance operating at Easton, the r e s i d e n t i a l unit i n t h i s study. S p e c i f i c a l l y , for the purposes of t h i s study, emotional disturbance i s a pattern of behaviour, abnormal or destructive enough (to s t a f f and others) to have caused concern among parents, s o c i a l workers, and other mental health professionals to the extent that the c l i e n t i n question was considered i n need of r e s i d e n t i a l treatment, and thus r e f e r r e d to Easton. The s p e c i f i c symptom patterns l a b e l l e d emotional disturbance i n t h i s context include: b i z a r r e or psychotic behaviours such as wrist slashing; a n t i - s o c i a l behaviours such as f i r e - s e t t i n g or violence to others; and developmental problems, such as learning d i s a b i l i t i e s r e s u l t i n g i n truancy, confusion as to sexual i d e n t i t y or school phobia. Adolescent For the purposes of t h i s study, an adolescent i s a person between the ages of twelve and seventeen years. Treatment Environment or Cottage Atmosphere For the purposes of t h i s study, cottage atmosphere i s defined as those aspects of the environment measured by the Community Orientated Program Environment Scale (Moos, 1974) hereafter referred to as the COPES. There are three dimensions i n t h i s instrument: the Relationship dimension, including the subscales, Involvement, Support, and Spontaneity; the Program dimension, which includes the subscales, Autonomy, P r a c t i c a l Orientation, Personal Problem Orientation, and Anger and Aggression; and the System Maintenance dimension, which includes the subscales, Order and Organization, Program C l a r i t y , and Staff Control. D e f i n i t i o n s of these variables are given i n Appendix A. 56 Cohesion For the purposes of t h i s study, cohesiveness i s conceptually defined as a t t r a c t i o n to the group or resistance to leaving. This i s the d e f i n i t i o n upon which the index.:: of cohesion used i n t h i s study i s based. Operationally, i n the Seashore Cohesion Index (Seashore, 1954) a group w i l l be said to have a high degree of cohesiveness i f i t s members: 1. perceive themselves to be a part of a group, 2. prefer to remain i n the group rather than leave, 3. perceive t h e i r group to be better than other groups with respect to the way members get along together, help each other and s t i c k together. Res i d e n t i a l Treatment In t h i s study, r e s i d e n t i a l treatment can be defined as the Easton program which consists of a f u l l time, twenty-four hour a day, therapeutic process, i n a community s p e c i a l i z e d to the needs of the c l i e n t s , and i n t e g -r a t i n g various modes of intervention, such as group therapy, family therapy, and i n d i v i d u a l psychotherapy, into an i n d i v i d u a l i z e d treatment plan. A l l facets of the c l i e n t ' s l i f e i n residence are seen as providing opportunities for learning and growth; the m i l i e u i t s e l f , and the r e l a t i o n s h i p s therein are the primary sources of intervention. Population The subjects i n t h i s study consist of two groups, c l i e n t s and s t a f f , l i v i n g or working at the r e s i d e n t i a l treatment centre, Easton, i n July, 1979. C l i e n t s This group consisted of 31 emotionally disturbed adolescents d i s -playing various symptoms (see Chapter I I ) . In July, 1979, there were ten c l i e n t s i n residence i n Cottage One ( o f f i c i a l l y eleven, but one c l i e n t was 57 a prolonged runaway case), ten i n Cottage Two, and eleven i n Cottage Three, one of whom was omitted from the study since she was on the point of discharge, and also too psychotic to complete the test given to the c l i e n t s . Cottage Two contained f i v e boys and f i v e g i r l s , whereas Cottages One and Three each con-tained s i x boys and four g i r l s . The average age of these c l i e n t s was 15 years, 3 months. The ages of the c l i e n t s d i f f e r e d s l i g h t l y from cottage unit to cottage unit as follows: In Cottage One the average age of c l i e n t s was 15 years, 8 months; i n Cottage Two, 14 years, 9 months; i n Cottage Three, 15 years, 1 month. The c l i e n t s i n residence i n Cottage One at the time of the study were then s l i g h t l y older than i n the other two cottages (see Table 26). The average length of stay i n residence for the Easton c l i e n t s at the time of the study was 6-7 months. In Cottage One the average length of stay was s l i g h t l y higher (7.9 months) than i n the other cottages (see Table 25). The c l i e n t s were admitted from group homes and foster home placements as well as from t h e i r own home setting (see Table 23). In terms of severity of disturbance, the only two categories that seem c l e a r l y defined i n the l i t e r a t u r e with p r e d i c t i v e value as f a r as out-come i s concerned are a psychotic/non-psychotic diagnosis, formulated before or on admission to residence. At the time of t h i s study, Cottage Two con-tained one c l i e n t so diagnosed, while Cottages One and Three each contained two psychotic c l i e n t s . The most frequent o f f i c i a l diagnosis given on admission to Easton c l i e n t s i s "adjustment reaction of adolescence". This and other such diagnostic categories were not considered s p e c i f i c enough to be useful i n th i s study. The s o c i a l workers i n each cottage, however, were asked to subjectively rate t h e i r c l i e n t s as to poor, f a i r and good prognosis. 58 The r e s u l t s can be found i n Appendix C, Table 24. On an i n d i v i d u a l l e v e l the severity of disturbance of the c l i e n t s i n the cottages seems s i m i l a r , a l b e i t that t h i s i s a d i f f i c u l t factor to delineate. The socio-economic status (SES) of the Easton c l i e n t s i s d i f f i c u l t to c a l c u l a t e due to the v a r i a b i l i t y of placement before admission, SES usually being calculated on the parents' education or occupation. However, i n a previous study ( N e i l l , 1976) the c l i e n t population at Easton was gen-e r a l l y described, based on father's occupational category, as approximately "one h a l f lower c l a s s , one quarter middle c l a s s , and one quarter upper c l a s s . " Easton does not accept c l i e n t s below the normal range of I.Q. (a score of at l e a s t 80 on the Weschler I n t e l l i g e n c e Scale f o r Children) although other factors that may lower I.Q. scores, such as environmental deprivation, are taken into account. As far as school performance i s concerned, at the end of the 1979 school year, a rough estimate of c l i e n t s ' educational l e v e l i n the Easton school program calculated that approximately 20% of the pop-u l a t i o n were performing at t h e i r age-appropriate grade l e v e l ; 20% on the other hand were remedial, that i s at l e a s t two grades behind t h e i r age-appropriate grade l e v e l i n English and Math; and the remaining 60% were c l i e n t s for whom behavioural and emotional problems seemed to block con-s i s t e n t academic achievement. These three categories of c l i e n t s seemed to be d i s t r i b u t e d f a i r l y evenly over the three treatment cottages. The pattern that seems to emerge here i s a s i m i l a r one for each cottage group. No one cottage seemed at the time of the study to vary greatly with respect to the number, gender, age, and length of time i n residence of i t s c l i e n t population, or with respect to the sev e r i t y or kind of disturbance i n that population. 59 The chief factor i n the assignment of c l i e n t s to cottages i s the a v a i l a b i l i t y of beds. However, there i s some attempt to avoid placing more than two c l i e n t s who have been diagnosed psychotic i n any one cottage at any one time. The Staff The Easton s t a f f consists of 45 c h i l d care counsellors, with support s t a f f c o n s i s t i n g of s o c i a l workers, administrators, consulting p s y c h i a t r i s t s , and s p e c i f i c program s t a f f . The cottage team of c h i l d care counsellors are the primary therapists and the creators of the therapeutic environment. This study, therefore, has focussed on these teams. The s t a f f i n the three cottages, 15 i n each, were s i m i l a r with respect to professional t r a i n i n g (see Chapter I I ) , length of time employed at Easton, and length of time spent i n t h e i r present cottage (see Tables 21, 22). The f a c t that they were selected for employment at Easton and have generally remained there for a considerable amount of time (average length of stay i n July, 1979, was 3.5 years) suggests that they possess c e r t a i n s i m i l a r i t i e s as far as the personality t r a i t s that are required from and valued by the Easton s t a f f as a whole. The r o l e expectations, supervisory structure and job routines for these s t a f f members are standardized across the unit as a whole. The sim-i l a r i t y concerning treatment philosophy between the s t a f f i n a l l three cottages i s r e f l e c t e d by the lack of a s i g n i f i c a n t difference between these groups as measured by the COPES Scale, Form I, which measures the group's perception of an i d e a l treatment environment (Moos, 1974). If the s t a f f as i n d i v i d u a l s and as counsellors shared many s i m i l a r -i t i e s , however, there was one s i g n i f i c a n t difference between the s t a f f groups as perceived by the Easton supervisory team. This difference was i n 60 r e l a t i o n to the cohesiveness of the s t a f f teams. For some time before July 1979, the consensus of the supervisory team was that Cottage Three s t a f f formed a highly cohesive team, whereas the Cottage Two s t a f f were experien-cing considerable d i f f i c u l t y i n t h i s area. Concern was frequently expressed i n the weekly supervisory meetings about t h i s state of a f f a i r s and i t s per-ceived e f f e c t on the capacity of the Cottage to o f f e r e f f e c t i v e treatment to i t s residents. Administrative steps were taken s h o r t l y a f t e r J u l y , 1979, to change the configuration of s t a f f i n Cottage Two and to provide more support to the Cottage Two supervisors, with the hope of increasing the perceived e f f e c t i v e -ness of the cottage team. The supervisor of Cottage Two described the s i t u -a t i o n f or the year leading up to the time of t h i s study as being one i n which unresolved s t a f f c o n f l i c t s , poor communication, the formation of subgroups and cli q u e s , and a general climate of lack of t r u s t regarding the expression of f e e l i n g s and i n d i v i d u a l differences i n the s t a f f group led to a low l e v e l of treatment effectiveness. This supervisor stated to the researcher that, i n h i s opinion, the standard of s t a f f i n t e r a c t i o n had improved somewhat dur-ing the year but was s t i l l inadequate, and thus the cottage was only able to provide a r e l a t i v e l y low l e v e l of treatment. The s p e c i f i c ways i n which t h i s lack of cohesiveness among the s t a f f affected the treatment environment were not completely c l e a r , however, the consensus among cottage s t a f f and super-v i s o r y s t a f f was that i t did indeed do so. Instruments Cohesion The instrument used to measure s t a f f cohesion was the Seashore Group Cohesiveness Index (1954). This index measures group cohesiveness, defined as a t t r a c t i o n to the group or resistance to leaving, and morale, or pereep--61 t i o n of the group i n r e l a t i o n to other groups. The measure consists of three questions: 1. Do you f e e l that you are r e a l l y a part of your work group? 2. How would you f e e l about moving to another work group? 3. How does your group compare to other groups on each of the following points: The way i n which people get along together; the way i n which people s t i c k together; and the way i n which people help each other on the job. The f i r s t two questions can be answered by one of f i v e choices, and the three items i n the t h i r d question can each be answered by one of three choices (see Appendix A). The o r i g i n a l study using t h i s instrument was a study of 228 section s h i f t groups i n a company manufacturing heavy machinery, and attempted to r e l a t e group cohesion to p r o d u c t i v i t y l e v e l . This instrument i s the i n s t r u -ment of choice i n modern research concerning the group cohesion v a r i a b l e (Mikalachk, 1969; and Wheaton, 1974). Seashore states (1954) concerning the v a l i d i t y of the instrument, The f i r s t two c r i t e r i a appear to be r e l a t i v e l y pure t r a n s l a t i o n s from the formal d e f i n i t i o n of cohesiveness as a t t r a c t i o n to group. The t h i r d c r i t e r i o n i s i n two respects l e s s s a t i s f a c t o r y . The d e f i n i t i o n requires an 'objective' ( i . e . not se l f - e v a l u a t i o n a l ) measure of the degree of attractiveness. The a v a i l a b l e measures, however, appear to include kinds of r e l a t i o n s h i p among group mem-bers other than those implied by mutual att r a c t i v e n e s s . In addition, since the a v a i l a b l e measures are i n terms of s e l f - e v a l u a t i o n of the group, they contain an element of general s a t i s f a c t i o n with the group, perhaps properly c a l l e d 'morale'. These instrument problems could not be avoided without impaired r e l i a b i l i t y and without omission of an aspect of the d e f i n i t i o n of the v a r i a b l e to be measured. It i s not possible to determine the extent to which the cohesiveness measure i s thus contaminated. However, the possible presence of these extraneous elements suggests a degree of caution i n i n t e r p r e t i n g an obtained r e l a t i o n s h i p between the cohesiveness measure and measures of e f f e c t (p. 36). 62 The variance found between groups on t h i s scale i n t h i s study was s i g n i f i -cant beyond the .001 l e v e l . Table 31 shows the degree of i n t e r c o r r e l a t i o n s among the responses to the questions i n t h i s index. Seashore (1954) states, "These c o r r e l a t i o n s are judged to be s u f f i c i e n t l y high to j u s t i f y the conclusion that there i s a common element i n the responses to the f i v e questions. This lends support to t h e i r combination into a sin g l e index of cohesiveness." The i n t e r c o r r e l a -tions among mean scale values for the groups on scales comprising the index of cohesiveness ranged from .15 to .70 i n Seashore's study. Mikalachki (1969) reports that he tested the r e l i a b i l i t y of the Seashore Scale for h i s sample by means of an item-test c o r r e l a t i o n described by G u i l f o r d (1950). The r e l i a b i l i t y of the Seashore Scale i n t h i s case was .979, which was s i g n i f i -cant at the .001 l e v e l of confidence. Environment Scale The instrument used to measure Treatment Environment was the Community Orientated Programs Environment Scale compiled by Moos (1974), Forms R (real) and I ( i d e a l ) . This instrument w i l l be referred to as COPES. The measure contains three dimensions: Relationship, Treatment Program, and System Maintenance. There are three subscales measuring the Relationship dimen-sion. These are Involvement, Support, and Spontaneity. There are four sub-scales measuring the Treatment Program dimension. These are Autonomy, P r a c t i c a l Orientation, Personal Problem Orientation, and Anger and Aggression. L a s t l y , there are three subscales measuring the System Maintenance dimension: Order and Organization, Program C l a r i t y , and St a f f Control. A d e f i n i t i o n of these subscales and the test i t s e l f can be found i n Appendix A. The COPES items are to be answered true, i f an i n d i v i d u a l believes they are generally c h a r a c t e r i s t i c of h i s program, and f a l s e , i f he believes they are not gen-e r a l l y c h a r a c t e r i s t i c of the program. 63 The COPES instrument was developed d i r e c t l y from the Ward Atmosphere Scale compiled by Moos (1974) and i s conceptually i d e n t i c a l and methodo-l o g i c a l l y very s i m i l a r to t h i s instrument. Moos, i n h i s book, Evaluating  Treatment Environments (1974) states, concerning the formulation of the Ward Atmosphere Scale (WAS) that, the choice of items was guided by the o v e r a l l concept of environmental press (Pace and Stern, 1958) that i s , an item had to i d e n t i f y c h a r a c t e r i s t i c s of an environment which could exert a press toward Involvement, towards Autonomy, and so on. For example, an emphasis on Involvement i s i n f e r r e d from the following items: 'Members put a l o t of energy into what they do around here,' and 'This i s a l i v e l y place.' (p. 37). He also states concerning the formulation of the COPES instrument that "some of the items were d i r e c t t r a n s l a t i o n s from s i m i l a r items i n the WAS, others were worded somewhat d i f f e r e n t l y to obtain better item s p l i t s i n community Ii programs (p. 228). Moos states that the c r i t e r i a by which he derived the COPES were: F i r s t , r e l i a b i l i t y and v a l i d i t y ; second, not more than 80% nor le s s than 20% of subjects should answer an item i n one d i r e c t i o n , ( t h i s c r i t e r i o n was established to avoid items that were c h a r a c t e r i s t i c only of extreme programs); t h i r d , there should be approximately the same number df items scored true as scored f a l s e , within each subscale, to c o n t r o l for acquiescence response set; and fourth, items should not c o r r e l a t e s i g n i f i -cantly with the Halo Response Set Scale, which assessed both p o s i t i v e and negative halo i n the program perceptions. The COPES manual states that a broad range of American and B r i t i s h programs were included i n the normative sample, which currently numbers 54 programs. These programs include adolescent r e s i d e n t i a l centres, the subject of t h i s study, halfway houses, and day care centres. Some could be classed as t r a n s i t i o n a l residences for former mental patients, some as a l t e r n a t i v e s to h o s p i t a l i z a t i o n . 64 Table 27 gives the means and standard deviations of Form R subscales over the 54 programs, separately for members and s t a f f . The l o g i c of having separate member and s t a f f norms was derived from r e s u l t s with the WAS on which the COPES scale was based. Here there was often a considerable d i s -crepancy between patient and s t a f f perceptions of h o s p i t a l based treatment programs. Moos points out that t h i s "two subculture" notion has proved i n COPES r e s u l t s to be less applicable to community based programs, although the di r e c t i o n s of the differences which do e x i s t are consistent with those found on wards, i . e . s t a f f see treatment programs more p o s i t i v e l y than do members. Table 28 gives the i n t e r n a l consistencies (Kuder-Richardson Formula 20) and average item subscale c o r r e l a t i o n s for each of the ten subscales f o r members and s t a f f , on Form R, i n the i n i t i a l group of 21 programs. Internal consistencies were calculated following Stern (1970) using average w i t h i n -program item variances. The subscales have acceptable i n t e r n a l consistency and moderate to high average item to subscale c o r r e l a t i o n s . Table 29 gives the i n t e r c o r r e l a t i o n s of the 10 subscale scores f o r the same 21 programs. The highest i n t e r c o r r e l a t i o n i s .50, and the only c l u s -ter of subscales which show even moderate i n t e r c o r r e l a t i o n s i n both member and s t a f f samples was composed of the Relationship dimensions of Involvement, Support, and Spontaneity. I t thus appears, as Moos states, that the 10 sub-scales measure d i s t i n c t , a l b e i t correlated c h a r a c t e r i s t i c s of member and s t a f f perceptions of program atmosphere. The r e s u l t s of one-way analysis of variance indicated that a l l 10 subscales s i g n i f i c a n t l y d i f f e r e n t i a t e d among the 21 programs f or both member and s t a f f responses. The COPES manual states that the proportion of subscale variances accounted f o r by the differences among these programs varied from a low of 5 percent on the P r a c t i c a l Orientation subscale for s t a f f , to a 65 high of over 50 percent on both Autonomy and Order and Organization subscales for s t a f f , i n d i c a t i n g that the percentages of variance accounted for by differences among programs may be quite s u b s t a n t i a l . Test-retest r e l i a b i l i t y , p r o f i l e s t a b i l i t y and the r e l a t i o n s h i p s of the subscales to the background variables of the respondents and to s o c i a l d e s i r a b i l i t y scales have been generalized from the WAS where these factors were a l l found to be s a t i s f a c t o r y . Moos states i n the COPES manual (1974), Since the content and structure of the ten COPES and ten WAS subscales are d i r e c t l y p a r a l l e l , and since patient and s t a f f c h a r a c t e r i s t i c s i n these two types of programs are c l o s e l y comparable, these r e s u l t s may be generalized as applicable to COPES (p. 8). In Form I of the COPES, the Form R items and i n s t r u c t i o n s have been reworded so that members and s t a f f can answer them f or the type of program they would i d e a l l y l i k e . The means and standard deviations f o r the American normative sample are found i n Table 30. The average item to subscale cor-r e l a t i o n s for the ten subscales varied from .35 to .55. The subscale i n t e r -nal consistencies varied from a low of .70 for Program C l a r i t y to a high of .88 for Personal Problem Orientation, and thus were quite s u b s t a n t i a l f o r both member and s t a f f samples. Moos states that Form I has "adequate psychometric c h a r a c t e r i s t i c s " (COPES manual, 1974) . As to the uses of Form I, Moos suggests that i t may be used i n conjunction with Form R to i d e n t i f y s p e c i f i c areas i n which members and s t a f f f e e l change should occur, or by i t s e l f to assess the general value orientations of members and s t a f f i n a program. ••• Form I i s d i r e c t l y p a r a l l e l to Form R, i . e . the scoring keys for the two forms are i d e n t i c a l . Other Measures In addition to the cohesion and environment measures, two socio--metric questions concerning preferred work partners and s o c i a l friendships 66 were included with the cohesion scale. A questionnaire was also given to the s o c i a l workers of each cottage concerning the c l i e n t s ' diagnosis on admission, prognosis, s o c i a l s k i l l s , and length of stay i n the cottage. The f i l e s and records at Easton were used to ascertain for the cottage s t a f f groups duration of Easton employment and present cottage placement. The f i l e s were also used to specify the average length of stay, at the time of measurement, for the c l i e n t s i n each cottage group. The amount of time c l i e n t s spent i n the locked room during July, and the number of c l i e n t run-aways, and acts of violence i n each cottage, during t h i s time were also taken from Easton records. Data C o l l e c t i o n Procedures Data c o l l e c t i o n took place i n July-August, 1979. The cohesion index sociometric questions, and COPES Form R were given as a packet to each s t a f f on July 4th. A covering l e t t e r was included (see Appendix B). Before t h i s time the researcher had attended s t a f f meetings and supervisory meetings to acquaint the s t a f f with the study requirements. The nature of the study was not discussed; the main topics were, f i r s t , the neeid for the quick completion of the instruments by the e n t i r e s t a f f , and second, the absolute necessity for complete independence, lack of c o l l a b o r a t i o n and discussion among s t a f f concerning these instruments during the study period. A small number of the s t a f f were on vacation at t h i s time. These s t a f f were contacted previously, and the tests were mailed to t h e i r homes, completed and returned when they resumed work. C o n f i d e n t i a l i t y was also a p r i o r i t y . The measures were numbered by a secretary and returned to her. She then forwarded the completed measures to the researcher. The COPES Form I was d i s t r i b u t e d to the s t a f f three weeks l a t e r i n the same manner. 67 The COPES Form R was also taped (tape recordings were used i n the norming sample) and given to each c l i e n t group i n the same s e t t i n g on the 18th of July. The answer sheet was deemed too confusing for c l i e n t use, so a larger d i t t o format was used, and answers were indicated by T or F rather than with t i c k s i n boxes as i n the published answer sheet. The i n s t r u c t i o n s used i n the tape recording can be found i n Appendix B. Moos himself suggests such modifications i n the test manual. The s o c i a l workers also received t h e i r questionnaires at t h i s time, and other relevant information was taken from f i l e s and records. The s t a f f and c l i e n t s were extremely cooperative throughout the study. Only one s t a f f neglected to return the measure, reducing the number of s t a f f subjects i n Cottage Three to 14. Three s t a f f i n each cottage also refused to answer the sociometric questions, and the researcher received considerable feedback that these questions were objected to by a considerable number of those who did i n f a c t complete them. The researcher was assured by the supervisory s t a f f that no c o l l a b o r a t i o n or discussion concerning the measures was taking place. A l l test scoring was checked for e r r o r s . One error was found and corrected. The computer programs used i n the analyses were: S.P.S.S. (Nie et a l . , 1975), MULTIVAR (Finn, 1972), LERTAP (Nelson, 1974) and ANOVA 11 (Carlson and Hazlett, 1971). Data Analysis Procedures The data analysis was divided into three stages. The preliminary analysis consisted of an item analysis of the Seashore Group Cohesiveness Index and the Community Oriented Programs Environment Scale (COPES) to ascertain the r e l i a b i l i t y and the v a l i d i t y of the above instruments. Also 68 a one-way analysis of variance (ANOVA) was used to ascertain i f there were s i g n i f i c a n t difference between the cottage s t a f f groups on the f a c t o r , group cohesion. The e f f e c t of l e v e l s of Cohesion on the s t a f f ' s perception of the treatment environment as r e f l e c t e d i n the COPES instrument, Forms R and I was then analyzed using multivariate analysis of variance ( l e v e l s of cohesion by subscales i n COPES). The e f f e c t of l e v e l s of s t a f f cohesion on the c l i e n t perception of the environment was analyzed, using a one-way analysis of variance and re l a t e d to the frequency of such behaviour as c l i e n t runaways. The t h i r d stage of the analysis consisted of an examination of the p r o f i l e of the Easton program as i t i s perceived by c l i e n t s and s t a f f i n r e l a t i o n to the COPES normative sample and the stated philosophy and focus of the Easton centre. Hypotheses were tested allowing a Type I error p r o b a b i l i t y of .05. Differences among l e v e l s for a p a r t i c u l a r factor were examined, using Tukey's procedure (Glass and Stanley, 1970). The sociometric scores obtained from the s t a f f were discarded due to a lack of complete returns and e t h i c a l objections made by those s t a f f who did i n fa c t complete them. Assumptions and Limitations The design of t h i s study i s properly regarded as a quasi-experimental design (Campbell and Stanley, 1963) since the cottage groups constitute n a t u r a l l y assembled rather than randomly selected c o l l e c t i v e s , i n which pre-experimental sampling equivalence can be assumed. The examination of factors such as the length of s t a f f work experience at Easton and q u a l i t y of c l i e n t prognosis for each cottage, i s an attempt to l i m i t the e f f e c t s of major s i g n i f i c a n t v a r i a b l e s other than s t a f f cohesion, and ensure that the cottages were i n fa c t genuinely comparable. 69 The quasi-experimental nature of the design, however, does q u a l i f y the external v a l i d i t y of the study; Thus generalising the r e s u l t s of t h i s study to another r e s i d e n t i a l treatment centre would be questionable, e s p e c i a l l y since the f i e l d of r e s i d e n t i a l treatment contains such a d i v e r -s i t y of models and patterns of program implementation, including the s e l e c -t i o n of c l i e n t s for p a r t i c u l a r s e t t i n g s . The question of the e f f e c t of reactive arrangements also l i m i t s the external v a l i d i t y of the study. I t was assumed that the respondents answered the questions with candor, and did not give answers calculated to create a c e r t a i n impression of t h e i r treatment cottage. The answers on the cohesion index did follow the pattern predicted by the Easton supervisory group, which suggests that on t h i s instrument at l e a s t the responses were candid. The standardised format and i n s t r u c t i o n s , and the assurance of anonymity were designed to f a c i l i t a t e honest responses. CHAPTER IV RESULTS AND DATA ANALYSIS Stage 1; Preliminary Item and Test Analysis The f i r s t part of the preliminary analysis consisted of an item analysis on the Seashore Cohesion Index (Seashore, 1954) and the COPES (Moos, 1974) using the LERTAP computer program (Nelson, 1974). The means, standard deviations and r e l i a b i l i t i e s for the Cohesion Index are presented i n Table 1. R e l i a b i l i t i e s were calculated using Hoyt's ANOVA ( i n t e r n a l con-sistency) method, the r e l i a b i l i t y f o r the Cohesion Index being calculated at .87. However, the Cohesion Index was repeated a f t e r a period of three weeks, so that a c o e f f i c i e n t of s t a b i l i t y was also c a l c u l a t e d . The value of t h i s c o e f f i c i e n t was .73. Each item on t h i s instrument correlated at a p o s i t i v e and adequate l e v e l with the other test items. Thus each item can be said to be perform-ing c o r r e c t l y . TABLE I COHESION INDEX: TEST STATISTICS Cohesion Time 1 Cohesion Time 2 (n = 44) Mean 15 15.64 Standard Deviation 3.40 2.94 R e l i a b i l i t y (Hoyt Internal Consistency) .87 .85 Test-Retest .73 71 The means, standard deviations and r e l i a b i l i t i e s f o r the COPES Form R and Form I are presented i n Tables II and IV r e s p e c t i v e l y . Again r e l i a b i l i t i e s were calculated using Hoyt's ANOVA ( i n t e r n a l consistency) method and Cronbach 1s alpha for the composite, here calculated at .75 for COPES, Form R, and .65 for COPES, Form I. The r e l i a b i l i t i e s of some of the subscales, e s p e c i a l l y the COPES, Form R, subscales numbered 3, 7, and 10, that i s , Spontaneity, Anger and Aggression, and Staff Control, are low. However, the standard deviations for these subscales are also low, suggest-ing that the r e l i a b i l i t y estimate was lowered by a lack of variance. Considering the sample as a whole, the subtest means are a l l r e l a t i v e l y high. This implies that there were many items which s t a f f answered s i m i l a r l y . These items, then, do not contribute to the test's a b i l i t y to discriminate between i n d i v i d u a l s , thus lowering the r e l i a b i l i t y estimates. This i s to be expected i n a centre such as Easton, where there i s a c e r t a i n homogeneity among s t a f f and much emphasis on team work. For example, the expression of Anger and Aggression i s valued highly at Easton as a cathar-t i c force and i s consistently used as such i n the cottages ( t h i s i s r e f l e c t e d i n t h i s v a r i a b l e ' s high mean value), thus a lack of variance i s to be expec-ted on such a subscale. This phenomenon also occurs on the COPES, Form I. For example, the subtest 1, Involvement, has a low r e l i a b i l i t y and a small standard deviation. The COPES, Form R, and Form I, subtest c o r r e l a t i o n s are given i n Tables III and V r e s p e c t i v e l y . Again, the negative or minimal c o r r e l a t i o n s occur on COPES v a r i a b l e s , such as Anger and Aggression (variable 7) which have a very small amount of v a r i a b i l i t y i n t h e i r scores. However, the general lack of high c o r r e l a t i o n between subscales implies that they measure d i s t i n c t but correlated program c h a r a c t e r i s t i c s , as perceived by the s t a f f . TABLE II COPES FORM R: TEST STATISTICS, EASTON SAMPLE Subtests 1 2 3 4 5 6 7 8 9 10 Tot a l Mean 17.66 17.50 17.11 15.02 15.93 18.86 19.30 14.80 17.43 16.27 169.89 Standard Deviation 1.70 1.91 1.35 1.70 1.90 1.46 .85 1.80 2.24 1.55 9.38 R e l i a b i l i t y .53 .65 .33 .45 .55 .60 .18 .44 .72 .33 .75* (Hoyt, Internal Consistency) (n =44) NOTES: Number of Items = 100. Raw Scores have 10 added. *Cronbach's Alpha For Composite. TABLE III COPES FORM R: TEST STATISTICS, SUBTEST CORRELATIONS j 1 2 3 A 5 6 7 8 9 10 1 — .513 .312 .493 .556 .235 -.009 .312 .322 -.327 2 -- .275 .489 .670 .393 -.036 .497 .558 -.315 3 — .322 .239 .032 -.009 .211 .284 -.071 4 — .626 .254 .044 .146 .278 -.338 5 — .325 -.045 .459 .572 -.192 6 — .352 .140 .119 -.179 7 — -.035 -.154 -.133 8 — .705 .054 9 — -.015 10 (n = 44) TABLE IV COPES FORM I: TEST STATISTICS, EASTON SAMPLE Subtests 1 2 3 4 5 6 7 8 9 10 To t a l Mean 19.20 19.27 18.52 16.82 17.89 19.43 18.70 15.95 18.82 14.64 179.25 Standard Deviation .90 1.26 1.02 1.50 1.87 .95 1.21 2.56 1.59 2.11 7.81 R e l i a b i l i t y (Hoyt, Internal Consistency) .32 .65 .37 .44 .65 .47 .45 .78 .69 .63 .65' (n = 44) NOTES: Number of Items = 100 Raw Scores have 10 added. *Cronbach's Alpha For Composite. TABLE V COPES FORM I: TEST STATISTICS, SUBTEST CORRELATIONS 1 2 3 4 5 6 7 8 9 10 1 — .540 .335 .354 .647 .193 -.304 .456 .496 .052 2 — .373 .309 .466 -.003 .069 .363 .454 .003 3 — .504 .263 .074 -.229 -.044 .289 -.319 4 — .341 -.025 -.005 -.245 .132 -.271 5 — .277 -.066 .470 .502 .254 6 — -.068 .209 -.101 -.024 7 — -.484 -.306 .021 8 — .610 .431 9 — .340 76 Delineation of Cohesion Levels The f i n a l part of the preliminary analysis consisted of a one-way analysis of variance (Cohesion by the three cottage groups) using the SPSS computer program (Nie et a l . , 1975). Table VI shows the means and standard deviations for the cohesion factor and a summary ANOVA table i s presented i n Table VII. As shown i n Table VII, there was a s i g n i f i c a n t d i f f e r e n c e between the cottage groups on t h i s f a c t o r . Table VIII gives the post hoc comparisons using Tukey's procedure to determine which contrasts between cottages were s i g n i f i c a n t for the cohesion v a r i a b l e . As can be seen from the Table, there were s i g n i f i c a n t group mean differences on the factor cohesion between Cottage One and Two, and Cottage Two and Three. The contrast between Cottage One and Three, however, f a i l e d to reach the desired (p ""C .05) l e v e l of s i g n i f i c a n c e . At t h i s point the p o s s i b i l i t y of pooling Cottages One and Three to obtain j u s t two l e v e l s of cohesion was considered. However, i t i s usual before pooling to test for s i g n i f i c a n t differences at a relaxed alpha l e v e l of .20 (Winer, 1971), thus preventing a Type II erro r . But i n t h i s case, even i f alpha i s set at an alpha l e v e l of .10, there i s a s i g n i f i c a n t difference between Cottages One and Three (.90 3, 42,= 2.99). As a r e s u l t pooling was not considered legitimate, and i t was decided to consider a l l three cottages separately. Cottage One became synonymous with the Middle l e v e l of the factor Cohesion; Cottage Two with the Low l e v e l of Cohesion; and Cottage Three with the High l e v e l of Cohesion. These three l e v e l s of the factor Cohesion now became the indepen-dent variables i n the next stage of the a n a l y s i s . TABLE VI COHESION INDEX — MEANS AND STANDARD DEVIATIONS Cottage One Two Three Means 15.87 11.53 17.79 Standard 2.36 2.69 1.18 Deviation TABLE VII SUMMARY ANOVA — COHESION INDEX Sources of V a r i a t i o n SS MS D.F. Between 300.17 150.09 2 31.11* Within 197.82 4.83 41 * p << .05; .95 F 2, 41, = 3.23 TABLE VIII COHESION INDEX: POST HOC COMPARISONS Contrast Observed Value f ,=H.| . — H - i - 7.65* Yz*=H 1 =H -3. 3.38 Y 3 = H i = ^ - 3 . 11.04* NOTES: jH-|. = population mean corresponding to Cottage One. "^•2..= population mean corresponding to Cottage Two. H-3.= population mean corresponding to Cottage Three ~\p - observed values at ¥ using corresponding sample means. * pZ> .05; .95 CL 3, 42, = 3.44 79 Stage 2 Ef f e c t s of Staff Cohesion Level on Treatment Environment The e f f e c t of the l e v e l s of Cohesion on the s t a f f ' s perception of the treatment environment as r e f l e c t e d i n the COPES instrument, Forms R and I, was analysed using a multivariate analysis of variance (MANOVA). The means and standard deviations f o r COPES, Form R, and COPES, Form I, are presented i n Tables IX and X, re s p e c t i v e l y . Table XI shows the summary MANOVA table for COPES, Form R. Table XII gives the summary MANOVA table for COPES, Form I. As shown i n Table XI, there was a s i g n i f i c a n t cohesion e f f e c t (p < .05) on the s t a f f perception of the r e a l treatment environment, as r e f l e c t e d i n the scores on the COPES, Form R. The univariate F s t a t i s t i c s for the subscales are also shown i n Table XI. The subscales: Support (2), Autonomy (4), P r a c t i c a l Orientation (5), Personal Problem Orientation (6), and Staff Control (10) showed a s i g n i f i c a n t cohesion e f f e c t . Table XIII shows the post hoc comparisons for the e f f e c t of l e v e l s of cohesion on the COPES Form R subscales, using Tukey's procedure. These comparisons yielded the following r e s u l t s : 1. On the v a r i a b l e s , Support and Personal Problem Orientation, Cottage Two (low cohesion) i s s i g n i f i c a n t l y lower than the other cottages. 2. On the va r i a b l e , Autonomy, Cottages One and Two are s i g n i f i c a n t l y lower than Cottage Three. 3. On the va r i a b l e , P r a c t i c a l Orientation, Cottage Two i s s i g n i f i c a n t l y lower than Cottage Three. 4. On the v a r i a b l e , Staff Control, Cottage Two i s s i g n i f i c a n t l y higher than Cottage Three (high cohesion). TABLE IX OBSERVED CELL MEANS AND STANDARD DEVIATIONS COPES FORM R Variables 1 Involv. 2 Supp. 3 Spon. 4 Auto. 5 Pract. 6 Pers. 7 Anger 8 Order 9 C l a r i t y 10 Control 1 17.80 18.33 17.13 14.73 16.00 19.60 19.60 15.07 17.67 16.27 (MID.COH.) 1.57 1.35 1.06 1.91 1.65 .63 .74 1.98 2.09 .96 roups 2 16.93 16.13 16.60 14.20 14.87 17.93 19.13 14.40 17.07 17.27 roups (LOW COH.) 1.83 1.99 1.24 1.42 1.96 1.75 .83 2.03 2.9.1 1.58 Cottage G 3 18.28 18.07 17.64 16.21 17.00 19.07 19.14 14.93 17.57 15.21 Cottage G (HIGH COH.) 1.49 1.59 1.59 1.05 1.52 1.27 .95 1.33 1.55 1.37 Program 17.7 17.5 17.1 15.0 15.9 18.9 19.3 14.8 17.4 16.3 Means Deviation TABLE X OBSERVED CELL MEANS AND STANDARD DEVIATIONS COPES FORM I Variables 1 Involv. 2 Supp. 3 Spon. 4 Auto 5 Pract. 6 Pers. 7 Ang er 8 Order 9 C l a r i t y 10 Control 1 (MID.COH.) 19.00 1.07 18.73 1.91 18.33 1.35 17.27 2.05 17.73 2.19 19.40 .91 18. 80 1.01 15.13 2.67 18.53 1.77 14.87 2.13 roups 2 19.47 19.67 18.60 16.60 18.27 19.40 18. 00 17.60 19.60 14.87 roups (LOW COH.) .64 .49 .74 1.29 1.79 1.18 1.31 2.03 .74 2.39 o 60 3 19.14 19.42 18.64 16.57 17.64 19.50 19. 36 15.07 18.29 14.14 Cotta (HIGH COH.) .95 .76 .93 .85 1.65 .75 .93 2.20 1.82 1.83 Cotta Program Means 19.2 19.3 18.5 16.8 17.9 19.4 18. 7 15.9 18.8 14.6 Mean Standard Deviation oo TABLE XI MULTIVARIATE ANALYSIS OF VARIANCE COPES FORM R (REAL) Source M u l t i v a r i a t e Test Univariate Univariate F S t a t i s t i c s df F df 1 2 3 4 5 6 7 8 9 10 Between 20 2.83* 2 2.55 7.73* 2.29 6.85* 5.57* 6.41* 1.49 .56 .30 8.67* Within 64 41 2.69 2.78 1.72 2.29 2.97 1.69 .71 3.30 5.16 1.76 * p < : .05; .95 F 2, 41 = 3.23 TABLE XII MULTIVARIATE ANALYSIS OF VARIANCE COPES FORM I (IDEAL) Source M u l t i v a r i a t e Test Univariates Univariate F S t a t i s t i c s df F df 1 2 3 4 5 6 7 8 9 10 Between 20 1.3406 2 1.05 2.34 .39 1.02- .47 .05 5.59 5. 74 3 .12 .55 Within 64 41 .82 1.50 1 .08 2.24 3.59 .94 1.21 5. 37 2 .29 4.57 .95 F 2, 41 = 3.23 oo TABLE XIII POST HOC COMPARISONS FOR COHESION EFFECT Dependent Contrast Observed Value Variables 4.7* .6 4.51* % - R i . —M-i- 1.36 4 Vx-M.l. —H-3. 3.87* Autonomy ^ j _ R 3 5 > 1 5 * 2 V,-iW.,. Support =^-'' ""^ 5-Y.-M.i. - M . i - 2.56 P r a c t i c a l V ^ H ' - ~ ^ 2 ' 2 5 Orientation Vj^ff-a- ~^-3 4.79* -H . i . 4.91* 0 Personal -H.3- 1.56 Problem y 3*H.a- 3.53* Orientation - R a . 2.94 10 Y*=H.L -H.3. 3.00 Staff Control 4i=M.a. - H -3 . 5.86* NOTES: M x .. = population mean for Cottage One (Medium Cohesion) M 2 .. = population mean for Cottage Two (Low Cohesion) M 3 .. = population mean for Cottage Three (High Cohesion) = observed values of y using corresponding sample * p < . 0 5 : .95 V' 42, = 3.44 FIGURE 3 STAFF: COPES, FORM R. — SUBSCALE PROFILES "I f " I ™T f 1 1 1 1 1— 1 2 3 ^ 5 6 7 8 9 10 COPES Subscales. Cottage 1 ( Mid Cohesion ). Cottage 2 ( Low Cohesion ). Cottage 3 ( High Cohesion ). 85 Figure 3 shows the COPES subscale means for a l l cottages. As can be seen from Table XII, a m u l t i v a r i a t e analysis of variance revealed no s i g n i f i -cant differences between the cottages on the scores of the COPES, Form I, the p r o b a b i l i t y for a Type I error being set at p ""^  .05. This r e s u l t corres-ponded with the r e s u l t of a preliminary one-way ANOVA which also revealed no differences between cottages on t h i s v a r i a b l e . The s i g n i f i c a n t u n ivariate F s t a t i s t i c s found on variables 7 and 8 i n Table XII are examples of Type I er r o r s . Therefore, since there was no s i g n i f i c a n t v a r i a t i o n between cottages i n the COPES, Form I, scores (the s t a f f ' s perception of an Ideal treatment environment), the COPES, Form R ( s t a f f perception of the Real treatment environment) was taken as the dependent v a r i a b l e rather than the diff e r e n c e between COPES, Form R, and COPES, Form I. A one-way analysis of variance using the AN0V11 computer program (Carlson and Hazlett, 1971) was used to analyze the c l i e n t s ' perception of the r e a l treatment environment i n the d i f f e r e n t cottages, as measured by the COPES, Form R. These means and standard deviations are shown i n Table XIV and Table XV. A summary ANOVA i n Table XVI shows that there i s a s i g n i f i c a n t group mean difference between the c l i e n t groups and t h e i r perception of the treatment environment. Table XVII gives the post hoc comparisons, using Tukey's procedure to determine which contrasts between cottages were s i g -n i f i c a n t as regards the perception of r e a l treatment environment. As Table XVII shows, the only s i g n i f i c a n t group mean differe n c e on t h i s factor was between Cottages One (medium l e v e l cohesion) and Two (low l e v e l cohesion). The Cottage One mean was the lowest. The researcher, who observed the t e s t i n g s i t u a t i o n , noted at that time that the Cottage One group of c l i e n t s were p a r t i c u l a r l y r e b e l l i o u s , 86 rowdy and d i f f i c u l t to control compared with the other cottage groups. I t seems l o g i c a l to regard t h i s r e s u l t as a r e f l e c t i o n of the c l i e n t delinquent culture which existed i n Cottage One at t h i s time, and which manifested i t -s e l f i n the tes t i n g s i t u a t i o n . There were no s i g n i f i c a n t differences found between Cottage Three (high l e v e l cohesion) and Cottage Two (low l e v e l cohesion). Thus i n t h i s sample, high and low l e v e l s of s t a f f cohesion do not appear to a f f e c t the c l i e n t s ' perception of treatment environment. TABLE XIV COPES FORM R. SUBSCALE MEANS (CLIENTS, N = 30) Cottage 4.0 3.9 4.4 4.4 3.5 6.5 8.5 4.2 4.1 7.2 One Cottage 4.8 5.4 6.0 5.7 7.2 6.5 8.2 4.9 5.8 7.6 Two Cottage 4.6 5.2 6.8 5.0 5.3 6.9 8.9 3.2 5.2 7.0 Three 1 2 3 4 5 6 7 8 9 10 Subscales 87 TABLE XV MEANS AND STANDARD DEVIATIONS: COPES FORM R EASTON CLIENTS Cottage One Two Three Means 50.7 61.7 58.1 Standard Deviation 9.13 7.92 11.15 TABLE XVI SUMMARY ANOVA: COPES FORM R, CLIENTS Sources of S.S. M.S. O.F. F Va r i a t i o n Between 624.06 314.53 2 3.49* Within 2433.13 90.12 27 * p <^.05; - 9 5 P s, 27 = 3.35 88 TABLE XVII CLIENTS: POST HOC COMPARISONS FOR COHESION EFFECT Contrast Observed Value V 3.66* 2.47 1.19 'M^  ... = C l i e n t population mean for Cottage One (Medium Cohesion) M^ ... = C l i e n t population mean for Cottage Two (Low Cohesion) M^ ... = C l i e n t population mean for Cottage Three (High Cohesion) = Observed Values of using corresponding sample means. * p <C .05; .95 ^ 3, 27 = 3.56 TABLE XVIII COTTAGE OBSERVATIONS FOR THE MONTH OF JULY 1979 Cottage Une Two Three n = io 10 10 Locked Room Hours 52 (involving 3 subjects) 98 (involving 6 subjects,) 16.5 (involving 3 subjects) Number of Runaways 12 6 3 Viole n t Incidents (directed towards s t a f f ) 2 3 0 89 The l a s t part of the second stage of the analysis was to examine the cottage locked room hours, runaways and documented " s p e c i a l occurrences" or v i o l e n t incidents. These are shown i n Table XVIII. The amount of locked room time followed the same pattern as the v a r i a b l e s t a f f cohesiveness. That i s , the amount of locked room time was appreciably higher i n Cottage Two, the cottage with the lowest s t a f f group cohesion, lower i n Cottage One, and very low i n Cottage Three, the cottage with the highest l e v e l of s t a f f cohesion. The number of v i o l e n t incidents also appear to have increased as s t a f f cohesion decreased. These two observations appear to suggest that the cohesiveness of s t a f f does have some influence upon c l i e n t acting-out behaviour, or perhaps the methods by which s t a f f deal with such behaviour. The number of c l i e n t runaways was highest i n Cottage One, which at t h i s time was involved i n a highly delinquent c l i e n t sub-culture, one c l i e n t i n p a r t i c u l a r tending to p r e c i p i t a t e large group runaways. These data, because of the small number of groups involved (three cottages), cannot form the basis for any d e c i s i v e conclusions concerning the r e l a t i o n s h i p between c l i e n t behaviour and other v a r i a b l e s . I t can only suggest the nature of such r e l a t i o n s h i p s , i f indeed they do e x i s t . Stage 3 Stage 3 of the analysis i s more d e s c r i p t i v e i n nature and consists f i r s t of converting the c l i e n t s ' and s t a f f ' s subscale mean raw scores on the COPES Form R into standard scores based on the normative samples for the COPES instrument, which contained programs s i m i l a r to Easton, and c a l c u l a t i n g the o v e r a l l standard score program mean from these scores. These standard scores are given i n Tables XIX ( s t a f f ) and XX ( c l i e n t s ) . 90 I t i s then possible to create a program p r o f i l e which describes Easton i n r e l a t i o n to the average score obtained by members i n the American Normative Sample (Figure 4), and i n r e l a t i o n to that i n s t i t u t i o n ' s own stated goals and values (Figure 6) and which also delineates such factors as possible differences between s t a f f perceptions of the program and c l i e n t perceptions of the same program (Figure 5). i. Figure 4 suggests that the Easton program as perceived by the s t a f f i s only below average on the fa c t o r s , Autonomy, Order and Organization, and P r a c t i c a l " Orientation, the highest v a r i a b l e being Staff Control. The c l i e n t s ' perceptions (Figure 5) seem to d i f f e r from those of the s t a f f , p a r t i c u l a r l y on the v a r i a b l e s , Involvement, Support, Personal Proble Orientation, and Program C l a r i t y . A further discussion of these p r o f i l e s can be found i n the following chapter. I t i s , of course, not possible to draw clear conclusions from these p r o f i l e s without t e s t i n g the apparent differences which appear on the graphs for s t a t i s t i c a l s i g n i f i c a n c e . They must be viewed from a purely d e s c r i p t i v e perspective. Lem TABLE XIX STAFF: COPES FORM R, SUBSCALE. MEANS - STANDARD SCORES Subscales: 1 2 3 4 5 6 7 8 9 10 Cottage 63 65 62 42 54 79 77 34 59 61 One n = 16 n = 15 n = 14 Easton 60 62 60 34 40 69 66 45 51 71 Cottage Two 56 43 58 33 45 70 74 30 54 65 54 37 51 27 29 61 63 42 47 75 Cottage Three 71 65 71 56 66 82 79 34 64 53 66 62 67 45 56 71 68 45 55 64 Program Mean for 63 58 64 44 55 77 77 33 59 60 60 54 61 35 42 67 66 44 51 70 92 TABLE XX CLIENTS: COPES FORM R, SUBSCALE. MEANS - STANDARD SCORES Subscales 1 2 3 4 5 6 7 8 9 10 Cottage One 33 26 42 38 33 60 72 26 26 65 Cottage Two 41 39 54 51 62 60 69 34 45 69 Cottage Three 37 35 62 42 50 63 74 19 36 65 Program Mean for 37 33 53 44 48 61 72 26 36 66 Easton FIGURE 4 COPES FORM R — EASTON PROGRAM PROFILE (BASED ON STAFF NORMS) COPES Form R Subscales. * Mean f o r American Normative Sample. 94 FIGURE 5 EASTON PROFILE — CLIENTS AND STAFF (BASED ON CLIENT NORMS) COPES Form R Subscales. Mean f o r American Normative Sample. Cl i e n t s ( N=30 ) Staff ( N=44 ) 95 FIGURE 6 COPES: REAL AND IDEAL SCORES FOR EASTON PROGRAM (STAFF ONLY) COPES Subscales. Mean Score f o r Easton Cottages on COPES Form R ( R e a l ) . Mean Score f o r Easton Cottages on COPES Form I ( I d e a l ) . 96 CHAPTER V DISCUSSION OF THE RESULTS E f f e c t s of Staff Cohesion Level The o v e r a l l pattern of r e s u l t s coincided with the expectations and c l i n i c a l judgement of the Easton supervisory team, which was that the three cottages varied i n the cohesiveness of the s t a f f group, Cottage Three being the most cohesive and Cottage Two the l e a s t cohesive, and that these l e v e l s of cohesion affected the treatment environment and, by i m p l i c a t i o n , t r e a t -ment outcome. In general the empirical data appear to v a l i d a t e the convic-t i o n of the Easton unit that s t a f f cohesion i s re l a t e d to the q u a l i t y of the r e s i d e n t i a l treatment environment, as perceived by the s t a f f . The COPES instrument i d e n t i f i e d s p e c i f i c v a r i a b l e s ( d e f i n i t i o n s of which are given i n Appendix A) which the s t a f f perceived as being s i g n i f i c -antly influenced by cohesion l e v e l . For example, Autonomy was more i n evidence i n the highly cohesive cottage. This appears l o g i c a l when re l a t e d to the v a r i a b l e , S t a f f Control, which was higher i n the low cohesion cottage. One would expect Autonomy to vary inversely with the v a r i a b l e , Staff Control. S t a f f Control has a negative connotation at Easton, as i s i l l u s t r a t e d by the means for the COPES Form I (Table VIII) i n that the a b i l i t y to take respon-s i b i l i t y and become independent are seen as one of the main goals of a therapeutic community, and one of the prime tasks of adolescence. These two v a r i a b l e s , then, are c l o s e l y r e l a t e d to the treatment goals of an adolescent r e s i d e n t i a l u n i t . These two variables would also appear to r e l a t e to the number of locked room hours, which were consider-97 ably higher i n the low cohesion cottage. I t i s possible to deduce from these facts that c l i e n t autonomy i s perhaps' only possible when the s t a f f experience the " s o c i a l s o l i d a r i t y " which Bettelheim (1974) constantly r e f e r s to, and which he suggests gives the s t a f f a sense of s e c u r i t y which enables them to i n t e r a c t i n a more open and non-authoritarian manner with t h e i r c l i e n t s . The lack of s t a f f cohesion,on the other hand, would appear to r a i s e the need f o r structure, r u l e enforcement and s t a f f c o n t r o l i n general. P r a c t i c a l Orientation was also s i g n i f i c a n t l y affected by both high and low l e v e l s of cohesion. I t seems p l a u s i b l e that a cottage environment which i s promoting c l i e n t autonomy and does not f e e l the need for stringent s t a f f c o n t r o l i s also a place where plans for the future seem relevant, and where concrete s k i l l s can be taught and solutions to p r a c t i c a l problems can be explored. The COPES Subscales, Support and Personal Problem Orientation, are two v a r i a b l e s which express aspects of treatment that are very highly valued at Easton, where much emphasis i s placed on caring for others, v a l i d a t i n g and sharing i n d i v i d u a l f e e l i n g s , and learning to understand one's problems and behaviours. Cottages One and Three did not d i f f e r , on these v a r i a b l e s , but the v a r i a b l e s did appear to be negatively affected by the low l e v e l of s t a f f cohesion present i n Cottage Two. The fa c t that these two v a r i a b l e s are the highest scoring variables on the COPES, Form I. ( s t a f f ' s view of the Ideal treatment environment) speaks to t h e i r s i g n i f i c a n c e i n the Easton philosophy of treatment, and suggests that s t a f f cohesion very much a f f e c t s the a b i l i t y of the s t a f f to implement the Easton treatment philosophy. Bettleheim's (1974) point that the s t a f f i n such a centre need team co-hesiveness i n order to r e l a t e openly and t h e r a p e u t i c a l l y with t h e i r c l i e n t s again seems relevant here. I t would seem l o g i c a l that these variables are 98 also negatively affected by a high l e v e l of S t a f f Control. It now seems pertinent to consider the v a r i a b l e s which showed no s i g n i f i c a n t cohesion e f f e c t . F i r s t , Order and Organization were uniformly below average i n a l l cottages. The low value placed on t h i s v a r i a b l e i s i l l u s t r a t e d by the r e l a t i v e l y low Order and Organization mean value i n the s t a f f COPES, Form I. This area appears to be considered r e a l t i v e l y unimpor-tant regardless of the l e v e l of s t a f f cohesion. Five of the questions out of the ten which go to make up t h i s subscale, however, concern neatness and tidyness i n the environment. These may not seem l i k e the most s i g n i f i c a n t of v a r i a b l e s to s t a f f i n a cottage dealing with s e r i o u s l y disturbed adoles-cents and t h e i r behaviour patterns. The expression of anger and aggression, on the other hand, i s highly valued at Easton, and the v a r i a b l e so named has the highest mean value of a l l the variable s i n the COPES, Form R (completed by the s t a f f ) , and i s uniformly high regardless of the l e v e l of s t a f f cohesion. The expression of anger may have a d i f f e r e n t q u a l i t y , however, i n a cottage with high s t a f f control and low c l i e n t autonomy as compared with a cottage which had r e l a t i v e l y low s t a f f c ontrol and high c l i e n t autonomy. In any event, the general value which i s placed on the v e n t i l a t i o n of negative f e e l i n g s and assertion of i n d i v i d u a l needs i n the Easton program would appear to be strong enough to override any cohesion e f f e c t . There were no s i g n i f i c a n t differences between the cottages on the v a r i a b l e , Spontaneity. This i s a l i t t l e s u r p r i s i n g i n that such a v a r i a b l e would appear to t i e i n with the v a r i a b l e s , Personal Problem Orientation and Support. I t may be that the general values of the unit are again operating here since Spontaneity (expressing yourself and your f e e l i n g ) , l i k e Anger and Aggression, i s seen as a p o s i t i v e value at Easton. 99 The lack of a cohesion e f f e c t for the va r i a b l e , Program C l a r i t y , would seem to be rela t e d to the standardization of the program structure throughout the unit, which i s perhaps clearer to the s t a f f than to the c l i e n t s . Rules, routines and expectations are made e x p l i c i t to the s t a f f and follow a s i m i l a r general structure i n a l l cottages. The s t a f f also seem to share a common treatment philosophy (see following s e c t i o n ) . I t i s i n t e r e s t i n g to note that the c l i e n t s did not agree with the s t a f f con-cerning the l e v e l of Program C l a r i t y operating at Easton (see Figure 5). The lack of a cohesion e f f e c t for the v a r i a b l e , Involvement, can be seen i n the context of the s t a f f ' s overview of the Easton program a c t i v i t i e s , such as school, arts and c r a f t s , a r t therapy, and recreation. To the s t a f f , i t may appear that the environment i s very stimulating and that the c l i e n t s are r e l a t i v e l y busy and involved i n the program. Staff Perceptions of Ideal Treatment Environment (COPES, Form I) The fi n d i n g of no s i g n i f i c a n t differences between the three cottages on the COPES, Form I, or Ideal Program Environment Scale, requires comment. O r i g i n a l l y , the researcher had planned to use the dif f e r e n c e score between COPES, Form R, and COPES, Form I, as the measure of the q u a l i t y of the perceived treatment environment. However, since there were no s i g n i f i -cant difference between the cottages on t h i s t e s t , and thus any variance r e f l e c t e d i n such difference scores would simply be a r e f l e c t i o n of the variance i n the COPES, Form R, scores, i t was decided to simply use the COPES, Form R, score for t h i s purpose. Obviously, i f the differ e n c e scores were used, Cottage Three, the highly cohesive cottage with the highest scores on the COPES, Form R, would be closest to the Ideal. However, the fact i t s e l f that there were no cottage differences measured on t h i s instrument suggests that Easton as a unit has a uniform, 100 clear and consistent set of treatment i d e a l s that are subscribed to by the majority of the s t a f f . Bettelheim (1974) states that a c l e a r commitment to a consistent treatment philosophy i s e s s e n t i a l i n r e s i d e n t i a l treatment. These r e s u l t s suggest that Easton has exactly t h i s . What are the i d e a l s which the Easton s t a f f adhere to? According to the r e s u l t s of t h i s test (Figure 6), the highest value i s placed on the Relationship Dimension v a r i a b l e s of Support, Involvement, and Spontaneity, on the Treatment Program Dimension v a r i a b l e s of Personal Problem Orientation, and Anger and Aggression, and on the System Maintenance Dimension v a r i a b l e of Program C l a r i t y . Order and Organization and Staff Control are seen by the Easton s t a f f as being r e l a t i v e l y unimportant i n the Ideal treatment environment. The v a r i a b l e s valued here would appear to be those which sup-port an i n t e r a c t i o n orientated m i l i e u where there i s considerable freedom of expression, sharing of personal problems and an attempt to understand or gain i n s i g h t into the dynamics of such problems. The use of COPES, Form I, also makes possible a comparison between Real and Ideal scores (Figure 6) which could be then used as a form of pro-cess evaluation for the Easton unit, giving the Easton s t a f f s p e c i f i c information as to which variables the majority of t h e i r peers appear to value and see as needing improvement. C l i e n t s ' Perceptions of Real Treatment Environment (COPES, FORM R) One s i g n i f i c a n t difference between cottages was found on t h i s t e s t . Cottage One (average cohesion) c l i e n t s had a s i g n i f i c a n t l y more negative perception of t h e i r treatment environment than the c l i e n t s i n Cottage Two. It was the consensus of the Easton supervisory group and the Cottage One s t a f f that a formidable peer group delinquent culture existed i n the Cottage at t h i s time. The number of c l i e n t runaways for the month of July 101 also r e f l e c t s the existence of such a c u l t u r e . I t i s suggested that t h i s peer group delinquent culture negatively biased the r e s u l t s of the COPES i n Cottage One. As to the reasons for the uniformity of c l i e n t perceptions of the environment i n cottages with low and high s t a f f cohesion l e v e l s , many con-jectures can be made. The r e s u l t s may have been influenced by the f a c t that the test i t s e l f i s a l i t t l e long (100 items) for c l i e n t s who tend as a group to be d i s t r a c t i b l e and e a s i l y f r u s t r a t e d . C l i e n t s , too, may genuinely not be able to discriminate c l e a r l y concerning the treatment v a r i a b l e s i n t h e i r environment. Goffman (1961) proposes that i n an i n s t i t u t i o n two d i f f e r e n t s o c i a l and c u l t u r a l worlds develop, one of the c l i e n t s and one of the s t a f f , and that there i s i n fact l i t t l e contact between them. If i n f a c t t h i s was so, the c l i e n t perceptions of t h e i r environment would be made from a t o t a l l y d i f f e r e n t perspective than that of the s t a f f . Moos (1974) states that s t a f f are generally more p o s i t i v e about treatment programs than c l i e n t s . Obser-vations of the Easton Alumni group meetings, which c l i e n t s attend j u s t before discharge, suggest to the researcher that while i n the program the peer culture pressures the c l i e n t to view the Easton program negatively. However, upon leaving the program, the c l i e n t often appears to change his perspective to a more p o s i t i v e one. This observation may be biased, however, since c l i e n t s who continued to view the program i n a very negative l i g h t would not be l i k e l y to attend the Alumni group meetings. C l i e n t Behaviours Moos (1974) states, "moderate to substantial r e l a t i o n s h i p s e x i s t between average patient behavioural c h a r a c t e r i s t i c s ( i . e . disturbed behaviour) and treatment environment" (p. 143). Examining the recorded c l i e n t behaviours 102 i n the cottages for the month of July, one finds that two of these behaviours do decrease as s t a f f cohesion r i s e s . I t i s not c l e a r , however, i f these f i g -ures r e f l e c t the frequency and s e v e r i t y of c l i e n t acting out or simply the s t a f f methods of dealing with such c r i s e s . A s t a f f who i s part of a highly cohesive team, working i n a cottage which focusses on autonomy and minimises s t a f f c ontrol, may not use the locked room to control acting out behaviour, or may be more e a s i l y able to defuse a p o t e n t i a l l y v i o l e n t s i t u a t i o n . Whether these observations are a r e f l e c t i o n of c l i e n t behaviour or s t a f f reactions to that behaviour, or both, they remain i n t e r e s t i n g and suggest the kind of l i n k which treatment environment may have with treatment outcome i n that frequent violence or other behaviours which necessitate many hours i n the locked room are often preludes to premature discharge from the Easton program. Discussion of Program P r o f i l e s Easton i n Relation to Other Programs Moos (1974) states that, "wards that are successful i n keeping patients out of the h o s p i t a l emphasise Autonomy and Independence, a P r a c t i c a l Orientation, Order and Organization, and a reasonable degree of Staff Control. They also emphasise Personal Problem Orientation and the free and open expression of Anger" (p. 196). Taking the f i r s t three v a r i a b l e s (see Figure 4), one would not predict long community tenure for Easton c l i e n t s a f t e r discharge. The l a s t two, however, are very much part of the Easton program. I t i s d i f f i c u l t to compare such programs. Easton i s not a "ward", and i s orientated towards a s p e c i a l kind of c l i e n t . Nevertheless, the COPES p r o f i l e enables Easton to compare the environment variables operating i n t h e i r program to those of other programs and to consider outcome studies such as the one above i n the l i g h t of the 103 Easton program. The s i g n i f i c a n c e and i n t e r r e l a t i o n s h i p of the environmental v a r i a b l e s have been already discussed. I t i s worth noting again, perhaps, that the s t a f f perceives the Easton Program to be above average on a l l COPES vari a b l e s , except Autonomy, Order and Organization and P r a c t i c a l Orientation. C l i e n t arid Staff Perceptions of the Easton Program The perceptions of the c l i e n t s and s t a f f concerning the Easton environ-ment appear to d i f f e r considerably (see Figure 5) e s p e c i a l l y on the v a r i a b l e s Program C l a r i t y , Involvement and Support and somewhat on Personal Problem Orientation. Moos i n the COPES manual states that members and s t a f f generally perceive a r e l a t i v e l y s i m i l a r emphasis on Relationship (variables 1, 2, 3) and System Maintenance (variables 8, 9, 10) dimensions. This suggests that a discrepancy as wide as the one found i s not a generally expected occur-rence. This poses many questions. Is t h i s , as was suggested concerning the c l i e n t s COPES, Form R, scores, a r e f l e c t i o n of a two-culture s p l i t at Easton? Are the s t a f f misjudging the e f f e c t of the program on the c l i e n t s i n these areas of r e l a t i o n s h i p and program c l a r i t y ? The c l i e n t s seemingly are not perceiving the program r u l e s , procedures and expectations as c l e a r l y as the s t a f f believe. This v a r i a b l e i s an area where the s t a f f i d e a l i s somewhat higher than the present r e a l i t y (Figure 6), which suggests that the s t a f f recognise the need for improvement i n t h i s area. The c l i e n t s apparently also perceive themselves as l e s s involved i n the day to day programming and le s s supported by other c l i e n t s and s t a f f than the s t a f f perspective would suggest. The majority of s t a f f seem to believe that there i s an above average degree of sharing and encouragement i n the program. The c l i e n t s appear to disagree. What may be viewed as support from the point of view of the s t a f f culture perhaps may not be seen i n the same l i g h t by the adolescent c l i e n t . The s t a f f and c l i e n t s agree, 104 however, that there i s r e l a t i v e l y l i t t l e encouragement for the c l i e n t s to be autonomous and independent, and that order and organization are low, while s t a f f control seems to be above average. They also agree concerning the main focus of the program, namely, the variables Personal Problem Orientation and Anger and Aggression. It i s not possible to draw clear conclusions from t h i s data without testing the apparent differences for s t a t i s t i c a l s i g n i f i c a n c e . S t a f f Perceptions of the Real versus the Ideal Environment The COPES p r o f i l e s show discrepancies i n the Real and Ideal t r e a t -ment environments (see Figure 6) which could be used as d e s c r i p t i v e data i n an ongoing process evaluation. The Anger and Aggression score i s the only Real score which appears higher than i t s corresponding Ideal score. The Easton s t a f f seem to believe that there i s a l i t t l e too much expression of negative f e e l i n g s i n the cottages. The Staff Control score i s the only Ideal score that i s lower than i t s Real counterpart. This seems to imply that i d e a l l y the Easton s t a f f would l i k e to play a l e s s parental and a u t h o r i t a r i a n r o l e . The p r o f i l e seems to suggest that the Easton s t a f f p a r t i c u l a r l y f e e l the need to improve the program i n the r e l a t i o n s h i p dimension and i n the area of c l i e n t autonomy, to help t h e i r c l i e n t s f i n d more solutions to p r a c t i c a l problems, and to create more c l a r i t y regarding the expectations and goals of the program for the c l i e n t s , while reducing the l e v e l of s t a f f c o n t r o l . 1 0 5 CHAPTER VI SUMMARY AND CONCLUSIONS Summary of the Study In 1959, Fritz Redl, one of the pioneers of residential treatment in North America, emphasised the need for the clinical assessment of the relative impact of the identified key variables which constitute a residen-t i a l "therapeutic milieu". He saw this as an "urgent" task. Since that time, the number of residential treatment centres has continued to grow (Pappenfort and Dinwoodie, 1970) and the cost of such treatment, always high, has continued to rise. In addition, the issue of accountability has come more and more to the forefront in this field, as in education and the social sciences in general. It appears, then, that the task outlined by Fritz Redl has become even more urgent. This point is stressed by Durkin and Durkin (1975) who emphasise the need for process evaluation of residential treatment programs and suggest that an approach which re-lates treatment process variables to functional and dysfunctional aspects of such programs are generally more useful than the more usual but d i f f i -cult outcome studies. What, then, are the key process variables involved in a residential therapeutic milieu? Many such variables have been identified, but the factor that is stressed in the literature as being the most crucial is the treatment staff and their ability to work together as a cohesive team (Easson, 1969; Bettelheim, 1974). The pertinent question i s , then, which specific vari-ables in a treatment environment are influenced by a factor such as staff cohesion? 106 To turn from the general to the p a r t i c u l a r , the Easton r e s i d e n t i a l treatment program, the subject of t h i s study, i s i n 1980 on the verge of a su b s t a n t i a l expansion, and also taking the f i r s t steps towards recognising the need for process evaluation of the program. The Easton program has focussed p a r t i c u l a r l y on s t a f f cohesion as the main bui l d i n g block i n residen-t i a l treatment. I t appears, then, that t h i s s e t t i n g i s a p a r t i c u l a r l y appro-p r i a t e one to use i n an attempt to begin to tackle the urgent task outlined by Redl, more s p e c i f i c a l l y , to look at the cohesiveness of s t a f f teams and to attempt to assess the impact of t h i s v a r i a b l e on the treatment environment. In order to do t h i s , the s t a f f i n the three r e s i d e n t i a l cottages at Easton were given the Seashore Group Cohesiveness Index (Seashore, 1954) to determine i f d i f f e r e n t l e v e l s of t h i s factor were indeed present. The Easton supervisory team believed that such l e v e l s d i d indeed e x i s t at t h i s time. An analysis of the Cohesiveness Index resulted i n the d e l i n e a t i o n of three l e v e l s of cohesion: high, average or medium, and low. These s t a f f groups were then assessed as to t h e i r perceptions of the r e a l treatment environment and the i d e a l treatment environment, as assessed by the COPES, Forms R and I (Moos, 1974), the hypothesis being that the more cohesive the s t a f f group the higher the q u a l i t y of the perceived treatment environment. The cottage c l i e n t groups were also asked to evaluate t h e i r treatment environment, the hypothesis being that the more cohesive the s t a f f group the more p o s i t i v e the c l i e n t perception of the environment would be. The incidence of c l i e n t acting out behaviour was also examined, the expectation being that there would be le s s acting out on the part of c l i e n t s as the l e v e l of s t a f f cohesion rose. F i n a l l y , a program p r o f i l e of Easton was constructed using standard scores on the COPES, Form R, instrument i n order to describe Easton i n r e l a t i o n to other s i m i l a r programs and i n r e l a t i o n to the aims and goals of 107 Easton i t s e l f . Conclusions of the Study 1. The l e v e l of s t a f f group cohesion i s re l a t e d to the q u a l i t y of the treatment environment as perceived by the s t a f f . S p e c i f i c a l l y , a s i g -n i f i c a n t cohesion e f f e c t was found on the following environmental v a r i a b l e s (see Appendix A for def initions.. of. these v a r i a b l e s ) : a) Support and Personal Problem Orientation were s i g n i f i c a n t l y lower i n the cottage where the s t a f f group exhibited a low cohesion l e v e l . b) Autonomy was s i g n i f i c a n t l y higher i n the cottage where s t a f f exhibited a high cohesion l e v e l . c) P r a c t i c a l Orientation was s i g n i f i c a n t l y lower i n the cottage with low s t a f f cohesiveness as compared to the cottage with high s t a f f cohesiveness. d) Staff Control was s i g n i f i c a n t l y higher i n the cottage with low s t a f f cohesiveness. e) The variables that did not appear to be s i g n i f i c a n t l y influenced by l e v e l s of s t a f f cohesion were: Involvement, Spontaneity, Anger and Aggression, Order and Organization, and Program C l a r i t y . 2. The c l i e n t perception of the treatment environment did not appear to be affected by the l e v e l of s t a f f cohesion. The cottage with an average l e v e l of cohesion, however, was associated with the most negative c l i e n t perception of the environment, perhaps r e f l e c t i n g the strong peer group delinquent culture present i n the cottage. The c l i e n t locked room hours and number of v i o l e n t incidents, however, did correspond with the pattern of s t a f f cohesiveness i n the cottages. 108 3. There appears to be a high l e v e l of consensus concerning the Ideal treatment environment among the Easton s t a f f . 4. The program p r o f i l e s suggest that the Easton Program as perceived by the s t a f f i s above average on a l l the COPES environmental v a r i a b l e s ex-cept Autonomy, and Order and Organization, and P r a c t i c a l Orientation, and that c l i e n t perceptions appear to d i f f e r from those of the s t a f f p a r t i c u l a r l y with respect to the v a r i a b l e s , Involvement, Support, Personal Problem Orientation, and Program C l a r i t y . Implications of the Study The main implications of t h i s study would appear to be that: 1. S t a f f cohesion i s a s i g n i f i c a n t v a r i a b l e i n r e l a t i o n to the q u a l i t y of a treatment environment, and thus should be f a c i l i t a t e d and fostered by systematic means. 2. The COPES, Forms R and I, have considerable value i n the d e s c r i p t i o n and process evaluation of r e s i d e n t i a l treatment centres. 3. Other variables such as group values and judgements, and c l i e n t peer group pressure also need to be delineated and taken into account i n the evaluation of r e s i d e n t i a l treatment. 4. C l i e n t s such as those i n residence at Easton may perceive t h e i r ^environment from a d i f f e r e n t perspective than that of the s t a f f . Suggestions for Further Research There are other process v a r i a b l e s , such as those mentioned above, which could provide f r u i t f u l areas of enquiry and new perspectives on the mechanisms of r e s i d e n t i a l treatment. However, the outstanding need i n the f i e l d at the moment i s for a study which combines process v a r i a b l e s such as 109 s t a f f cohesion, peer group culture and program value structure with measures of treatment outcome. In such a study, i t i s f e a s i b l e to r e l a t e process va r i a b l e s to treatment environment, and treatment environment to s p e c i f i c indices of treatment outcome. Thus i t should be possible to determine not only i f r e s i d e n t i a l treatment works, for whom and under what circumstances, but also how s p e c i f i c elements of such treatment programs a f f e c t treatment outcome, that i s , how r e s i d e n t i a l treatment works. Only then can successful treatment strategies be duplicated and generalized. The methodological constraints which:'confront such a study are severe. However, studies which out l i n e the e f f e c t of process v a r i a b l e s are the ground on which such an outcome study should l o g i c a l l y be based. 110 BIBLIOGRAPHY Adler, A. "General concepts i n the r e s i d e n t i a l treatment of disturbed c h i l d r e n , " C h i l d Welfare, 1968, 47, 519-23. Aichhorn, A. Wayward Youth. New York: Viking Press, 1934. 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How does your work group compare with other work groups at Easton i n the way the people get along? (1) ' Better than most. (2) _____ About the same as most. (3) ' Not as good as most. How does your work group compare with other work groups at Easton when i t comes to s t i c k i n g together to get what the group wants? (1) Better than most. (2) '' About the same as most. (.3) ' Not as good as most. How does your work group compare with other work groups at Easton i n the way the people help each other on the job? (1) Better than most. (2) ______ About the same as most. (3) ' Not as good as most. What three people i n the cottage do you see most of s o c i a l l y (both during and a f t e r working hours)? 7. What three people i n the cottage do you most l i k e to work with? (1) :  (2) (3) NOTE: The f i r s t f i v e items of t h i s questionnaire constitute the Seashore Index of Group Cohesiveness. The l a s t two items are Sociometric questions. 120 COPES SUBSCALES AND DEFINITIONS Involvement Support Spontaneity Autonomy P r a c t i c a l Orientation Person Problem Orientation Anger and Aggression Order and Organization Program C l a r i t y Staff Control measures how act i v e members are i n the day-to-day functioning of t h e i r programs, i . e . , spending time constructively, being enthusiastic, doing things on th e i r own i n i t i a t i v e . measures the extent to which members are encouraged to be h e l p f u l and supportive towards other members, and how supportive the s t a f f i s towards members. measures the extent to which the program encourages members to act openly and express t h e i r f e e l i n g s openly. assesses how s e l f - s u f f i c i e n t and independent members are encouraged to be i n making t h e i r own decisions about t h e i r personal a f f a i r s (what they wear, where they go) and i n t h e i r r e l a t i o n s h i p s with the s t a f f . assesses the extent to which the member's environment orients him towards preparing himself f o r release from the program. Such things as t r a i n i n g f o r new kinds of jobs, looking to the future, and setting and working towards goals are considered. measures the extent to which members are encouraged to be concerned with t h e i r personal problems and fee l i n g s and to seek to understand them. measures the extent to which a member i s allowed and encouraged to argue with members and s t a f f , to become openly angry and to display other aggressive behaviour measures how important order and organization i s i n the program, i n terms of members (how do they look), s t a f f (what they do to encourage order) and the house i t s e l f (how well i s i t kept). measures the extent to which the member knows what to expect i n the day-to-day routine of h i s program and how e x p l i c i t the program rules and procedures are. assesses the extent to which the s t a f f use measures to keep members under necessary controls, i . e . , i n the formulation of r u l e s , the scheduling of a c t i v i t i e s and i n the r e l a t i o n s h i p s between members and s t a f f . Copes Manual (Moos, 1974). -COMMUNITY ORIENTED PROGRAMS ENVIRONMENT SCALE FORM R Rudolf H. Moos, Phd. Instructions There are 100 short statements i n t h i s booklet. There are statements about programs. Please decide which statements are true of your program and which are not. On the separate answer sheet, mark under T (True) when you think the s t a t e -ment i s true, or mostly true of your program; mark under F (False) when you think the statement i s f a l s e , or mostly f a l s e . Please be sure to answer every statement and to f i l l i n your name and the other information requested. Do not make any marks on t h i s booklet. CONSULTING PSYCHOLOGISTS PRESS, INC. 527 College Avenue, Palo A l t o , C a l i f o r n i a , 94306. 122 1. Members put a l o t of energy into what they do around here. 2. The heal t h i e r members here help take care of the less healthy ones. 3. Members tend to hide t h e i r f e e l i n g s from one another. 4. There i s no membership government i n t h i s program. 5. This program emphasizes t r a i n -ing for new kinds of jobs. 6. Members hardly ever discuss t h e i r sexual l i v e s . 7. I t ' s hard to get people to argue around here. 8. Members' a c t i v i t i e s are care-f u l l y planned. 9. If a member breaks a r u l e , he knows what the consequences w i l l be. 10. Once a schedule i s arranged for a member, the member must follow i t . 11. This i s a l i v e l y place. 12. Staff have r e l a t i v e l y l i t t l e time to encourage members. 13. Members say anything they want to the s t a f f . 14. Members can leave here any-time without saying where .they are going. 15. There i s r e l a t i v e l y l i t t l e emphasis on teaching members solutions to p r a c t i c a l problems. 16. Personal problems are openly talked about. 17. Members often c r i t i c i z e or joke about the s t a f f . 18. This i s a very well organized program. 19. If a member's program i s changed, s t a f f always t e l l him why. 20. The s t a f f very r a r e l y punish members by taking away t h e i r p r i v i l e g e s . 21. The members are proud of t h i s program. 22. Members seldom help each other 23. I t i s hard to t e l l how members are f e e l i n g here. 24. Members are expected to take leadership here. 25. Members are expected to make det a i l e d , s p e c i f i c plans for the future. 26. Members are r a r e l y asked per-sonal questions by the s t a f f . 27. Members here r a r e l y argue. 28. The s t a f f make sure that t h i s place i s always neat. 29. St a f f r a r e l y give members a det a i l e d explanation of what the program i s about. 30. Members who break the rules are punished for i t . 31. There i s very l i t t l e group s p i r i t i n t h i s program. 32. Staff are very interested i n following up members once they leave the program. 33. Members are c a r e f u l about what they say when s t a f f are around. 34. The s t a f f tend to discourage c r i t i c i s m from members. 35. There i s r e l a t i v e l y l i t t l e d i s -cussion about exactly what members w i l l be doing a f t e r they leave the program. 36. Members are expected to share t h e i r personal problems with each other. 37. St a f f sometimes argue openly with each other. 123 38. This place usually looks a l i t t l e messy. 39. The program rules are c l e a r l y understood by the members. 40. I f a member f i g h t s with another member, he w i l l get into r e a l trouble with the s t a f f . 41. Very few members ever volunteer around here. 42. Staff always compliment a member who does something w e l l . 43. Members are strongly encour-aged to express themselves f r e e l y here. 44. Members can leave the pro-gram whenever they want to. 45. There i s r e l a t i v e l y l i t t l e emphasis on making s p e c i f i c plans for leaving t h i s program. 46. Members t a l k r e l a t i v e l y l i t t l e about t h e i r past. 47. Members sometimes play p r a c t i c a l jokes on each other. 48. Members here follow a regular schedule every day. 49. Members never know when s t a f f w i l l ask to see them. 50. Staff don't order the members around. 51. A l o t of members ju s t seem to be passing time here. 52. The s t a f f know what the members want. 53. Members spontaneously' set up t h e i r own a c t i v i t i e s here. 54. Members can wear whatever they want. 55. Most members are more con-cerned with the past than with the future. 56. Members t e l l each other about t h e i r intimate personal pro-blems . 57. S t a f f encourage members to express th e i r anger openly here. 58. Some members look messy. 59. The members always know when the s t a f f w i l l be around. 60. I t i s important to c a r e f u l l y follow the program r u l e s here. 61. This program has very few s o c i a l a c t i v i t i e s . 62. Staff sometimes don't show up for t h e i r appointments with members. 63. When members disagree with each other, they keep i t to them-selves . 64. The s t a f f almost always act on members' suggestions. 65. Members here are expected to demonstrate continued concrete progress toward t h e i r goals. 66. Staff are mainly interested i n learning about members' f e e l i n g s . 67. Staff here never s t a r t arguments. 68. Things are sometimes very disorganized around here. 69. Everyone knows who's i n charge here. 70. Members can c a l l s t a f f by th e i r f i r s t names. 71. Members are pretty busy a l l of the time. 72. There i s r e l a t i v e l y l i t t l e sharing among the members. 73. Members can generally do whatever they f e e l l i k e here. (Continued) 124 74. Very few members have any r e s p o n s i b i l i t y f o r the program here. 75. Members are taught s p e c i f i c new s k i l l s i n t h i s program. 76. The members r a r e l y t a l k with each other about t h e i r per-sonal problems. 77. Members often gripe. 78. The dayroom or l i v i n g room i s often untidy. 79. People are always changing t h e i r meinds here. 80. Members may interrupt s t a f f when they are t a l k i n g . 81. Discussions are very i n t e r e s t -ing here. 82. Members are given a great deal of i n d i v i d u a l attention here. 83. Members tend to hide t h e i r f e e l i n g s from the s t a f f . 84. Members here are very strongly encouraged to be independent. 85. Staff care more about how members f e e l than about t h e i r p r a c t i c a l problems. 86. Members are r a r e l y encouraged to discuss t h e i r personal problems here. 87. Staff here think i t i s a healthy thing to argue. 88. Members are r a r e l y kept waiting when they have appointments with s t a f f . 89. Members never quite know when they w i l l be considered ready to leave t h i s program. 90. Members w i l l be transferred or discharged from t h i s pro-gram i f they don't obey the r u l e s . 91. Members often do things together on weekends. 92. The s t a f f go out of t h e i r way to help new members get acquainted here. 93. Members are strongly encouraged to express t h e i r f e e l i n g s . 94. Staff r a r e l y give i n to pressure from members. 95. Members must make de t a i l e d plans before leaving t h i s program. 96. S t a f f strongly encourage members to t a l k about t h e i r pasts. 97. Members r a r e l y become angry here. 98. The s t a f f strongly encour-ages members to be neat and orderly here. 99. There are often changes i n the rules here. 100. The s t a f f make and enforce a l l the rules here. 125 COMMUNITY ORIENTED PROGRAMS ENVIRONMENT SCALE (COPES FORM I) (Moos, R. H., 1974) There are 100 statements i n t h i s booklet. They are statements about programs. They ask you what you think an Ideal Program would be l i k e . You are to decide which of these statement would be true of an Ideal  Program and which would be f a l s e . True — Mark beside the T i f you think the statement i s TRUE, or mostly true, of an Ideal Program. False — Mark beside the F i f you think the statement i s FALSE or mostly f a l s e , of an Ideal Program. Please be sure to answer every statement. 1. Members w i l l put a l o t of energy into what they do. 2. The h e a l t h i e r members w i l l help take care of the less healthy ones. 3. Members w i l l tend to hide t h e i r f e e l i n g s from one another. 4. There w i l l be no membership government i n the program. 5. The program w i l l emphasize t r a i n i n g for new kinds of jobs. 6. Members w i l l hardly ever discuss t h e i r sexual l i v e s . 7. I t w i l l be hard to get people to argue. 8. Members' a c t i v i t i e s w i l l be c a r e f u l l y planned. 9. If a member breaks a r u l e , he w i l l know what the consequences w i l l be. 10. Once a schedule i s arranged for a member, the member w i l l have to follow i t . 11. I t w i l l be a l i v e l y place. 12. Staff w i l l have r e l a t i v e l y l i t t l e time to encourage members. 13. Members w i l l say anything they want to the s t a f f . 14. Members w i l l be able to leave anytime without saying where they are going. 126 15. There w i l l be r e l a t i v e l y l i t t l e emphasis on teaching members solutions to p r a c t i c a l problems. 16. Personal problems w i l l be openly talked about. 17. Members w i l l often c r i t i c i z e or joke about the s t a f f . 18. I t w i l l be a very well organized program. 19. If a member's program i s changed, s t a f f w i l l always t e l l him why. 20. The s t a f f w i l l very r a r e l y punish members by taking away t h e i r p r i v i l e g e s . 21 The members w i l l be proud of the program. 22. Members w i l l seldom help each other. 23. I t w i l l be hard to t e l l how members are f e e l i n g . 24. Members w i l l be expected to take leadership. 25. Members w i l l be expected to make detai l e d s p e c i f i c plans for the future. 26. Members r a r e l y w i l l be asked personal questions by the s t a f f . 27. Members w i l l r a r e l y argue. 28. The s t a f f w i l l make sure that the place i s always neat. 29. Staff w i l l r a r e l y give members a detai l e d explanation of what the program i s about. 30. Members who break the rules w i l l be punished f o r i t . 31. There w i l l be very l i t t l e group s p i r i t i n the program. 32. S t a f f w i l l be very interested i n following up members once they leave the program. 33. Members w i l l be c a r e f u l about what they say when s t a f f are around. 34. The s t a f f w i l l tend to discourage c r i t i c i s m from members. 35. There w i l l be r e l a t i v e l y l i t t l e discussion about exactly what members w i l l be doing a f t e r they leave the program. 36. Members w i l l be expected to share t h e i r personal problems with each other. 37. Staff w i l l sometimes argue openly with each other. 38. The place w i l l usually look a l i t t l e messy. 39. The program rules w i l l be c l e a r l y understood by the members. 40. If a member f i g h t s with another memver, he w i l l get into r e a l trouble with the s t a f f . 41. Very few members w i l l ever volunteer. 42. Staff w i l l always compliment a member who does something w e l l . 43. Members w i l l be strongly encouraged to express themselves f r e e l y . 44. Members w i l l be able to leave the program whenever they want to. 45. There w i l l be r e l a t i v e l y l i t t l e emphasis on making s p e c i f i c plans for leaving the program. 127 46. Members w i l l t a l k r e l a t i v e l y l i t t l e about t h e i r past. 47. Members w i l l sometimes play p r a c t i c a l jokes on each other. 48. Members w i l l follow a regular schedule every day. 49. Members w i l l never know when s t a f f w i l l ask to see them. 50. Staff won't order the members around. 51. A l o t of members w i l l j u s t seem to be passing time. 52. The s t a f f w i l l know what the members want. 53. Members w i l l spontaneously set up t h e i r own a c t i v i t i e s . 54. Members w i l l be able to wear whatever they want. 55. Most members w i l l be more concerned with the past than with the future. 56. Members w i l l t e l l each other about t h e i r intimate personal problems. 57. S t a f f w i l l encourage members to express t h e i r anger openly. 58. Some members w i l l look messy. 59. The members w i l l always know when the s t a f f w i l l be around. 60. I t w i l l be important to c a r e f u l l y follow the program r u l e s . 61. The program w i l l have very few s o c i a l a c t i v i t i e s . 62. Staff sometimes w i l l not show up for t h e i r appointments with members. 63. When members disagree with each other, they w i l l keep i t to themselves. 64. The s t a f f w i l l almost always act on members' suggestions. 65. Members w i l l be expected to demonstrate continued concrete progress toward t h e i r goals. 66. Staff w i l l be mainly interested i n learning about members' f e e l i n g s . 67. Staff w i l l never s t a r t arguments. 68. Things w i l l sometimes be very disorganized. 69. Everyone w i l l know who's i n charge. 70. Members w i l l c a l l s t a f f by t h e i r f i r s t names. 71. Members w i l l be pretty busy a l l of the time. 72. There w i l l be r e l a t i v e l y l i t t l e sharing among the members. 73. Members w i l l generally do whatever they f e e l l i k e . 74. Very few members w i l l have any r e s p o n s i b i l i t y for the program. 75. Members w i l l be taught s p e c i f i c new s k i l l s i n the program. 76. The members w i l l r a r e l y t a l k with each other about t h e i r personal problems. 77. Members w i l l often gripe. 78. The dayroom or livingroom w i l l often be untidy. 128 79. People w i l l always be changing t h e i r minds. 80. Members w i l l be able to interrupt s t a f f when they are t a l k i n g . 81. Discussions w i l l be very i n t e r e s t i n g . 82. Members w i l l be given a great deal of i n d i v i d u a l a t t e n t i o n . 83. Members w i l l tend to hide t h e i r f e e l i n g s from the s t a f f . 84. Members w i l l be very strongly encouraged to be independent. 85. Staff w i l l care more about how members f e e l than about t h e i r p r a c t i c a l problems. 86. Members w i l l r a r e l y be encouraged to discuss t h e i r personal problems. 87. Staff w i l l think i t i s a healthy thing to argue. 88. Members w i l l r a r e l y be kept waiting when they have appointments with s t a f f . 89. Members w i l l never quite know when they w i l l be considered ready to leave the program. 90. Members w i l l be transferred or discharged from the program i f they don't obey the r u l e s . 91. Members w i l l often do things together on the weekends. 92. The s t a f f w i l l go out of t h e i r way to help new members get acquainted. 93. Members w i l l be strongly encouraged to express t h e i r f e e l i n g s . 94. S t a f f w i l l r a r e l y give i n to pressure from members. 95. Members w i l l have to make detail e d plans before leaving the program. 96. Staff w i l l strongly encourage members to ta l k about t h e i r past. 97. Members w i l l r a r e l y become angry. 98. The s t a f f w i l l strongly encourage members to be neat and orderly. 99. There w i l l often be changes i n the r u l e s . 100. The s t a f f w i l l make and enforce a l l the r u l e s . -129 QUESTIONNAIRE RE EASTON CLIENTS Please t i c k appropriate answer: A. Is t h i s person diagnosed psychotic on admission? 1. Yes 2. No B. How long has t h i s person been i n residence (number of months)? C. What i n your opinion i s the prognosis for t h i s person? 1. Poor 2. F a i r 3. Good D. Would you say t h i s person adds p o s i t i v e l y to the cottage atmosphere? 1. Often 2. Sometimes 3. Never Please answer each question for each c l i e n t : C l i e n t I C l i e n t II A. B. " C. " D. ~ A. B. C. D. C l i e n t I I I A. B. C. D. C l i e n t IV C l i e n t VI A. B. C. D. C l i e n t V A. B. •D. A. B. C. •D. C l i e n t VII C l i e n t VIII C l i e n t IX C l i e n t X C l i e n t XI C l i e n t XII A. B. C. D. A. B. C. D. A. B. C. D. A. B. C. D. A. B. C. D. A. B. C. D. 130 APPENDIX B LETTERS AND INTRODUCTORY REMARKS USED IN THE STUDY i TAPED INTRODUCTORY STATEMENT FOR COPES FORM R FOR ADMINISTRATION TO ADOLESCENT CLIENTS I am going to read some statements about programs l i k e Easton. L i s t e n c a r e f u l l y and decide which statements are true of your cottage and which statements are f a l s e . Your name i s not on the sheets I have given you, so no one except you w i l l ever know how your respond. After your hear each statement, make your decision: Is the statement you have heard true, or mostly true; f a l s e , or mostly f a l s e , for your cottage? If i t i s true, put a T for true i n the box marked with the statement number. If i t i s f a l s e , put an F for f a l s e i n the box marked with the statement number. For example, i f you believe statement one i s true i n your cottage, put a T i n box one. If you believe statement one i s f a l s e for your cottage, put an F i n box one. T for true, and F for f a l s e . Please mark T or F for every statement. I w i l l repeat every statement once. Here i s the f i r s t statement. NOTE: On the board i n the Administration Room i s written: T = True F = False 132 July 1979. Dear Staff Member: Enclosed are two questionnaires that I would l i k e you to complete. They are part of a study that I am doing on the Maples. One question-naire i s a Cottage Atmosphere Scale and one a Work Group Scale. They take about f i f t e e n minutes to f i l l i n altogether. When these question-naires are returned, there w i l l be one more to complete the study. I t i s very important to have a l l the questionnaires f i l l e d i n at approximately the same time so I would appreciate i t i f you could complete them as soon as possible. I t i s also important f o r them to be f i l l e d i n independently; that i s , without discussion with others. I would l i k e not to discuss the d e t a i l s of the study at t h i s point as i t may influence the r e s u l t s , but I w i l l make the data a v a i l a b l e to the cottage and discuss i t f u l l y once the analysis i s completed. A l l information on the questionnaires w i l l be s t r i c t l y c o n f i d e n t i a l . I w i l l not know who has completed each questionnaire, only the number assigned to i t . The secretary w i l l assign the numbers, but w i l l not read the questionnaires. This i s to encourage people to answer the questions as frankly and honestly as possible. I r e a l l y appreciate your time and energy invested i n completing these questionnaires. Completed questionnaires should be returned to the administration secretary as soon as possible, at the l a t e s t two or three days a f t e r the questionnaire was received. Thank you very much. Encls. SIGNED "Sue Johnson" July 1979 Dear S t a f f : Thank you for f i l l i n g i n the f i r s t questionnaire for me. Enclosed i s the f i n a l questionnaire which asks about your view of the IDEAL Treatment Environment, and a repeat of the Work Group questionnaire. I t i s important that i t i s f i l l e d out independently, without discussion, and returned to the administration secretary as soon as possible, at the l a t e s t within two or three days of re c e i v i n g the questionnaire. Thank you so much. Encl. SIGNED "Sue Johnson" APPENDIX C EASTON DEMOGRAPHIC DATA 135 • TABLE XXI STAFF: LENGTH OF EMPLOYMENT AT EASTON Cottages One Two Three Months 4 82 94 100 34 13 86 49 42 54 27 3 80 36 46 62 3 24 54 32 34 56 26 32 34 44 20 48 56 32 50 30 37 24 2 38 16 48 54 12 72 62 42 45 92 Means 48 39 41.5 Grand Mean = 43 months. Under 6 months 1 2 1 Employment Over 2 years 11 13 11 Over 6 years 3 2 2 TABLE XXII STAFF: LENGTH OF EMPLOYMENT IN COTTAGE AT TIME OF STUDY Cottage One Two Three Months 4 12 11 10 12 13 18 30 16 12 27 3 48 36 7 12 3 1 24 15 34 1 4 32 34 17 20 48 21 2 34 30 37 16 2 34 16 4 12 4 12 44 12 45 13 Means 19.5 18 18.6 TABLE XXIII PLACEMENT OF CLIENTS BEFORE ADMISSION TO EASTON Cottages One Two Three From Group Homes and P s y c h i a t r i c Care From Foster Parents From Family of O r i g i n TABLE XXIV PROGNOSIS ASSIGNED TO CLIENTS BY COTTAGE SOCIAL WORKERS Cottages One Two Three Poor Prognosis F a i r Prognosis Good Prognosis TABLE XXV CLIENTS: LENGTH OF RESIDENCE IN COTTAGES AT TIME OF STUDY 138 Cottages One Two Three Months 4 4 8 6 9 10 7 2 8 18 9 5 12 2 8 1 5 6 2 9 5 12 12 4 9 5 4 8 4 10 Means 7.9 6.1 6.8 Months 139 TABLE XXVI AGE OF CLIENTS AT TIME OF STUDY Cottages: One Two'„ . Three 15 years, 4 mos 13 years, 8 mos. 16 years, 8 mos, 16 years, 0 16 years, 0 17 years, 5 15 years, 6 13 years, 0 14 years, 9 16 years, 0 14 years, 8 12 years, 10 17 years, 0 15 years, 0 14 years, 10 17 years, 1 13 years, 6 15 years, 9 15 years, 2 17 years, 1 17 years, 2 14 years, 0 14 years, 2 13 years, 0 16 years, 10 17 years, 0 15 years, 0 15 years, 4 15 years, 4 14 years, 4 Means: 15 years, 8 mos. 14 years, 9 mos. 15 years, 1 mo. APPENDIX D COPES 'NORMATIVE DATA AND OTHER STATISTICS SEASHORE COHESION INDEX STATISTICS TABLE XXVII COPES: MEANS AND STANDARD DEVIATIONS OF FORM R SUBSCALES FOR AMERICAN NORMATIVE SAMPLE MEMBERS STAFF No. (N = 54 (N = 779 (N = 32 (N = 357 of Programs) Members) Programs) Staff) Subscale Items Mean S.D. S.D. Mean S.D. S.D. Involvement 10 6 .22 1. ,32 (2. ,53) 6 .37 1. ,61 (2. .72) Support 10 6 .77 1. ,15 (2, ,08) 7 .30 0. ,97 (2. ,03) Spontaneity 10 5 .50 1. ,21 (2, .15) 5 .54 1. ,44 (2. ,27) Autonomy 10 5 .87 1. ,11 (I. .86) 7 .25 1. .41 (2, .35) P r a c t i c a l Orientation 10 5 .56 1. .21 (2, .19) 6 .92 0, .91 (I. .92) Personal Problem (2 .53) Orientation 10 4 .90 1. .57 (2 .55) 6 .06 1, .84 Anger & Aggression 10 4 .16 1. .98 (2 .56) 6 .48 1 .92 (2 .67) Order & Organization 10 7 .13 1, .32 (2 .28) 5 .87 1 .65 (2 .41) Program C l a r i t y 10 6 .55 1 .07 (2 .03) 7 .38 1 .13 (1 .99) Staff Control 10 5 .13 1 .25 (1 .99) 3 .60 1 .38 (2 .20) TABLE XXVIII COPES: INTERNAL CONSISTENCIES AND AVERAGE ITEM-SUBSCALE CORRELATIONS FOR FORM R SUBSCALES Average Internal Item-Subscale Consistency Correlation Members Staff Members Staff Involvement .79 Support .67 Spontaneity .63 Autonomy .62 P r a c t i c a l Orientation .64 Personal Problem ,78 Orientation Anger and Aggression .82 Order and Organization .81 Program C l a r i t y .68 Staf f Control .67 Mean .79 .82 .48 .46 .64 .44 .42 .75 .43 .46 .89 .38 .49 .64 .44 .43 .84 .52 .50 .86 .51 .52 .87 .53 .53 .77 .45 .44 .76 .40 .45 .78 .41 .47 143 TABLE XXIX COPES: FORM R SUBSCALE INTERCORRELATIONS MEMBERS (N = 373) and STAFF (N = 203) ti c o o •rl & •rl 4-) CD CO rH CD N 4-J CD •ri ' r l rH O U c U O U ti 60 cd cd PH O 00 bO rH 4-1 •rl < U U ti rH 4-1 O o cd cd e u ti 4-1 cd o c J-iTJ MH CO CD CD cu c 00 UH H T H 00 cd o cd CD r l C M u 4-1 PH O < o PH 27 -08 49 32 06 27 -12 44 47 -08 39 13 17 34 -27 25 00 04 34 -27 Subscales Involvement Support Spontaneity Autonomy P r a c t i c a l Orientation Personal Problem Orientation Anger & Aggression Order & Organization Program C l a r i t y Staff Control 39 43 19 36 10 07 28 -12 40 28 27 -12 29 32 -19 44 24 42 11 01 23 -26 31 28 30 34 14 19 46 24 -30 20 -40 ti o •rl 4-1 >* 4-1 ti 4-1 cd OJ •H rH 4-1 e CD >. cd ti 4J ti e U CD > SH cd o •H »rl rH o 4-1 ti 4-1 M o a , ti o O O > P- o 4-1 cd ti ti ex 3 u M cn cn < PH 50 34 13 44 39 21 16 22 02 16 25 -06 14 46 -29 06 -30 01 26 27 04 30 "49 -21 -13 03 -47 37 28 19 18 38 07 00 04 10 -01 NOTE: Member cor r e l a t i o n s are above the diagonal, and s t a f f c o r r e l a t i o n s below (decimals omitted). TABLE XXX COPES: MEANS AND STANDARD DEVIATIONS OF FORM I SUBSCALES FOR AMERICAN NORMATIVE SAMPLE MEMBERS STAFF No. (N = 47 Programs) (N = 618 (N = 26 Programs) (N = 252 of Members) Sta f f ) Subscale Items Mean S.D. S.D. Mean S.D. S.D. Involvement 10 7. .82 1. ,24 (2 .02) 8 .51 0. ,73 (1. ,38) Support 10 7. .78 0. ,90 (1. .92) 8 .35 0. ,65 (1. .51) Spontaneity 10 6. .37 1. ,21 (2 .17) 7 .91 0. ,87 (1. .57) Autonomy 10 6, .53 1. .10 (1 .86) 7 .56 0. .93 (1. .67) P r a c t i c a l Orientation 10 6, .85 0, .99 (2 .12) 8 .22 0. .63 (1. .25) Personal Problem .30) Orientation 10 5, .44 1. .56 (2 .81) 6 .91 1. .09 (2, Anger & Aggression 10 3 .69 1, .54 (2 .52) 6 .36 1. .24 (2 .69) Order & Organization 10 8 .04 0, .88 (1 .87) 7 .26 1, .19 (2 .19) Program c l a r i t y 10 7 .87 0 .94 (1 .92) 8 .39 0. .61 (1 .24) Staff Control 10 5 .00 1 .37 (2 .07) 3 .59 1 .29 (2 .12) 145 TABLE XXXI INTERCORRELATIONS AMONG MEAN SCALE VALUES FOR SECTION SHIFT GROUPS ON SCALES COMPRISING THE SEASHORE INDEX OF COHESIVENESS Q.50 Q.52 Q.50a Q.50f Q.50g Q.51 Really part of group Q.52 Want to stay i n group Q.50a Way men get along Q/50f Way men s t i c k together Q.50g Way men help each other Mean tet r a c h o r i c c o r r e l a t i o n for two or more al t e r n a t i v e breaks on each scale. N = 228 groups. .30 .15 .21 .32 .37 .38 .34 .64 .62 .70 APPENDIX E EASTON SAMPLE TREATMENT SHEET 147 TREATMENT SUMMARY (Sample No. 1) NAME J), DATE 1. P r i v i l e g e s , Limits and Program Program on grounds Fitness - 3 times a week at Groups pool, gym - l i v i n g room and Planning outside a c t i v i t i e s . Sunday, Tuesday, Thursday - community T, • n c J Pool - aquametrxcs for 15 School - Thursday 10:45 - 12:00 noon minutes nonstop 1:15 - 2:30 p.m. _ . . „ ., m /c n nr, L i v i n g room - warm up for Friday 10:45 - 12:00 noon _ _° . _ _ n i , , 5 - 7 minutes followed by L i f e s k i l l s - learn bus routes, a c t i v i t i e s at the gym or run errands for the cottage/June. pool or running i n the f i e l d 2. Medication Discourage her 222 and ASA intake. Give her time i n her room (10 min.) then t a l k to her about how she i s f e e l i n g before giving her her medication. 3. Family Contact Conferences once every three weeks During Christmas vacation. 4. Projected Duration of Treatment Four to eight months 5. Treatment goals 1. Improve family r e l a t i o n s h i p s 2. Improve self-worth (I make my family angry, therefore I am no good) 3. Narrow the gap between how she sees he r s e l f and how she i s seen by others, i . e . , she sees he r s e l f as p l a i n , slow and unat t r a c t i v e . 4. Improve her s o c i a l s k i l l s . 5. To help her get i n touch with the love and rage she has for her family. 6. Proposed Methods df Treatment 1. Confront sexual manipulation 2. Encourage her to get physical contacts from peers and s t a f f through wrestling. 3. Improve r e l a t i o n s h i p s with family through family conferences and one-to-one psychotherapy with George. 4. Encourage her to get her p r i v i l e g e s 5. Discourage alcohol dependency by examining family s i t u a t i o n s which led to t h i s dependency 6. Support her to get clear with people re manipulation and avoidance of her fe e l i n g s , e s p e c i a l l y sexual and depressive f e e l i n g s 7. Give her p o s i t i v e strokes 8. Encourage physical a c t i v i t i e s through f i t n e s s 9. Support her with mathematical problems from school. 148 TREATMENT SUMMARY (Sample No. 2) NAME D, DATE 1. P r i v i l e g e s , Limits and Program 1. A l l p r i v i l e g e s except o f f - s h i f t change, a l l groups, therapy group on Thursday evenings. 2. School - Tuesday. 3. L i f e s k i l l s . 4. Skiing - Tuesday u n t i l 7, a f t e r s k i i n g , gym and pool a c t i v i t i e s . 5. Art therapy two times a week. 2. Medication Discourage 222 and ASA intake. Get her to take some time out to relax and t a l k to her about how she i s f e e l i n g . Try neck massages - she gets tense on neck and shoulder area. 3. Family Contact Conferences every three weeks and home v i s i t s every second weekend as arranged with treatment team. 4. Projected Duration of Treatment Two to three months - beginning of June discharge? 5. Treatment Goals 1. Improve family r e l a t i o n s h i p s . 2. Improve self-worth. 3. Improve self-awareness (narrow gap between how others see her and how she sees h e r s e l f ) . 4. Improve s o c i a l s k i l l s . 5. To reach an agreement with her family on where she w i l l go upon discharge. 6. Proposed Methods of Treatment 1. Family conferences and home v i s i t s . 2. Psychotherapy. 3. L i f e s k i l l s - encourage use of her p r i v i l e g e s . 4. Art therapy. 5. Continue to share thoughts and fe e l i n g s with kids and s t a f f . 6. P o s i t i v e strokes and VALIDATION. 7. Extended home v i s i t - 10 days. APPENDIX F SOME DEFINITIONS OF TERMS AND TREATMENT METHODS USED IN RESIDENTIAL TREATMENT 150 SOME DEFINITIONS OF TERMS AND TREATMENT METHODS COMMONLY USED IN RESIDENTIAL TREATMENT 1. Life-Space Interview: (Wineman, 1959). This i s an intervention technique developed by F r i t z Redl with reference to the r e s i d e n t i a l treatment s i t -uation. A s i m i l a r concept c a l l e d the "marginal" interview i s found i n the work of Bettleheim. "Life-Space" i s a term taken from the e c o l o g i c a l model, r e f e r r i n g to a l l the various inner and outer forces that impinge upon an i n d i v i d u a l at any one time. The concept developed i n response to c l i e n t problem behaviours i n a r e s i d e n t i a l s e t t i n g which required on-the-spot handling of an interview type nature. The l i f e - s p a c e interview i s conducted by any professional who i s i n the s i t u a t i o n , i n the process of in t e r a c t i n g with the c h i l d or adolescent. Redl defines two kinds of i n t e r -view: one he c a l l s "emotional f i r s t - a i d on the spot," and the second he terms "the c l i n i c a l e x p l o i t a t i o n of l i f e events." The f i r s t kind of l i f e -space interview speaks for i t s e l f ; the second can contain various components such as " r e a l i t y rub-in," "symptom estrangement" or gaining the allegiance of the healthy part of the c l i e n t to look c r i t i c a l l y at h i s pathological behaviours and t h e i r secondary gains, new too l salesmanship, and manipul-ati o n of the boundaries of the s e l f or helping the c l i e n t l e a r n where he ends and other people's r i g h t s and processes begin. The context of t h i s technique i s that of ego psychology; Wineman talks of the "ego-disturbed c h i l d " who, for example, has a marked impoverishment of rea c t i o n tech-niques, thereby needing the counsellor or therapist to engage i n "new too l salesmanship." 151 Ego Development: The ego i s defined i n conventional psychoanalytic theory as a set of functions which mediate between the i n s t i n c t s and the outside world. There are many models of ego development. Perhaps the most well known i s that of Erickson (1950), who sees the c h i l d progressing through a sequential s e r i e s of c o n f l i c t s or c r i s e s , beginning with the Trust versus Mistrust c o n f l i c t , and ending with Ego I n t e g r i t y versus Despair. The development of a healthy ego i s usually seen mainly as the r e s u l t of stable consistent, p o s i t i v e , interpersonal and i n t r a f a m i l i a l r e l a t i o n s , i n par-t i c u l a r with the mothering f i g u r e . Instances of ego weakness would be impaired ego functions, namely perception, cognition, a f f e c t and action; constant i n s t i n c t u a l anxiety; persistence of p r i m i t i v e defense mechanisms with r e l i a n c e or deni a l , projection and regression; lack of basic t r u s t ; i n a b i l i t y to r e l a t e to others; lack of impulse con t r o l ; and primary process thinking, such as megalomania. A l l the main a u t h o r i t i e s on r e s i d e n t i a l treatment (Bettleheim, Redl, and Whittaker) use t h i s concept as providing a useful perspective from which to look at and plan interventions for emotionally disturbed c h i l d r e n and adolescents. Psychotherapy: The American P s y c h i a t r i c Association Manual f or 1975 defines psychotherapy as "the treatment of mental and emotional disorders based pr i m a r i l y on verbal and nonverbal communications with the pa t i e n t . " I t thus encompasses many p a r t i c u l a r techniques, such as hypnosis or ge s t a l t therapy, and many si t u a t i o n s such as group or one-to-one psychotherapy. Psychotherapy i s always done i n the context of a meaningful r e l a t i o n s h i p and the goal i s to resolve intrapsychic c o n f l i c t s and/or b u i l d ego strength. Psychotherapy can be distinguished from psychoanalysis i n that psycho-analysis emphasizes the necessity for regression on the part of the c l i e n t , 152 and the r e l a t i o n s h i p between the therapist and the c l i e n t i s seen mainly i n terms of transference. Psychotherapy, on the other hand, i s more of a cooperative s i t u a t i o n where there i s a r e a l , as well as a transference, r e l a t i o n s h i p between the therapist and the c l i e n t . Less regression i s fo s -tered, and the therapist may concentrate on supportive techniques, helping the c l i e n t to b u i l d up h i s ego resources, or expressive techniques, helping the c l i e n t to express and thus understand h i s c o n f l i c t s and the dynamics of his l i f e s i t u a t i o n (Wolberg, 1967). Psychotherapy can be viewed as a r e -education process, a means of learning about patterns of thinking, f e e l i n g and behaving. Psychotherapy i s usually, then, a shorter process and much more sui t a b l e for ch i l d r e n or adolescents who do not generally have the ego strength necessary f o r psychoanalysis. The aim of both modes i s to produce catharsis and change through i n s i g h t ; i n psychotherapy, however, the healthy part of the c l i e n t i s focussed on, whereas i n psychoanalysis the focus tends to be more on the c l i e n t ' s pathology. In the r e s i d e n t i a l treatment l i t e r a t u r e , the c r u c i a l issue around psychotherapy, which d i f f e r s from a l i f e - s p a c e interview or c r i s i s intervention, i s that whatever form i t takes, i t must be integrated into the general treatment planning and mi l i e u management of the treatment centre. 4. Family Counselling/Therapy: This perspective on emotional disturbance emphasizes the family i n t e r a c t i o n process as a necessary condition for disturbance. In the pathological f a m i l i e s studied by Vogel and B e l l (1960), for example, i t was found that a p a r t i c u l a r c h i l d had become involved i n the tensions e x i s t i n g between the parents. The c h i l d i s then used as a scapegoat. Haley (1963) gives more emphasis to the family unit 153 as a system, and stresses the point that to treat a malfunctioning c h i l d i n the absence of the system which h i s malfunctioning r e f l e c t s i s essen-t i a l l y f u t i l e . The goal of family therapy, then, i s to examine the r o l e s , communication patterns, and underlying dynamics of the family system i n r e l a t i o n to the disturbance of the c l i e n t . Most recent l i t e r a t u r e on r e s i d e n t i a l treatment stresses the importance of family contact, education, and counselling. 

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