Behavioral Support Systems in mental health residential units

In mental health residential environments one of the most difficult things is keeping the clients engaged with the programming and their challenging behaviors to a minimum. Every unit of every organization has a behavioral support system in place (along with structured activities) to achieve this objective. The efficiency and effectiveness of these systems will dictate how successful that program will be. Some months ago, we realized that the one we had wasn’t being effective enough, and that translated into individual behavioral issues that affected the normal functioning of our program as a whole.

In the unit where I work, we utilize a system to record behavioral frequencies. It provides us with  data on the type of behaviors that are occurring as well as how often these behaviors are occurring. Such data is important to track behavioral progress or regression. Based on the concept of climbing up a ladder to reach discharge, pro-social behaviors move the client up the ladder and misconduct moves the client down the ladder. Also, privileges increase as the client moves from red, to yellow, to orange to green. The other purpose of the system is to function as a motivational tool.

Some time ago, we realized that the motivational factor wasn’t being strong enough and that the Point Level System wasn’t helping improving those skills that were meant to be fostered.

That’s when Perry Alleman, the Lead Counselor of the unit during that time suggested the idea of a Token System which could support the Point Level System. Perry moved on to another program shortly after but I didn’t let go his idea of a Token System. I felt it was something worth trying. So I started working with my team to develop such system.

Other units of the program had already been using similar systems, directly tied to their respective Point Level Systems. Our project differed from their approach in one point. We wanted to keep it from overlapping with the Point Level System, while still supporting it.

So, we started to assess all of our clients’ performances in order to detect improvement needs and ways to reinforce those skills where they were lagging.

A major challenge, due to the diversity of our unit’s population, was to conceive a system that could be applied to everyone but without losing an individualized approach (which is one of the core values of the Devereux Foundation).

We also needed a system simple enough for the clients and staff to understand/manage and at the same time, engaging. Take into account that most of our teenage clients have oppositional/defiant disorders so finding something that pleases everyone is sometimes a daunting task.

Emma Finn, Martin Carbonell and Steve Wigmore, Direct Support Professionals of the unit started detecting each client’s needs and so, we started putting our ideas together. We tied their residential goals and Behavior Support Plans and came up with a set of goals such as completion of hygiene routine, outstanding room care, timely bedtime, etc. Note that, not every category would apply to every client.

For each goal, a certain amount of tokens would be awarded after daily/weekly/monthly completion, and those tokens could be traded at the beginning of the week for toys, hygiene products, CD Players, note books and other stuff in line with the clients’ preferences. Some items are more “desirable” than others and so is their “token price”.

We also wanted something they could use once they were discharged from the program. I mean, give “real world” context to the system. We wanted to teach the clients how to administrate their money (without using real money… we didn’t want a black market running within the program) and build a “savings” discipline.

In order to achieve this a small tweak was suggested by Steve. If a client decided to save their tokens, he would get a bonus (in tokens) credited to his account.

After a pilot test drive was conducted, we went on to rolling the system out. Since the first day, the clients were surprisingly engaged with it and some issues we were having (like not going to bed on time or helping with the daily chores became less frequent).

Also, from early on, spending patterns became very clear. Some clients became “savers”, while others became “spenders”. The savers were the highest functioning clients (IQs ranging from 50s to 70s). They decided which item from the store they wanted (sometimes one that they knew it would take them weeks, if not months to acquire) and started saving towards them. The spenders (IQs of ±40 and lower functioning) traded their tokens as soon as they got enough to buy some of the cheapest items. They would still express their desire for the most expensive ones, but couldn’t refrain from spending.

Down the road, we would like to add a lending system, where the clients could borrow tokens and deadlines to pay for them.

In conclusion, we created the system in a way that could be easily tailored according to individual needs, and fast. So far the results have exceeded our expectations. The clients are so into it that they have put pressure on us to stay on our toes. This has also helped new staff get quickly up to speed at learning the system due to their demands and level of engagement. And trust me, the extra daily paperwork at the end of the night, pays with gains in behavioral improvements on the clients’ side, and relieving work stress levels on ours’.

Article by Fernando

The guy in charge of this blog - husband, Psychologist, former Manager, Blogger, Job Coach, Recruiter and Information Junkie. Yes, I am all that.

Fernando has written 237 awesome articles for us at FT Careers Blog

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