Effective and Efficient School-Based Mental Health

What to Expect from Behavioral Health Consulting

Fri, 09 Jan 2026 06:38:36 GMT

Navigating the complexities of the modern healthcare landscape can be overwhelming for both social service agencies and families. Whether you face changing rules in California or care for a child with a mental health disorder, the next steps may not be clear. This is where behavioral health consulting comes in.

But what does a behavioral health consultant actually do? Unlike traditional therapy, which focuses on clinical treatment for an individual, behavioral health consulting is about systems, strategies, and sustainable solutions.

Here is what you can expect when you partner with a professional consultant.

1. A Comprehensive Organizational Audit

For agencies, the first step is often an evaluation of your current operations. In an era where workforce retention is a critical challenge, a consultant looks beyond the surface. We analyze your mission, strategy, and culture to identify where the disconnects are happening.

You can expect a deep dive into your data. This will show if your evidence-based practices (EBPs) deliver the results you promised stakeholders.

2. Navigating Regulatory Compliance

California’s regulatory environment is one of the most rigorous in the nation. If you are an agency, you may need STRTP consulting or preparing for CARF accreditation .

In either case, your consultant should act as a project manager. We bridge the gap between procrastination and preparation. We make sure your policies and procedures meet state and national standards.

3. Empowerment Strategies for Families

For parents, the Intensive Parent Model acts as a specialized form of training to help consulting. Instead of solving parenting programs, this model focuses on helping the parent result their stress first, then understand the behavioral strategies their children need.

4. Specialized Training and Education

Expect a focus on professional development. We offer more than 60 training courses for your staff to improve their skills and, in turn, employee retention. By learning how to properly intervene with youth experiencing aggression or understanding the impact of ACEs in youth, our courses ensure your staff have the tools they need to succeed. Whether you need trauma-informed care or suicide prevention training, our behavioral health training meets your staff's needs.

5. Measurable Outcomes and Long-term Sustainability

Finally, you should expect results. Our goal is to help your organization. It helps you move from reacting to problems to being proactive.

By the end of a consulting engagement, you should have a clear roadmap. You should also have better compliance. You should have a stronger workforce.

Ready to take the next step?

If your organization is facing funding uncertainty or struggling with staff turnover, don’t wait until the situation becomes a crisis. Contact Praxes Behavioral Health today to learn how our tailored consulting services can help you reach, achieve, and excel.

Should Behavioral Health Shift More to Private Funding?

dan.thorne@praxesmodel.com (Dan Thorne) — Fri, 25 Apr 2025 17:45:11 GMT

It might be the right moment for these organizations to explore new funding opportunities, whether large or small.

This week, I came across an interesting article on the Reason Magazine website about Hillsdale College , and it made me think about its connections to behavioral health. The piece discussed how the Trump administration is freezing Harvard’s federal funding due to their policies, illustrating how the government might try to influence how universities operate. It's a bit concerning that a university's fate could swing with the different administrations. Whether this will happen is still uncertain, but it's clear that Harvard is gearing up for a lengthy and expensive legal battle over it. The article also highlights how Hillsdale has strategically grown its endowment over time, allowing it to fully cut ties with the state of Michigan and become entirely privately financed.

Now, the notion of private funding for behavioral health organizations may seem a bit out there, especially since Medicaid is currently the largest funder of mental health services in the country. For organizations to sever ties with Medicaid feels like a risky move. However, numerous large non-profit organizations have already established significant fundraising programs, backed by generous donors and annual events like golf tournaments and other engaging activities. They could gradually reduce their dependence on Medicaid by boosting these efforts or considering private insurance as a viable option.

And what about the smaller agencies? Those “Mom and Pop” organizations often find they don’t have the time to focus on fundraising. However, with the winds of politics shifting, it might be the right moment for these organizations to explore new funding opportunities, whether large or small. Launching a fundraising program and seeking support from private or local foundations for grants could build a financial safety net, helping to lessen their reliance on Medicaid.

In addition to the political landscape, the economic environment also plays a huge role in Medicaid funding. Over the last twenty years, federal funding has faced collapses during critical moments, like the Great Recession in 2008 and the COVID pandemic in 2020, leading to reduced income, lower taxes, and less available funding for Medicaid. Finding options for private funding to complement Medicaid payments could very well be the way forward for both large and small behavioral health organizations.

Mixed Forecast about Behavioral Health Landscape: What It Means

dan.thorne@praxesmodel.com (Dan Thorne) — Fri, 25 Apr 2025 17:39:15 GMT

Organizations may not be focused on the right strategies.

Behavioral health providers have varying opinions about the business landscape in the next four years, according to a survey by Praxes Behavioral Health conducted in March and April 2025. The study gathered over four hundred responses from nationwide behavioral health organizations. Participants shared their views on their company’s administrative, financial, and clinical operations. This mixed forecast suggests potential challenges and opportunities for which providers must be prepared.

Fewer than 50% of participants believe their organization will remain favorable over the next four years. This same group also responded regarding projected changes in funding, employee retention, productivity, and available services during this period. Specifically, 38% plan to pursue government funding, 36% seek grant opportunities, and 25% target managed care organizations. When asked about the anticipated severity of client illnesses in the coming four years, 40% indicated it would decrease, while 35% expected an increase. Participants identified key areas of significant concern within their organizations.

The following list ranks these areas from highest to lowest concern:

1. Client engagement

2. Access to care

3. Cultural competence

4. Technology integration

5. Workforce challenges

6. Rising demand for services

7. Quality of care

8. Crisis management

9. Funding and resources

10. Regulatory compliance

Based on these findings, several trends could be occurring:

1. Organizations may not be focused on the right strategies. If over 50% of staff are not sure their organization is heading in a favorable direction, this uncertainty can create more stress and uncertainty. Leaders need to look at their short-term plans year by year and decide how they will move from surviving to thriving in the next four years.

2. A shift may be going away from government funding sources. Whether the Trump administration cuts Medicaid funding or not (which is advertised, but nothing is set in stone), behavioral health organizations need to read the tea leaves and find funding alternatives in grant funding or in fundraising opportunities. The potential impact of such cuts could lead to a significant reduction in available resources, making it even more crucial for organizations to seek alternative funding sources.

3. Answers must be found to deal with the lack of client engagement and the need for access. For example, the average wait time to seek therapy is six weeks. When clients can see a therapist, the drop-out rate in treatment runs between 20% and 57%. This means that clients have to wait a long time to enter treatment, and when they do, they may not stick around. These factors do not satisfactorily answer the growing need for mental health services. Agencies must find solutions to expediting care while training staff to establish better rapport and therapeutic relationships with clients.

If you would like a copy of the survey results, please get in touch with us .

Repairing Your EBP Problem

dan.thorne@praxesmodel.com (Dan Thorne) — Thu, 17 Apr 2025 22:21:52 GMT

Assessing evidenced-based practices yearly ensure their effectiveness.

Leadership in behavioral health organizations often requires the implementation of at least one evidence-based practice (EBP), generally designed to enhance clinical outcomes or fulfill funding obligations stipulated by government contracts. Considerable resources are usually allocated for training staff in these practices, whether through dedicated “train the trainer” programs or by sending team members for specialized instructional sessions.

Although an EBP may be operational within an organization, it does not always produce the expected results. This scenario is relatively common in behavioral health settings nationwide. Historically, skeptics of EBPs have voiced concerns regarding issues like the lack of traditional treatment protocols and the ethical or cultural implications. However, these criticisms are not the primary causes of the current difficulties. More relevant factors include staff turnover, the ongoing costs associated with maintaining the practice , challenges in ensuring adherence among staff , the stress staff experience in conducting them , difficulties in tracking outcomes, and high rates of client dropouts .

Addressing these problems often entails seeking support for the EBP. The issues may not stem from the EBP itself, but rather from its perception of the organization. Initial steps should involve organizing discussions with clinical and program directors to confront these challenges. Subsequently, an evaluation should be conducted to ascertain whether the EBP will continue to be implemented, often dictated by contractual requirements, or if it should be phased out.

Even if staff members express favorable views about the EBP, assessing its associated costs and consequences remains critical. Collecting staff feedback on their intent to stay or leave in light of decisions regarding the EBP can provide insights into turnover expenses. Furthermore, considerations such as the necessity for staff retraining or enhanced supervision to ensure adherence to the model should be addressed. Additionally, evaluating the staff's effectiveness in engaging clients is crucial, as clients receiving both EBP and non-EBP services may discontinue their sessions if they do not establish a strong connection with their clinician.

To alleviate some of these challenges, obtaining informed consent at the beginning of sessions is essential, as it educates clients about the risks and benefits of the EBP. Moreover, proper screening at the outset is vital to determine whether clients meet the eligibility criteria for the practice, ensuring their symptoms are severe enough to gain from the EBP without being too severe to necessitate more intensive crisis intervention support.

Assessing costs, matching clinicians and clients to the correct EBP, ensuring fidelity, and evaluating sustainability plans must be done yearly to keep the EBP effective with clients.

Behavioral Health Workforce Retention Evaluations

dan.thorne@praxesmodel.com (Dan Thorne) — Thu, 17 Apr 2025 22:11:38 GMT

Without conducting a workforce retention evaluation, organizations will remain oblivious to the best approaches tailored to their unique situations.

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Parental Stress and Foster Care: A Crucial Aspect Often Overlooked

dan.thorne@praxesmodel.com (Dan Thorne) — Fri, 11 Apr 2025 22:22:15 GMT

The parent's overall well-being should serve as the foundational impetus for foster care agencies.

Imagine boarding an aircraft accompanied by your child. The flight attendant provides essential instructions regarding safety protocols, including the use of safety equipment, emergency procedures, seat belts, life vests, and other pertinent information. In the event of a loss of cabin pressure, it is explained that oxygen masks will descend for breathing. A crucial question arises: who should don the mask first, the parent or the child? For frequent flyers, it is a well-known guideline that the parent should secure their mask before assisting their child, as an incapacitated parent would be unable to aid their child effectively. This principle underscores a paramount truth: parents must prioritize their children's health and safety.

A similar paradigm should be applied to the foster care system. While foster care organizations actively recruit adults to serve as foster parents, there is a prevalent tendency to emphasize the needs of the child over those of the parent. A shift in focus is warranted, wherein the parent's well-being is recognized as equally significant.

As of 2024 , approximately 390,000 children are placed within the foster care system in the United States, supported by around 212,000 licensed foster homes. Although there has been a decline in the number of children within the system over the years, the mental health challenges faced by these children have persisted. A staggering 41% of the children carry some form of mental health diagnosis, while 90% have encountered trauma at some point in their lives, resulting in substantial challenges for their foster parents.

These difficulties faced by the children do not exempt foster parents from their issues. Foster parents may be more susceptible to experiencing parenting stress , as well as their own mental and physical health challenges. The impact of foster care on their mental health is considerable, necessitating our understanding and support.

Given the obstacles foster parents encounter, whether they receive the requisite training warrants inquiry. Research indicates that when foster parents are equipped with validated parenting training interventions, they often demonstrate enhanced capabilities in managing complex child behaviors and mitigating parenting stress. These findings highlight the importance of instructing foster parents in positive parenting techniques and intervening when potentially harmful behavior modification strategies are endorsed.

Foster care training prog rams help foster care workers understand the children they support. These courses cover critical topics such as trauma-informed care, crisis intervention, behavioral management, educational support for children, and substance use.

However, one must question how many of these training modules adequately address strategies for managing parental stress. While foster care and mental health agencies provide programs, such as Incredible Years , Triple P , and Parent-Child Interaction Therapy (PCIT) , which focus on parenting skills, they often overlook the principal concern: the stress experienced by foster parents.

Furthermore, between 25% and 50% of foster parents concurrently raise their biological children alongside fostering, yet these biological children typically do not face the same mental health challenges as foster children. Consequently, foster parents may lack the necessary skills to address the complexities that accompany these vulnerable children. As the obstacles intensify, foster parents may begin to isolate themselves, grappling with feelings of guilt and embarrassment regarding the foster child—a sentiment parallel to the stigma faced by biological parents of children with mental health concerns.

Another significant issue facing foster parents is the constraint on their time. The foster care system imposes substantial demands, with frequent home visits, appointments for the foster child, and meetings with county social workers and various professionals. For those already under stress before fostering, these additional responsibilities can exacerbate financial and familial strains.

In light of these challenges, foster care training programs must incorporate a curriculum that addresses the needs of parents. Courses focusing on stress management, assertive communication, building supportive systems, child development, mental health diagnoses, advocacy, and parenting skills will equip parents with comprehensive tools to navigate their responsibilities effectively.

Ultimately, prioritizing the needs of the parents will reinforce their capacity to act as caregivers while promoting the health of their foster children. The parent's overall well-being should serve as the foundational impetus for foster care agencies.

CARF Accreditation for Procrastinators

Fri, 11 Apr 2025 16:46:53 GMT

The best approach for CARF accreditation is to develop an ongoing preparation process.

When behavioral health organizations pursue accreditation, they aim to establish credibility, which can be essential for licensing or contracting. To obtain certification from entities such as the Commission on Accreditation of Rehabilitation Facilities ( CARF ) an organization must operate for at least six months before receiving approval. This preparation involves undergoing a survey process that necessitates thorough readiness.

Effective CARF accreditation requires a structured approach involving organization, analysis, and communication. Often, agencies postpone necessary preparations until the last minute, leading to a situation where they may pass their initial survey but receive numerous implementation recommendations. This pattern of procrastination may extend into subsequent evaluations. Therefore, it is advisable for behavioral health organizations seeking accreditation from CARF to adopt a proactive, ongoing preparation strategy. This proactive approach not only ensures a smoother accreditation process but also instills confidence in the organization's readiness.

An organization should initiate groundwork once the application is submitted to mitigate procrastination. Three key areas of planning are essential:

1. Policies and Procedures: Organizations should prioritize completing all relevant policies and procedure s that align with accreditation standards. These documents serve not only to inform surveyors but also to educate employees about the organization’s practices.

2. Document Analysis: Agencies should routinely gather and analyze daily documentation, such as critical incident reports. Reviewing these documents helps leadership identify significant issues and assess whether operational changes are necessary.

3. Employee Training: Organizations must ensure that employees receive training on specific topics mandated by the accreditation bodies. Common training areas include suicide prevention, behavior management, and newer topics such as corporate compliance and quality improvement. Documenting employee attendance at these training sessions is essential.

To prevent burnout, these activities should be conducted regularly, ideally monthly, over the six-month preparation period. By integrating these tasks into regular operations, the organization can seamlessly engage with the accreditation process from CARF. This approach not only eases the burden of preparation but also fosters continuous improvement in the organization’s operations and services, providing a sense of security about the process.

The best approach for CARF accreditation is to develop an ongoing preparation process. This continuous readiness not only ensures a smoother accreditation process but also instills confidence in the organization's ability to meet the standards set by CARF.

The Urgent Need to Address Trauma In Health Discussions

dan.thorne@praxesmodel.com (Dan Thorne) — Wed, 02 Apr 2025 22:56:39 GMT

One ten-question assessment could improve health, less incarceration, and decreased healthcare costs.

Last month, I read President Trump’s announcement that he was establishing a Make America Healthy Again (MAHA) Commission. I was curious about the recommendations, considering that Robert F. Kennedy Jr., or RFK Jr., would be the new head of the Department of Health and Human Services. I figured that childhood illness, chronic diseases, autism, and ADHD would be prominently covered. Unfortunately, one keyword that significantly impacts most of these conditions was not mentioned.

It's crucial to note that the word 'trauma' was notably absent from the MAHA Commission's focus. This is a significant omission, given the profound impact of trauma on a wide range of health conditions.

This omission was not a surprise. Trauma does not receive as much media attention as other conditions or factors in health. Project 2025 ’s plan, developed by the Heritage Foundation and used as a blueprint by the Trump Administration, never mentioned trauma. What was surprising was that RFK did not say it during the commission's formation. Having experienced the tragic death of his uncle at age nine and his father’s assassination at age 14, followed by his subsequent struggles with drug and alcohol abuse, I would have thought he would place a premium on trauma .

One would think that those who want to “Make America Healthy” would focus on what makes America unhealthy. After all, trauma susceptibility can be easily measured with the Adverse Childhood Experiences Survey ( ACEs ). This measure of ten questions examines whether the participant experienced abuse (physical, sexual, or emotional) along with neglect, domestic violence, and other events. It correlates with chronic mental and physical illnesses later in life. A recent report indicated that 80% of community physicians have never heard of the ACEs questionnaire, and only 3% reported using it in practice. So, if it were used, what could it find?

According to the Centers for Disease Control , 16% of adults have experienced four or more events from the ACEs; five of the top ten leading causes of death are associated with these ACEs, and preventing ACEs could reduce the number of adults with depression by as much as 44%.

However, MAHA, according to RFK Jr., focuses on chronic conditions. Could ACEs and the study of trauma help them? Research has shown that people with four or more ACEs are two to three times more likely to smoke, misuse alcohol, and develop chronic diseases, such as cancer and cardiovascular disease . These are compelling studies. And some might say this affects adults, but how about autoimmune diseases, which is mentioned in President Trump’s announcement? Research suggests that trauma not only increases healthcare costs but also leads to the onset of Rheumatoid Arthritis, Fibromyalgia, and Systemic lupus erythematosus or Lupus. This is because t rauma increases the inflammatory responses in the body, leading to the onset of autoimmune diseases.

What about ADHD, as RFK Jr. discusses; could it also be overdiagnosed? That is possible, as many symptoms of ADHD mimic or appear to be those of trauma , yet again, it was not mentioned in the announcement. Or obesity? While others are concerned about improving healthy eating habits, which is admirable, the Commission may focus on how trauma impacts obesity .

Yes, while RFK Jr. will make his focus in MAHA on food additives , beef tallow , raw milk , and french fries , recommending to the American Medical Association that all its physicians use the ACEs with all their patients, young and small, would do more to the health of this country. One ten-question assessment could improve health, less incarceration, and decreased healthcare costs.

The Assessment Episode in Netflix’s Adolescence Shows How Not to Interview a Youth with Aggression

dan.thorne@praxesmodel.com (Dan Thorne) — Wed, 02 Apr 2025 22:48:44 GMT

Briony's methods, while attempting to understand Jaime's actions, are risky.

For years, television shows have aimed to depict the therapeutic world to viewers, with examples like Good Will Hunting and In Treatment illustrating the therapeutic process. However, entertainment media focuses on drama, which doesn't always reflect the realities of the world of psychology. This makes for engaging television, but it often misrepresents client-therapist interactions.

Netflix’s Adolescence , which premiered in March, is an excellent show. It effectively illustrates how a young person's violent actions affect both the community and their family. It explores themes such as cyberbullying, smartphone culture , misogyny, and parental influence, making it a noteworthy series.

The third episode of Netflix's Adolescence, which features the final session between Jaime and his psychologist, Briony, is a prime example of how not to conduct an assessment session. Briony's lack of observation of and response to Jaime's behavior is a significant misstep.

Briony's methods, while attempting to understand Jaime's actions, are risky. Engaging a youth with a history of aggression, especially one she has witnessed in a fight, is a dangerous choice. While Netflix aims for authentic drama, Briony's methods serve as a cautionary example of how not to interview an aggressive youth, raising concerns about the safety of the characters.

The primary rule for behavioral health professionals is to prioritize personal safety. Unfortunately, there are moments when Briony appears threatened by Jaime’s outbursts—standing up, yelling, and throwing chairs—yet she permits these behaviors, which most psychologists would typically not allow.

Bringing hot chocolate to the session is a significant misstep. While interpretations of its significance as a gift vary, its presence poses a risk. Serving a hot drink to a youth exhibiting volatile behavior increases the risk of injury. It was only a matter of time before it could be thrown—a dramatic but imprudent choice for an assessment session. Briony was fortunate that no one got burned.

When Jaime looms over Briony, her failure to react is not just a plot device but a serious oversight. By not addressing this behavior, she inadvertently gives Jaime emotional, psychological, and physical control over her. A competent assessor would stand to balance the power dynamic and firmly request that Jaime sit or move. This approach serves as a plot device, but Briony could have faced physical harm without awareness.

Briony's postponement of saying goodbye to Jaime at the end of their last session is a moment that could have been used to highlight Jaime's volatility, but it unfolds unrealistically. A professional would initiate the session by informing the youth that their sessions are ending and outlining the following steps, allowing Jaime to process his emotions ahead of time. Surprises often unsettle youth displaying explosive behavior, and in this instance, Jaime ended up needing restraint to be removed from the session.

For dramatic effect, Briony escalates tension and aggression with Jaime. In reality, managing aggressive clients demands careful planning, understanding how to de-escalate situations, and alternative strategies to calm an angry youth. Had Briony worked in most agencies, she would likely have received at least a warning, if not termination.

Adolescence offers compelling insights into how teenagers influence each other and how their families handle these challenges. Yet, as a guide for engaging with aggressive youths, it exemplifies how not to approach the situation.

Trauma and Managing Triggers: Prevention or Reaction

dan.thorne@praxesmodel.com (Dan Thorne) — Fri, 28 Mar 2025 19:26:55 GMT

Preventive measures play a significant role in stopping trauma-related behaviors, helping clients avoid triggers, and developing strategies to manage their trauma. Understanding trauma triggers is a crucial step in managing trauma and can significantly enhance long-term well-being. Individuals who have experienced trauma, whether youths or adults, face substantial effects from their past. Research by Kaiser and the CDC revealed that adverse childhood experiences ( ACEs ) can impact individuals well into adulthood. The study examines several aspects, including injuries, mental and maternal health, infectious diseases, chronic conditions, risky behaviors, and lost opportunities. Supporting clients in mitigating the effects of trauma is vital.

To improve their coping abilities, clients should concentrate on their trauma triggers. Similar to other stimuli, these triggers precede a person's response. Internally, individuals may encounter feelings or thoughts associated with the traumatic event, such as flashbacks, physical discomfort, or memories. Externally, sensory information might also play a role. Encountering these precursors can lead to maladaptive behaviors, such as self-harm, anger, withdrawal, substance abuse, or sexual acting out. Various psychological treatments provide coping strategies to assist clients in managing their responses during these challenging moments.

The Boketto Center, for instance, lists several grounding techniques on its website. This represents a reactive approach where the client identifies the trigger and employs coping methods. Although beneficial, this strategy does not eliminate the original stress caused by the trauma. An alternative intervention focuses on preventing trauma triggers or identifying their origins. When clients relive or encounter their trauma, they often must respond. However, clients can minimize their effects by understanding which internal or external stimuli are influential. Preventive measures aim to stop trauma-related behaviors from occurring. For instance, if a client resorts to self-harm in response to a trigger, it may serve as a coping mechanism- providing a sense of control or stress relief. By identifying the circumstances that lead to these behaviors, such as recalling their abuser or specific events, clients can take steps to avoid them. They might analyze when they think of the trauma (for example, before bed or during meals) and engage in alternative calming activities- like talking to someone, practicing deep breathing, or exercising- to alleviate anticipated fears. This proactive approach helps clients develop strategies to lessen the impact of their trauma.

Other treatment modalities, such as Eye Movement Desensitization and Reprocessing ( EMDR ) or neurofeedback , assist clients in altering their cognitive and emotional responses to trauma. These techniques are often associated with more sustainable success alongside behavioral interventions.

Mission, Strategy, & Culture for Youth Residential Facilities

dan.thorne@praxesmodel.com (Dan Thorne) — Fri, 28 Mar 2025 17:08:28 GMT

Developing proper strategic plans that match the organization’s culture and mission will be crucial for today’s behavioral health organizations.

The Association of Children 's Residential & Community Services ( ACRC ) has released the 2025 Trends Report for its members. This annual report, the last of its kind, was created by consultants Tom Woll and Bill Martone. Its purpose is to assist staff and board members of agencies, oversight organizations, and associations in their strategic planning processes. The report highlights the challenges associated with strategic planning. Traditionally, many non-profit organizations engage in extended discussions about their future and direction. However, as the behavioral health landscape evolves with shifting funding, regulations, and client demands, the report suggests that organizations should focus their efforts more narrowly. Instead of formulating five-year plans, strategies should be revised annually. Organizations must concentrate on immediate actions that ensure their survival and allow for growth. The urgency of these immediate actions cannot be overstated. Consider this in the context of a treatment plan for a client. A young person may face multiple issues, such as running away, substance abuse, trauma, and depression. If a youth has too many goals to tackle, achievement becomes unfeasible. Therefore, the youth's treatment provider, in collaboration with the youth, should concentrate on two or three key areas first. Similarly, organizations must prioritize and “select their battles” to realize what is currently achievable.

The trends report further emphasizes the crucial role of aligning the organization's mission with its culture. This alignment is not just a theoretical concept but a practical necessity in the daily work of behavioral health staff. They face demanding jobs, irregular hours, often inadequate pay, and increasing administrative burdens. Yet, they persist in their field, driven by personal passion. Employee retention is a significant challenge for organizations, and addressing employees’ needs and hearing their voices fosters a culture of inclusivity that benefits the entire organization. As our clients yearn for recognition, our employees seek the same attentiveness. This alignment is not just a matter of policy, but a fundamental aspect of our work that we must all strive to uphold.

Finally, the report shares how mental health in schools, LGBTQ services and rights, and homelessness are future themes that should be addressed in services. The report concludes that, as has been seen over the years, those agencies willing to change will survive, while those that do not will fade. Adapting to changing needs is not just a suggestion, but a stark reality that we must all acknowledge. Developing proper strategic plans that match the organization’s culture and mission will be crucial for today’s behavioral health organizations. This adaptability is not just a choice but necessary for our continued relevance and effectiveness.

Behavioral Health Budgeting in 4 Simple Steps

dan.thorne@praxesmodel.com (Dan Thorne) — Fri, 14 Mar 2025 23:33:33 GMT

By carefully managing these interconnected elements, a behavioral health organization can build a robust budget that withstands the complexities of cost-reimbursement funding.

Budgeting for behavioral health organizations presents a unique and intricate challenge, differing from standard financial forecasting. This complexity is especially evident when collaborating with governmental agencies. Unlike typical budgets that concentrate on precise expenses and revenue, the landscape is notably altered when a behavioral health entity enters into contracts with State or County agencies. The budget transitions to a cost-reimbursed model when funding comes from governmental sources like MediCal/Medicaid or Medicare.

Typically, budgets in this sector are organized around fee-for-service reimbursements; for example, a provider offers care to a client and is later compensated with a specific fee for the service rendered as outlined in the corresponding contract.

A cost-reimbursed budget consists of three key components:

1. Revenue Projection: This entails estimating the total revenue or billing the behavioral health organization expects over the contract period, usually one year. The budget should represent the anticipated total revenue during this timeframe.

2. Unit Rate Calculation: Additionally, the budget must incorporate the rate per billing unit, which could be specified in minutes or hours, depending on the governmental agency's requirements. This rate may be $3.00 per minute or $180 per hour for mental health services.

3. Expense Management: This vital component includes all expenses related to contract execution throughout the year. It encompasses a comprehensive list of costs—including staff salaries, administrative fees , building rentals, office supplies, and other operational expenses.

When an agency secures a contract amount, its costs must closely align with anticipated revenue. Achieving a balance between services provided and expenses incurred is essential. For example, if the contract stipulates $1 million, the agency needs to aim to bill that amount while managing expenses at this same level. Using the established rate per minute, the agency must serve a specific number of clients detailed in the contract. After the contract year, a thorough cost report is compiled detailing costs and revenue. Depending on this report's results, the organization may owe the payer money, or vice versa—an outcome neither party wishes for. Hence, careful budget planning is crucial.

Faced with these multifaceted components, how can an agency effectively navigate them?

1. Start with Revenue: If your organization is working under a $1 million contract, your first step is to determine your billing rates per minute. For instance, if all services are billed at $3.00 per minute, you'd divide $1 million by $3.00, resulting in approximately 333,333 minutes. Dividing that number by sixty gives about 5,555 hours of staff time required to achieve that billing amount.

2. Determine Staffing Needs: Next, evaluate how many staff members are necessary to meet your billing goals. If each staff member can bill 20 hours weekly for 48 weeks, accounting for vacations, sick leave, and holidays, that equals 960 hours per person annually. Dividing the total needed minutes (5,555) by the annual billable hours per staff member indicates a requirement for about 5.79 full-time equivalents, or roughly six staff members.

3. Assess Expenses: At this point, it's time to quantify expenses. Calculate the staff salaries, benefits, and other operational costs mentioned previously, ensuring they combine to $1 million overall.

4. Make Revisions: It’s essential to understand that initial budget estimates seldom achieve precision on the first attempt. This stage necessitates adjustments to staff hours, positions, and expenses to close any gaps and ensure the final budget is perfectly aligned. By systematically modifying these elements, you can guarantee that your staffing capacity meets the requirements to bill the full $1 million while maintaining a balanced expense sheet. Flexibility and adaptability in the budgeting process are vital for success.

By diligently managing these interconnected components, a behavioral health organization can develop a solid budget that can endure the complexities of cost-reimbursement funding. This highlights the intricate and interdependent budgeting process, ultimately positioning the organization to provide essential services to the community successfully.

Four Ways to Reduce Adolescent Hospitalizations

dan.thorne@praxesmodel.com (Dan Thorne) — Fri, 14 Mar 2025 20:52:29 GMT

Inpatient hospitalizations are always a factor with high-risk youths, but they can be reduced.

Behavioral health organizations supporting adolescents encounter various challenges, particularly in community settings. Federal legislation like the Family First Prevention Services Act allocates funds to keep youths out of residential facilities. Although emphasizing community support for at-risk youths is a positive shift, it does not always address the crucial need for safety, preventing the risk of self-harm or harm to others.

Foster youth, those with trauma histories, and those struggling with substance abuse or mental health issues tend to require hospitalization more frequently. Many find themselves in a cycle of quick inpatient care for stabilization, only to return home and then back to the hospital shortly afterward. This cycle negatively impacts the youth, their families, and the community. Lacking the stability they need, these youths start to see themselves as “dangerous” or “damaged,” feeling out of control.

However, minimizing hospitalizations is an achievable goal. Organizations and staff can keep high-risk youths at home and out of the hospital with the right skills, training, and strategies.

How can this be achieved? Here are four strategies that you, as behavioral health professionals, social workers, and caregivers, can implement to reduce adolescent hospitalizations:

1. Involve staff with lived experiences in the treatment process. Parent partners create immediate positive impacts by engaging parents in treatment and listening to their concerns. They become active participants, not just passive observers. Peer partners assist youths in managing their behaviors, drawing from personal experiences of crises and emotional shifts. These connections with peer support staff significantly reduce hospitalizations.

2. Ensure youths on psychotropic medications adhere to their prescriptions. Proper medication can help youth overcome biochemical imbalances, reducing anxiety and stabilizing mood fluctuations. Cases often arise where a parent is advised that their child needs medication, yet they discontinue its use when the child complains or forget to renew it when it runs out. This lapse can lead to hospital visits when the youth struggles with self-control. Discussing any medication concerns should be directed to the psychiatrist rather than abruptly ceasing treatment.

3. Role-play with parents, caregivers, and youth to develop necessary skills. Equip both parents and youths with techniques to de-escalate potential crises. Typically, parents notice when their adolescent is nearing a crisis, recognizing signs, triggers, and cues but often feeling powerless without the right tools. By instructing the parents on handling crises, de-escalating anger, and guiding the youth towards calming techniques, such as deep breathing, they can manage the emotional turmoil more effectively.

4. Acknowledge the impact of trauma on hospitalizations. Triggers or flashbacks may provoke youths to seek relief from their distress. Under stress, individuals commonly experience fight-or-flight reactions or a desire to numb their pain, particularly trauma survivors. When triggered, they may respond with anger towards themselves or others. Staff or parents can assist youths in processing their feelings by naming emotions, reminding them that feelings are temporary, and providing calming strategies, like controlled breathing. These skills help youths gradually integrate traumatic experiences, reducing their future impact.

By learning and implementing these new skills, you, as staff and parents, play a crucial role in keeping high-risk youths safe at home.

FBA Explains Five Needs to Runaway

dan.thorne@praxesmodel.com (Dan Thorne) — Wed, 05 Mar 2025 23:51:14 GMT

The motivations behind running away can vary significantly among individuals.

When young people transition out of a foster home or residential placement, caregivers often experience confusion regarding the youth's decision to leave. Many may resort to various strategies, such as offering rewards, implementing consequences, or issuing threats, yet these methods frequently prove ineffective. A significant factor contributing to this ineffectiveness is a lack of understanding of the underlying motivations driving the youth's choice to leave. Young individuals may run away to escape adverse situations or pursue desired experiences, often for more intricate reasons than they appear.

Functional Behavior Analysis (FBA) provides a systematic approach to assessing a youth's behavior and motivations.By focusing on the ABCs—antecedents, behavior, and consequences —professionals can gain valuable insights into the youth's intentions. Additionally, gathering information from individuals close to the youth can help develop intervention strategies specifically tailored to their needs.

For example, when a young person runs from a residential facility, it raises the critical question: What prompts this departure? FBA identifies five potential functions that may underlie the youth's behavior:

1. Connection – Some youths seek to connect with trustworthy individuals and expand their social networks. They may leave to spend time with friends, significant others, or peers, as research suggests that many do not view leaving negatively; they desire social interaction.

2. Access—Some youths resist imposed rules because they desire independence. When seeking more control over their lives, these individuals may be labeled as having “oppositional” or “conduct” issues. In this context, running away represents a means to experience freedom, which can be redirected positively.

3. Escape – Certain youths' circumstances may be intolerable, prompting them to flee. This desperation can arise from external pressures, such as bullying or conflicts with authority figures, as well as internal triggers like past traumas. Their aim in running away is often to evade distressing conditions that evoke feelings of vulnerability.

4. Control – While some youths leave for safety, others seek to assert control over their lives. Having potentially endured traumatic environments, they may view running away as a declaration of autonomy.

5. Stimulation—Certain youths, particularly those who exhibit attention-related or autism-related behaviors, may have a heightened need for sensory engagement and movement. They might run away to escape uncomfortable sensations (such as excessive noise or heat) and achieve calm. For example, a youth might walk miles to experience "the cool breeze in my hair."

The motivations behind running away can vary significantly among individuals. FBA is a valuable tool for identifying these functions and developing tailored strategies to address them effectively.

Learn more about our online course in FBA and others.

Grant Strategies with an Uncertain Federal Pipeline

dan.thorne@praxesmodel.com (Dan Thorne) — Wed, 05 Mar 2025 23:46:34 GMT

Agencies relying on federal grants may pivot to other options.

Behavioral health organizations that depend on federal funding and various grants are currently navigating an uncertain landscape. This situation was exacerbated by an executive order that instituted a nationwide funding freeze on January 27, followed by a court injunction on February 11 that brought those freezes into question. As the specter of potential program cuts looms large, it is imperative for agencies to critically reassess their grant strategies in light of the unpredictable nature of federal funding programs.

In light of these challenges, Grantstation , a prominent nationwide clearinghouse for grant funders and seekers, suggests that organizations consider four strategic steps to maneuver through the uncertain funding terrain effectively:

1. Assess the Economic Impact: The future of grantmaking is poised to focus heavily on accountability and tangible outcomes. Mirroring the private sector's shift toward value-based reimbursement—which emphasizes evaluating service outcomes—future funding decisions will be driven by a desire to see demonstrable return on investment and cost savings. While grants are unlikely to vanish entirely, grant makers in Washington increasingly insist on understanding the cost benefits of their investments. Organizations must clearly articulate how their services translate into savings or noteworthy outcomes. For instance, consider demonstrating the financial benefits of programs that prevent youth from entering the juvenile justice system or quantifying the stability fostered by your housing initiatives.

2. Diversify Funding Sources: Relying solely on a single funding source is generally unwise—this precarious strategy can lead to significant vulnerabilities. Behavioral health organizations often depend heavily on one funding stream, commonly from state or county sources. In times fraught with uncertainty, however, a diversified approach to revenue generation is essential. Engaging with a mix of grants, private foundations, financial institutions, corporations, community foundations, and other revenue channels can provide valuable stability, even if these funds do not match the scale of federal allocations.

3. Advocate: While some CEOs may be hesitant to openly voice their concerns about impending funding shifts—fearing potential backlash or targeting—it is crucial to recognize that there are safer and more effective alternatives. Collaborating with lobbying organizations can be a powerful way to amplify your organization’s voice. By working with these entities, which have staff who maintain close relationships with legislators, you can strategically assert your perspectives on the funding landscape.

4. Seek Grant Management Support: Organizations like Grant Works are invaluable allies in navigating the complexities of the grant process. They provide essential support in managing grant operations and ensuring financial management aligns with necessary regulations, enabling organizations to focus on their mission while remaining compliant.

By implementing these effective grant strategies, your organization can enhance its chances of success in navigating the intricate realms of grant planning and development, ultimately positioning itself for greater resilience in an unpredictable funding environment.

Accreditation Success is More than Policies and Procedures

dan.thorne@praxesmodel.com (Dan Thorne) — Thu, 27 Feb 2025 16:06:58 GMT

Conducting annual data analyses, encouraging stakeholder input, and documenting employee skills prepares a behavioral health organization for accreditation.

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Medicaid Cuts Should Focus on Efficiency

dan.thorne@praxesmodel.com (Dan Thorne) — Thu, 27 Feb 2025 16:00:05 GMT

Cutting benefits poses a grave threat to thousands of lives.

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Medicaid Cuts Are Coming. Prepare Your Organization

dan.thorne@praxesmodel.com (Dan Thorne) — Fri, 21 Feb 2025 16:35:49 GMT

Your organization should adopt two primary strategies as viable alternatives.

Medicaid insurance currently serves approximately 79 million beneficiaries in the United States and is facing increased scrutiny from the White House. As the current administration contemplates reductions to the federal budget, all federal departments are undergoing a thorough evaluation of their staffing and program expenditures. Consequently, Medicaid cuts are anticipated, although these reductions' precise nature and extent remain undetermined.

Several strategies exist for implementing these cuts. According to the Kaiser Family Foundation ( KFF ), these strategies primarily focus on the Affordable Care Act's expansion of Medicaid coverage. One potential approach involves states increasing the federal costs associated with these expansions, which would result in reduced federal funding. Alternatively, states could discontinue the expansion, decreasing overall expenses.

The implications of these proposed cuts will differ by state. Some states, such as California, are likely to pursue methods that allow them to maintain matching contributions for beneficiaries, whereas others may consider substantial reductions to benefits. Additionally, some states may adjust eligibility criteria for recipients, with decisions swayed by political and financial factors.

Stakeholders engaged with this population recognize that diminished insurance coverage may lead to lower insurance costs. However, individuals losing their coverage do not cease to face mental health challenges, nor do they automatically terminate substance use. Such issues will likely re-emerge through increased emergency room visits, higher rates of incarceration, elevated psychiatric hospitalizations, homelessness, and even mortality. Evidence and studies substantiate the advantages of health coverage in mitigating societal costs.

Your organization should adopt two primary strategies as viable alternatives. Firstly, endeavor to advocate comprehensively within your state against the proposed cuts. Use relevant statistics, reports, and evidential data to illustrate the cost-benefit relationship of engaging Medicaid recipients with legislators. Collaborate with local and national healthcare lobbying organizations such as NAMI to emphasize that these cuts would increase overall costs. It is important to note that some states may contemplate specific reductions to present legislators with projected tax savings, which resonates positively with their constituents. However, the disparity between 10% and 50% cuts can be significant. Legislators tend to prioritize numerical data over anecdotal evidence; thus, providing comprehensive information may enhance their willingness to negotiate specific reductions while safeguarding others.

Secondly, it is prudent to prepare for new business initiatives. For the foreseeable future, Medicaid may not serve as a sustainable payer as it has in the past, and organizations must be ready to address the potential loss of a critical revenue stream. The time to explore new program opportunities is now. Grants may still be attainable, particularly for privately-operated programs. Notably, many social service organizations originated as charities dependent on private donations, a trend that may reemerge. Furthermore, non-governmental insurance plans might explore innovative approaches within the marketplace.

Medicaid faces potential cuts. However, similar to previous events like the Great Recession and the COVID pandemic, organizations should see these times as opportunities instead of challenges.

What Behavioral Health Executives Face in 2025

dan.thorne@praxesmodel.com (Dan Thorne) — Thu, 20 Feb 2025 16:25:11 GMT

Streamlining operations, leveraging technology, and exploring innovative approaches will allow behavioral health organizations to thrive.

The COVID-19 pandemic significantly altered the stigma surrounding behavioral health care and its underutilization, highlighting the need for treatment among many Americans . While this shift increased access and services, it posed numerous challenges for providers. NextGen Healthcare consulted with 30 behavioral health executives, who identified their top five challenges for 2025.

1. Finances – Two key issues will persist this year. First, inadequate reimbursement for providers makes it difficult to maintain operations. This issue is compounded by delays in reimbursement , forcing providers to seek debt financing or reduce their operations. Providers noted that, as the old saying goes, organizations cannot put all their eggs in one basket. Diversifying their business portfolios, including private and public financing, offers a buffer against fluctuating reimbursements and extended receivable days. Lastly, recruiting and retaining employees will continue to impact an organization’s stability.

2. Technology-Given the financial challenges, these executives use technology to streamline their operations. The potential of technology and AI will be scrutinized to help lower administrative costs and enhance efficiency . Electronic health records and the claims process will become more integrated to minimize duplicative tasks. Any way an organization can increase the volume of clinical services while lessening the paperwork burden on clinicians will simplify the treatment process.

3. Medicaid—As mentioned earlier, expanding into Medicaid programs can help counterbalance the unpredictability of the private insurance market. Medicaid beneficiaries often have more significant needs, resulting in longer-term treatment cycles. However, Medicaid also comes with drawbacks, such as lower reimbursements and uncertainty around state and federal funding in the future . The executives emphasized the need for more education and advocacy with legislative partners to foster an understanding of the health benefits associated with treating this population.

4. Diversification—The influx of behavioral health funding into the marketplace has significantly increased the number of providers. Competition is intensifying among traditional brick-and-mortar, field-based, telehealth-based, and hybrid models. Executives mentioned that targeting specialized markets can be an effective strategy to differentiate themselves in the marketplace. Emphasizing services for substance use, the ID/DD population, or the LGBTQIA+ community provides opportunities to create robust programs that deliver culturally competent treatment to specific groups.

5. Strategic Partnerships - Finally, executives indicated that forming strategic partnerships will be vital this year. Collaborating with government entities, school districts, regional health organizations, and other affiliations can establish an organization's strong pipeline of referrals and contracts. An example of this approach is how mental health providers are developing partnerships with school districts to assist with the mental health crisis in schools.

By streamlining operations, leveraging technology, and exploring innovative approaches to behavioral health, organizations can thrive in 2025 and develop strategic plans for the upcoming years.

You can find the article here.

Behavioral Health Productivity: The Plan B Option

dan.thorne@praxesmodel.com (Dan Thorne) — Fri, 07 Feb 2025 23:23:03 GMT

When behavioral health agencies aim to meet productivity standards for mental health services, they often face challenges.

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Behavioral Health Organization: The Three P’s

Fri, 31 Jan 2025 17:42:48 GMT

Using the three Ps as a behavioral health organization promotes a positive approach to growth, sustaining, and maintaining a business.

When potential new customers inquire about the essential qualities necessary for a successful behavioral health organization, it's important to draw on experience. After 45 years in this field, I have observed successes and failures. While sufficient capital, a solid business plan, and a potential payor base are essential, they are not enough to ensure survival in this industry. It's vital to consider the "three P's" that contribute to a thriving organization: Passion, Patience, and Persistence. Without these, even the most well-funded and strategically planned organizations can falter, as I've seen in numerous cases.

Passion is a fundamental quality in the behavioral health organization. Unlike many other fields, healthcare demands a deep commitment to improving individual lives. Most professionals in this domain have personal stories that motivate their involvement—many have personal histories as former foster children or have faced mental health challenges themselves. These personal narratives not only drive their work but also create a sense of empathy and connection with the audience. Some staff members are foster or adoptive parents, bringing valuable perspectives to their roles. Organizations such as Kaiser Permanente emphasize "passion" in their recruitment efforts because a strong desire to help others is critical for success. An effective mission statement will often highlight the importance of caring for others.

Patience is equally essential. Establishing a behavioral health organization or launching new services often requires significant time. For instance, in California, initiating a Short-Term Residential Therapeutic Program (STRTP) or Qualified Residential Treatment Program (QRTP) can take three to four years due to the necessary layers of program development and approvals from county and state governments. Many aspiring agencies become frustrated with this lengthy process; however, it is essential to recognize that thoroughness is crucial for maintaining credibility. The slow-moving nature of governmental processes exists for a good reason, as they aim to avoid issues such as ghost networks in insurance or i ncidents at group homes . Embracing patience is essential in navigating these challenges, and understanding this can reassure the audience about the importance of these processes.

Persistence complements patience, as behavioral health organizations cannot afford to let opportunities slip away. Although securing approvals or developing new business ventures takes time, active engagement is necessary. Building a network with individuals in managed care companies or governmental entities can lead to valuable collaborations. For example, there was a case where a client sought Medi-Cal approval for a residential treatment facility for substance use. After applying, no progress occurred for three months. However, leveraging contacts within the California Department of Health Care Services helped identify the PAVE system was the correct channel to expedite the approval process. Due to persistence, the client received state certification more quickly. This story of persistence should motivate organizations to be proactive in their own endeavors.

By emphasizing these three P's—Passion, Patience, and Persistence—behavioral health organizations can adopt a constructive approach to growth and sustainability within their business. What are some instances in your experience where these qualities have been crucial to the success of your organization?

Transitional Housing Placement Programs: Bridging Adulthood

dan.thorne@praxesmodel.com (Dan Thorne) — Fri, 24 Jan 2025 17:56:21 GMT

The challenge currently is that not enough THPPs exist in the community.

Transitional Housing Placement Programs (THPP) support foster youth transitioning from adolescence to adulthood. These programs offer a safe and stable living environment that enables young individuals to develop the skills necessary for independent living, free from the constant supervision typically associated with residential facilities or traditional foster homes.

As foster youth approach their 18th birthday, many experience a blend of excitement and anxiety. This age marks a significant milestone, representing a shift towards independence and a move out of the foster care system. Research from the THRU project reveals that nearly 40% of foster youth are at risk of experiencing homelessness by age 19. Additionally, a significant portion of the homeless population has had prior involvement with the foster care system. While residential programs, such as Short-Term Residential Treatment Programs (STRTPs) and Qualified Residential Treatment Programs (QRTPs), provide necessary stabilization, they often fail to equip youth with practical, real-world skills and support.

Participants in THPPs must adhere to state-specific guidelines , which generally involve part-time education, part-time employment, or active engagement in job or educational searches. Accommodations are made for those with disabilities that limit participation. Each participant is assigned a social worker or case manager who meets with them weekly to oversee their living situation and help them manage their budgets effectively. The program also offers comprehensive life skills training on various topics, including healthcare and financial management, which are vital for a smooth transition into adulthood.

Despite their importance, one of the primary challenges facing THPPs is the insufficient number of available programs within communities. While many states focus on residential and foster care solutions, there is an urgent need to enhance transitional housing options. Advocacy for the expansion of THPPs is critical in addressing this gap, as the scarcity of homes or apartments contributes significantly to the risk of homelessness among foster youth.

THPPs provide various opportunities while maintaining guidelines similar to those in traditional foster or residential care. These include Needs and Services Plans, mental health and medical care access, and involvement in a Child and Family Team. However, THPPs set themselves apart by granting participants greater freedom and autonomy, which helps them acquire essential life skills. Training covers diverse areas, such as budgeting, academic responsibilities, career planning, workforce development, and childcare. Unlike treatment-centric programs, THPPs prioritize case management, equipping youth with the necessary tools for independent living and a successful transition to adulthood.

CARF Mock Surveys: Are They Necessary?

Fri, 24 Jan 2025 15:53:57 GMT

A mock survey can reduce the stress level and pressure for an agency and prepare them for a better outcome for accreditation.

Preparing for accreditation can feel like navigating a complex maze, CARF mock surveys often play a vital role in this journey. These simulated assessments are designed to prime your agency for the real accrediting agency's thorough evaluation. However, the question remains: Is conducting a mock survey necessary in your preparation process?

A CARF mock survey, by definition, is a simulated evaluation that gauges your agency's readiness for accreditation. While it is not as extensive as the multi-day surveys conducted by accreditation bodies, it is comprehensive enough to provide meaningful insights into your agency's preparedness . During this one-day event, a consultant, on-site or virtually, will step into the role of the accrediting body, carefully assessing various aspects of your operations. The day typically unfolds with meetings involving leadership and staff, an in-depth clinical and administrative documentation review, and a guided tour of your facility. Following this review, the consultant compiles a detailed report outlining their findings and recommendations, a valuable tool to enhance your readiness for the survey.

Within the framework of the CARF mock survey, the consultant focuses on three pivotal areas of evaluation:

1. Documentation: It is crucial for the agency's policies and procedures to not only meet the standards set by the accrediting body but also to be readily accessible, clearly written, and sanctioned by agency leadership. In addition to overarching policies, related documentation—including strategic plans, quality assessments, risk management protocols, personnel files, and financial reports—must be meticulously organized and available for review.

2. Analysis: While regular operations define your agency's day-to-day functions, accreditation bodies are especially interested in the mechanisms for reviewing these operations. They seek to understand how the agency identifies and addresses weaknesses within its processes. Critical incidents, emergency drills, and annual evaluations are scrutinized. Many organizations struggle to meet accreditation standards in this aspect. However, a concise one-page summary of past events and actionable suggestions for future improvements can often satisfy accrediting bodies' requirements.

3. Training: Ongoing staff training is a fundamental expectation for accreditation, particularly in high-risk environments where clients may present suicidal or aggressive behaviors. The accrediting agencies require clear evidence that staff members are regularly trained on operational and clinical procedures and that retraining is mandated for those whose performance does not meet standards. Comprehensive records of these training sessions must be meticulously maintained.

So, is a mock survey essential?

The advantages of a CARF mock survey are significant. It serves as a simulated practice run, allowing your agency to identify and rectify potential deficiencies before the accreditation survey. This proactive approach reduces anxiety and uncertainty surrounding the objective evaluation, providing a clear pathway forward. A mock survey can be an invaluable resource for building confidence and competence for agencies new to the accreditation process or those that have faced challenges in prior evaluations.

Conversely, a mock survey may seem redundant for seasoned agencies that have successfully navigated multiple surveys. These organizations are often comfortable in the accreditation process and equipped with the knowledge and experience to know what to expect. Exceptions may arise if significant changes have been implemented or new programs are introduced; in such cases, a mock survey becomes more pertinent.

A CARF mock survey can diminish stress levels and pressure within an agency, setting the stage for a more favorable outcome during the accreditation process.

STRTP: The Program Statement

Wed, 08 Jan 2025 22:06:11 GMT

The program statement articulates what and how your organization will operate.

The STRTP (or Short-Term Residential Therapeutic Program) in California represents the prevailing framework for the residential or congregate care of children aged 0-18. This model implements a structured, trauma-informed approach aimed at stabilizing the emotional and psychological health of youths who have challenges remaining in-home or foster placements. The intended duration of care is approximately six months, after which the goal is to transition the youth to a less intensive level of care.

The acceptance of new STRTP facilities in a county is contingent upon several factors, including the demand for placements and the availability of beds. Initiating an STRTP requires a letter of support from the respective county, which necessitates submitting a comprehensive Program Statement and Plan of Operations .

The STRTP Program Statement elaborates on the operational framework for the facility, addressing critical aspects such as the targeted population, trauma-informed methodologies, youth engagement in service decisions, house rules, mental health services, and emergency intervention protocols. Compliance with the California Department of Social Services ( CDSS ) Community Care Licensing’s Interim Licensing Standards, version 5 ( ILS 5 ), is mandatory, encompassing over 340 pages of regulations designed to safeguard the health and safety of the youth while enhancing their overall functioning.

To minimize revisions and ensure a successful program statement, the document must effectively articulate the what and how of service delivery. For instance, when detailing house rules regarding dating, curfew, and cleanliness, it is essential to outline the instructional approaches employed to convey these rules to the youths. This includes establishing initial meetings with staff members—such as social workers and administrators—where rules are communicated verbally and in written form, allowing youths to pose questions and suggest modifications that remain compliant with overarching guidelines. The process must also define the circumstances under which rules may be amended and outline the frequency of reminders provided to the youths.

Counties expect a detailed explanation of operational procedures within the Program Statement that will serve as a practical reference for staff once the STRTP is operational. Clarity and precision in the documentation are critical to expedite the receipt of the letter of support.

Upon receiving the county’s letter of support, CDSS reviews the Program Statement and Plan of Operations and offers recommendations for enhancement. The agency is eligible for a site visit and may obtain a provisional license following their approval.

Praxes has successfully developed over 100 STRTP Program Statements and Operations Plans for various California organizations. Please contact us for further information on how our expertise can assist your organization.

DHCS Licensure for SUD – Understanding the Process

Wed, 08 Jan 2025 21:57:32 GMT

Advanced preparation for licensure ensures streamlined approval.

The DHCS (Department of Health Care Services) in California oversees the licensure of substance use disorder (SUD) programs. This licensure encompasses outpatient, partial hospitalization (intensive outpatient), and residential programs. For numerous organizations, it is imperative to obtain DHCS licensure before securing Medi-Cal contracts or provider certifications, as managed care plans also mandate this licensure. However, organizations may encounter a protracted process unless they thoroughly understand the relevant regulations.

The process for obtaining DHCS licensure for SUD commences with the organization submitting an Initial Provider Application . This application must include detailed information about the organization’s location, ownership, staffing, and program director qualifications. Additionally, the application requires documentation of fire clearance and zoning clearance (in the case of outpatient facilities), a lease agreement, articles of incorporation, and an operating agreement consistent with the organizational structure, such as that of a corporation or limited liability company.

Furthermore, the organization must provide comprehensive policies and procedures governing its operations. This information comes from the state’s standards . This documentation should encompass the operational schedule, community resources, quality management plan, admission guidelines, admission agreements, and other relevant materials. Upon completion, the application is submitted to Sacramento for review as part of the DHCS licensure for the SUD process. Subsequently, it is placed in the queue and assigned to an analyst who conducts a thorough assessment. Following this review, the organization will receive a letter indicating either the completion or incompletion of the application.

If the organization receives a letter of incompletion, specific information is lacking from the application or accompanying policies. Understanding the necessary components can significantly reduce delays in the application process. Adhering to the guidelines and requirements established by DHCS will facilitate a more efficient application procedure.

Once the application has been deemed complete, the next step in the DHCS licensure process for SUD involves scheduling a site visit. During this visit, the analyst will review client charts, existing policies, and proposed employee files and verify that the facility is equipped appropriately. For instance, the organization’s site must provide adequate parking per the facility's square footage, proper exit signage, and functioning fire prevention equipment, including fire sprinklers or extinguishers.

Praxes Behavioral Health has a proven track record of assisting organizations in successfully obtaining DHCS licensure for SUD. Please do not hesitate to contact us for further information regarding how we can support your organization.

CARF Accreditation: 3 Inspiring Reasons to Choose It

Wed, 08 Jan 2025 21:35:56 GMT

What makes CARF stand out as an accreditation organization

There are 3 compelling reasons why embracing CARF accreditation is vital for social service agencies. Federal, state, and local government entities often require agencies to achieve this accreditation to secure critical contracts. Managed care companies also insist that agencies partner with insurance providers. The journey to certification involves submitting applications and documents, followed by a thorough virtual or in-person survey that evaluates your agency's potential. Your social service agency can also explore accreditation through the Council on Accreditation ( COA ) or the Joint Commission ( TJC ). However, what makes CARF stand out?

1. Focused Expertise in Rehabilitation-Based Agencies: CARF, originally known as the Commission on Accreditation of Rehabilitation Facilities, specializes in rehabilitation and is deeply committed to social service agencies. Its standards empower these organizations, making the assessment process tailored and meaningful. With 30 unique programs categorized under Core Programs, Core Residential Programs, and Specific Populations, your organization can proudly choose areas that resonate with your mission, from Behavioral Health and Child and Youth Services to Opioid Programs .

2. Empowering Smaller Agencies: For new or smaller agencies, the standards set by COA and TJC can seem daunting and may not align with your aspirations. COA often requires lengthy document uploads, while TJC operates on short notice for surveys. CARF’s approach is more supportive and collaborative, fostering an environment where even smaller agencies can thrive.

3. A Collaborative and Enlightening Process: CARF surveyors bring extensive experience from the social service field, allowing for a unique partnership during the survey process. While TJC and COA offer valuable perspectives, CARF emphasizes an educational relationship that enriches your organization’s knowledge. As surveyors evaluate based on CARF standards, they generously share their professional insights, enhancing your ability to deliver quality services.

With over 25 years of experience conducting CARF surveys, Praxes Behavioral Health has achieved a 100% success rate in accreditation. Don't hesitate to contact us for more information about how we can inspire and support your journey.

Bullying Prevention: Is it the Parents or the Peers?

Fri, 10 Nov 2023 23:20:23 GMT

While some theorize that the parents are the source of the bullying, others look to the peers as the basis for it.

Bullying is a significant problem with youths, whether they are the target (victim) or the aggressor (bully). According to the National Center for Educational Statistics, 20% of students report being bullied. 41% of students bullied at school think it will happen again. The types of bullying differ. In the statistics, 13% were called names, 13% were the subject of rumors, 5% reported being physically assaulted, and 5% were excluded from activities.

To conduct bullying prevention activities, the onus for schools and professionals is to identify the source of the bullying. While some theorize that the parents are the source of the bullying, others look to the peers as the basis for it. Research suggests that it comes from both starting places equally. Many of the studies look at the type of attachment a youth has with parents or peers. Murphy et al. in 2017 indicated that “Individuals with secure attachments to parents and peers are less likely to be bullies and victims of bullying.” In surveys they conducted with adolescents about peer and parent attachment, they found that “having a secure attachment to peers may be a potentially protective factor against bullying involvement for males with insecure attachments to parents.” Chen et al., in 2021 , found several factors that affected bullying. “Parental behavioral control,” the parent’s ability to supervise and interfere in their youth’s activities, was an essential factor. Also, “deviant peer affiliation” became a significant element as well, meaning the types of peers who might engage in aggression, cheating, and substance abuse. The study found that while parents had some impact in reducing bullying activity, the youths who engaged in antisocial behavior were more of an influence on bullying activity.

Both of these studies also show how attachment is a significant factor in bullying prevention. Studies by Bowlby on attachment showed a correlation between insecure attachment, low trust, and lack of empathy. These are factors that lead to poor connections with others and can be a breeding ground for bullying.

For professionals working with youths being bullied, several strategies can be used. Improving social skills and positive connections with youths leads them to be in a group where bullying is not tolerated, and a social support system can inoculate them from abuse. Plus, working with parents and their communication skills also improves their positive influence on the youth. Bullying prevention needs a two-pronged approach: improving peer-level interactions along with parental communication.

Behavioral Health Grants: Find One in Your Lane

Fri, 10 Nov 2023 23:12:12 GMT

The closer to the organization’s “lane,” or its scope of expertise, the higher the likelihood it will be successful.

With the rapidly changing healthcare landscape, many organizations are exploring behavioral health grants. They see these as opportunities to expand their business or fill a gap in their services. But with thousands of grants, how does an organization make a decision on which to choose? The best approach is to find a grant that fits within their mission, their services, and their plans. In other words, the closer to the organization’s “lane,” or its scope of expertise, the higher the likelihood it will be successful.

Behavioral health grants are funding opportunities provided by government agencies, foundations, and other entities for the purpose of selecting and implementing programs or services. For example, Elevate Youth California offers opportunities for substance use prevention for youth and young adults in California, and grants.gov provides a multitude of different grant proposals nationwide. Some grants, such as those offered through the Amity Foundation , are for smaller organizations and prefer those with lesser revenue. The Mental Health Services Act, through their Children and Youth Behavioral Health Initiatives (CYBHI) , offered funding for construction and new practices. Predominantly, these grants are for non-profit organizations, but they may also be open to for-profit companies or practices.

The organization interested in participating in behavioral health grants first needs to identify their current services and where there may be a gap. Suppose an agency provides mental health and residential services for youth, such as an STRTP or QRTP. They need more staff to provide intensive services. They would want to look for a grant for their type of program (STRTP/QRTP) that advances the clinical practices they offer. To branch into other services, such as outpatient or foster care, would be out of their “lane.” Funding agencies or grantors want to know how their specified grant will be spent, what experience the agency has, and how it would fit the proposed grantee. An STRTP would have a chance to offer a practice suited for their residential care but may have difficulty justifying a grant for them to expand into foster care or outpatient care. Another example would be a foster family agency that wants to provide a similar program, such as Family Preservation. They are expanding their services, but the two programs have identical services, such as case management and parent education. Their opportunity to apply would be optimal.

Behavioral health grants can be an added source of revenue while filling a gap in services. But any organization considering it should identify what they want to do and whether the grant opportunity is too much of a reach or within their scope or their lane.

Motivational Interviewing Pros and Cons

Fri, 14 Jul 2023 20:07:17 GMT

The Pros and Cons exercise also provides the practitioner and client with extra insight into the driving forces behind the client’s need to continue their behavior.

Pros and Cons is one of the most successful techniques of Motivational Interviewing. And it’s not for the reasons most practitioners would think.

Motivational Interviewing is used with resistant clients or those who have difficulty making personal changes. Its methods benefit clients with substance use problems, weight or smoking, adolescents, and others. Motivational Interviewing puts the change mechanism in the client’s hands. Rather than direct the client to change, the goal is to move the client from resistance to ambivalence. Once clients do this independently, they can stop being stuck in the past and move on to the future.

Pros and Cons is a technique in Motivational Interviewing where the practitioner asks the client to list the pluses or minuses of one behavior. Usually, the client sees their actions as an essential part of who they are. And they defend the use of their sometimes self-destructive behavior. And in most cases, the pros of their behavior outweigh the cons. However, the ability of the client to see their choices in their actions helps them to be less resistant in their ability to change.

Moreover, the Pros and Cons exercise also provides the practitioner and client with extra insight into the driving forces behind the client’s need to continue their behavior. When listing the reasons they engage in the behavior, the client indicates what functions the behavior fulfills. It tells them how the client “feels” better, even if it leads to negative consequences. By offering these reasons, the practitioner can focus on these needs and help the client find different ways to meet them.

Consider the following examples:

A client wants to smoke pot and is very resistant to stopping. The practitioner then asks the client to list the substance’s pros and cons. Below might be some of the reasons for use or non-use:

Pros Cons

Emotional pain relief Could be arrested

Companionship with peers Irritable when I can’t use

Feels good Arguing with parents

Sleep better Poor schoolwork

In looking at the pros, the client indicates several themes that encourage their use. They use pot to escape emotional discomfort, socialize, improve their sensory experiences, and beat insomnia. If the practitioner can develop other coping skills with the client, their need for marijuana may lessen. Rather than arguing that the cons are more important than the pros, the practitioner’s focus on the pros moves the client from resistance to more change options.

Motivational Interviewing is one of our online training courses . For more information about our other courses, please get in touch with us .

Behavioral Health Consultant Advises: Own Your Project

dan.thorne@praxesmodel.com (Dan Thorne) — Fri, 14 Jul 2023 19:58:47 GMT

Ensuring you understand the behavioral health consultant's project from beginning to end saves you from future grief.

A behavioral health consultant is uniquely positioned to help an organization with their business challenges. Whether the role is administrative, clinical, financial, or programmatic, the consultant is considered the expert in solving the organization's problems. But this position as an advisor comes with some pitfalls if the organization does not take accountability during a consulting project to own the project.

When a project starts, each side has its own duties and responsibilities. The consultant conducts their project based on interviews and information gathered and submits deliverables at agreed-upon times. The client has specific responsibilities . Among them are providing the information needed, being upfront about their needs, and communicating with the consultant when the project needs to meet expectations. But what may be missing is that, when the project is done, the organization must embrace the deliverables and make them their own. Because if something happened to the consultant, would they know what to do?

Here's a hypothetical example of what can go wrong. Suppose a residential program wants to become accredited. The program hires a behavioral health consultant to do the work; the policies and procedures, training, and operations review; everything necessary to pass the accreditation. And the program receives its three-year accreditation. But one thing needs to be added. The program's Executive Director delegates too much responsibility to the consultant. They believe that no continued work is necessary once the accreditation is completed. Years pass without any policy updates or yearly reports to the accreditation agency. When it comes time to conduct the recertification for the organization, the program is unprepared. The Executive Director thought the accreditation was a "one-and-done" process.

It could be argued that the consultant was responsible for informing the organization about the ongoing renewal process (which might have happened). However, it is the Executive Director's (in this case) role to own and be accountable to their board from the beginning on the role of accreditation. It is the same process as an RFP . Although the consultant may write the RFP, it is still the role of the Executive Director to read it through and ensure the document reflects accurately before sending it to the funding entity.

Ensuring you understand the behavioral health consultant's project from beginning to end saves you from future grief.

Praxes Behavioral Health offers consulting on program development and more. Feel free to contact us for more information.

Sexual and Reproductive Wellness Under Fire?

Thu, 29 Jun 2023 16:14:56 GMT

Although county and state agencies should be aware of the laws and regulations, a community-based organization needs to educate and advocate.

Although most states, such as California, offer sexual and reproductive wellness education for foster youth through SB 89 , some governmental entities try to minimize its application. A report from the Imprint in May indicated that there are “10 states with no publicly available policies ensuring all foster youth have received age-appropriate education on sexuality and relationships.” The reasons for this component of education for foster youth are evident. Texas’ TribTalk 2018 indicated, “Girls in foster care are nearly five times more likely to get pregnant than girls who are not in foster care.” A report from Chapin Hall in 2016 indicated, among other things, that of foster youth that experienced pregnancy, 66% of young men and 70% of young women reported that it was unintentional.

To be clear, SB 89 in California indicates that children ages ten and older are to receive access to sexual and reproductive wellness and health education, remove barriers, and provide sexual health training. However, each agency should verify this requirement with their county or state.

Last year, I worked with a client developing a California residential treatment program. The population of the children at the home would be between those identifying as female, ages 6 to 12. The client wanted a letter of support from her county of residence to advance her program statement to the state. My client and I were talking to the Mental Health Department in that county about the program statement. Within it, we stated that Planned Parenthood would be a resource for birth control and sexual and reproductive health. The county representatives questioned why children this young would need this resource. I explained to them the state law (SB89) and that children aged ten and above can access this information at home. After a ten-minute back-and-forth discussion with the county representatives, they agreed that this resource was acceptable for the facility. This account is an example that, although county and state agencies should be aware of the laws and regulations, a community-based organization needs to educate and advocate. Otherwise, sexual and reproductive wellness will be non-existent.

Praxes Behavioral Health offers courses in sexual and reproductive wellness. Feel free to contact us for more information.

Advocacy for the Small CBO in 1 Step

Thu, 29 Jun 2023 16:07:58 GMT

Even a small CBO needs to assert itself for advocacy for their agency.

Community-based organizations (CBO) starting must practice advocacy in their business. Advocacy for them means promoting their services and defending their operations. This practice could be conducted with governmental agencies for passing licensure, policy approval, corrective action plans, and contract negotiation. Yet many small CBOs need more paperwork, delays, frustration, and impatience. These new organizations need one step to rise to the occasion when necessary.

The challenge for the small CBO is that they need more knowledge and time for advocacy. Larger CBOs benefit from belonging to associations that can lobby for them. Whether they be the National Council on Wellbeing, California Alliance of Child and Family Services , California Council on Community Behavioral Health Agencies , or The Association of Children’s Residential & Community Services , these organizations offer their members entrance to decision makers. Their staff has connections with lawmakers and governmental entities. However, the small CBO may not have the budget to support membership. In the future, these organizations and others will help them navigate the system. But what do they do in the meantime?

As we discussed earlier, having the Three P’s is necessary to be successful in advocacy. But that alone is not enough. The one step that is crucial for a small CBO is networking. While there are many benefits to networking, one extra one is knowing decision-makers. Developing and cultivating these relationships takes a long time but is highly worthwhile. I have often worked with executives at new CBOs to guide them to the right people, and the networking pays off in the present and the future. Serving on committees, volunteering for projects, and other efforts can add to the networking approach. If an executive struggles with a supervisor or manager, advancing to the top of the agency’s food chain is worthwhile. Sometimes this means looking up who the state department chief is and approaching them. This process is not to create an adversarial relationship but to improve connections. Networking with the right person can reduce delays, improve contracting, resolve conflicts, and even provide feedback to the governmental agency. The old adage, “It’s not what you know, but who you know,” is vital in the behavioral health field. Even a small CBO needs to assert itself for advocacy for their agency.

Praxes Behavioral Health offers consulting services to CBOs. Feel free to contact us for more information.

Supervisory Performance: Can Your Subordinate Also Be Your Friend?

Fri, 16 Jun 2023 15:49:45 GMT

Leaders must guide their managers to ensure they are clear on their roles to maximize supervisory performance.

Last year I conducted training for a behavioral health organization on supervisory performance. The organization needed help with employee and supervisory accountability . The training discussed how communication, skills, and attitude make for excellent leaders and other qualities . We also discussed how employees need structure, expectations, communication, praise, monitoring, and direction.

During the conversation on supervisory performance, one of the attendees asked if, as a supervisor, they can still be friends with their subordinates. They talked about how they were first-line staff at their organization and were promoted. The people they supervised were originally their friends and would engage in social gatherings outside of work. When the attendee received their new job, these activities continued, and they believed they were still an effective manager.

According to an article in Indeed , "Bosses, supervisors, and managers can be friends with their employees as long as the relationship doesn't interfere with professional matters. Their friendship can exist outside of work, but it can't affect either individual's productivity or reputation." An article on the Muse website states, "While good bosses should strive to have a deep, human relationship with their employees, the truth is the manager-employee relationship isn't a friendship." It even has the following quote: "As Colin Powell said, leadership sometimes means being willing to piss people off."

Returning to the training, my experience managing employees for over 30 years made me question the new supervisor's ability to be impartial to their friends/subordinates. How can one, I asked, give an employee a verbal warning and then go out for coffee with them? This relationship is similar to the dual relationships with clinicians; one cannot be a therapist, professional, or friend simultaneously. Therefore, the employee was given another perspective on their supervisory performance.

Having a subordinate as a friend creates mixed feelings and difficulties in the workplace. When I finished the training, the executive director spoke to me to thank me for clarifying their position, too. Suppose your behavioral health organization has supervisors who oversee individuals with whom they have been friends. In that case, the leaders must guide these managers to ensure they are clear on their roles to maximize supervisory performance.

Praxes Behavioral Health provides consulting and training for improving employee performance. For more information, feel free to contact us .

Why Bullies Bully

Fri, 09 Jun 2023 17:10:27 GMT

60% of school shooters reported being bullied in person or online.

Some may consider bullying a regular thing in society, but it is no laughing matter. According to statistics , here are some sobering facts about bullying:

· 46% of teens report being cyberbullied at least once.

· 60% of school shooters reported being bullied in person or online.

· Nearly 25% of LGBQ+ students were bullied at school.

· 22% of students get bullied during each school year

· 43%-48% of students reported that they would not intervene in bullying.

· At 79%, verbal harassment is the most common bullying at school.

· 84% of bullying in the UK happens through devices such as mobile phones or laptops.

· At 53.8%, Hispanics are bullied the most of all races at work.

· 30% of US workers are bullying victims.

· Rude name-calling is the most common form of child cyberbullying (32%).

Even though laws exist to address bullying, they do not stop it from occurring. Youths who act aggressively toward others do so for a multitude of reasons. And there are different types of bullying. Among them are verbal, sexual, prejudicial, and physical. Not to mention cyberbullying. Yet what leads one youth to try to show superiority over others comes from different motivations. At least from the youth’s perspective, these different motivations appear authentic. And their perspective helps us to understand better how to develop prevention programs for youths.

In Psychology in the Schools, Robert Thornberg published an article, Schoolchildren's social representations on bullying causes , in 2010. In it, he discussed his research on school-age youths’ social representations of the causes of bullying. He wanted to look at how much bullying occurred and how youths perceived it. And discussed it in their own words. They came up with six overall causes why bullies bully. In order of most to least frequent, they are:

Reaction to Deviance- as the most prevalent cause, the victim was seen as different, odd, or deviant. Just not fitting in with everyone else meant a youth was a target of bullies. It could be appearance, behavior, characteristics such as odd or nerdy, or disabilities.

Social Positioning-youths saw this as bullying to reach status in a school or group’s pecking order. They described three different types. In these cases, those acting aggressively picked youths seen as physically weak, shy, unpopular, younger, lonely, or new.

· Bullying for status was for kids who wanted to be the coolest, the toughest.

· Bullying for power occurred when youths were struggling for authority. About being the boss.

· Bullying for friendship meant acting aggressively to win or keep friends.

Work of Disturbed Bully-youths perceived an aggressive youth as someone who has problems. They had emotional or behavioral issues like attention problems, bipolar, and poor impulse control. Or the aggressor was a representation of trouble at home. Alcoholism. Violence. Poverty.

Revengeful Activity-youths saw this as an excuse to blame the victim for some harm that occurred to the aggressor. They were snitched on. Their little brother got in trouble. They felt ridiculed. A youth told the teacher about them. An eye for an eye mentality.

Amusing Game-youths describe this happening when the aggressor decides they’re bored. They want to have fun at someone else’s expense. The youth at recess finds another youth and pushes them, ridicules them, or does some other activity to make themselves feel better without caring about the collateral damage.

Social Contamination-youths say this occurs in a group format. Youths talked about how a student would be excellent and kind to them. But the comments changed once they were in a group and wanted to be part of the group. This shows how youths “change their stripes” depending on who they’re around.

Understanding this behavior, which is aggressive in nature, helps teachers, as well as behavioral health professionals, deal with youths acting like bullies. They’re not this way all the time. But in social or emotional conditions, they need to prove themselves at the demise of another. Developing assertive skills for youths helps them avoid bullying or being bullied.

PRAXES offers training on courses for BBS CEUs, among them Bullying Prevention and Early Intervention. For more information on training for your organization, please get in touch with us .

Suicide Prevention: The “C” Word

Fri, 02 Jun 2023 17:24:40 GMT

Suicide prevention is not only about treatment, it is also about the language.

When we talk about suicidal prevention, often the discussion turns to the “C” word. Why do the media and the public continue to use the word “Commit” when discussing suicide? This term is misused when people think about or want to kill themselves. And some in the behavioral health field may not understand the importance of this word and its impact on the client, their practitioner, and the behavioral health organization.

According to an article from the International Risk Management Institute , terms related to suicide evoke powerful images and messages. Those around the person contemplating suicide have their personal opinions about it, such as “they’re selfish” or “it’s their choice,” which complicate the matter. Plus, using terms like “commit” make the client seem like a criminal, similar to other “commit” phrases (committing murder, burglary, arson, etc.). The article points out alternative terms that practitioners and family members can use below:

Say this Instead of this

Died of suicide Committed suicide

Suicide death Successful attempt

Suicide attempt Unsuccessful attempt

Person living with suicidal thoughts or behavior Suicide ideator or attempter

Suicide Completed suicide

(Describe the behavior) Manipulative, cry for help, or suicidal gesture

Working with Dealing with suicidal crisis

If we want to reduce to improve suicide prevention in this country, there must be a different way to discuss this to talk about it. Education programs in school and with clients, discussing suicide with parents and families, and understanding the resources available are helpful to everyone. As posed in an article by the Centre for Suicide Prevention , “Like so much of the language we use, there are underlying, negative connotations to the phrases (we use).”

Other experts have examined the language as well. In an article on Speaking of Suicide , Dr. Stacey Freedenthal commented, “Some suicide prevention advocates use the term “completed suicide” because they view it as an acceptable alternative to “committed suicide.” Not all suicide prevention advocates agree, of course. The State of Maine’s Suicide Prevention Program, for example, states on its website , “Both terms (committed and completed) perpetuate the stigma associated with suicide and are strongly discouraged.”

When working with clients who have suicidal thoughts, it is vital to use a neutral form of language. Asking, “Have you had thoughts about killing yourself?” “Do you want to end your life?” and other strategies have the same impact of discussing the seriousness of their situation but with less stigma for the client. Suicide prevention is not only about treatment, it is also about the language.

5 Questions to Ask for A Corrective Action Plan (CAP)

Fri, 02 Jun 2023 16:45:39 GMT

The more an organization understands what the corrective action plan requires and asks these questions, the more likely it will improve and have fewer difficulties.

A behavioral health organization often must deal with a Corrective Action Plan (CAP). The CAP happens after surveys or audits are conducted when program documents are submitted for approval or at other occurrences. The agency requiring the CAP will identify gaps or missing information that needs to be submitted. Usually, a time frame is necessary for when the CAP will be resolved. What is the best way to tackle a CAP?

Several approaches can be used to conduct a CAP . However, it is best to ask several questions first before starting the process:

1. What is the mindset of the agency or reviewer? When answering a reviewer or auditor's questions for a CAP, you need to know what they want. Their requests may not be explicit; a technical assistance call is often vital to prevent numerous rewrites.

2. Is the deficiency a short-term or long-term problem? For example, a document may be missing from a personnel file, which is an easy fix. However, if the document was omitted due to a lack of oversight of personnel files, it could be a long-term problem. A mechanism should be addressed to prevent the problem from occurring.

3. Is the deficiency an employee problem or a process problem? Suppose an employee misses the deadline for completing a treatment plan; that could be related to the employee's lack of time management. But if the reason for the CAP is due to poor organization on the part of the employees, retraining may be necessary to improve conscientiousness in completing documentation timely.

4. Who will institute the correction and follow up on it? Someone must ensure the problem is fixed now and moving forward. Otherwise, it will stay uncompleted and be open to future deficiencies. An employee can be assigned a task to correct it, and someone must ensure it stays corrected.

5. Is the problem a policy, a document, or something else? The deficiency could mean rewriting or creating a policy or a document. But the deficiency could be related to staff not knowing how to conduct a task, such as clinical work. A system must be in place to keep the change in place.

The more an organization understands what the CAP requires and asks these questions, the more likely it will improve and have fewer difficulties.

Why Do Teens Use Drugs? FBA Says It Depends.

Thu, 25 May 2023 18:03:21 GMT

Functional Behavior Analysis (FBA) shows how the function of the behavior is the key to interventions.

Teenage alcohol and drug use is a problem that will continue without proper detection and treatment. The usage patterns have stabilized in some ways due to COVID-19. The National Institute on Drug Abuse indicates that substance use stabilized in 2022. However, SAMHSA reports that while cocaine, methamphetamine, and heroin usage is not growing, prescription usage is rising quickly.

Most programs (and families) try to understand why teens use drugs. One approach is to look at the causes. CHOC produced an article outlining some of these reasons, such as peer pressure, trauma, genetics, etc. However, while causes are valuable, they miss the real motive behind drug use.

Functional Behavior Analysis or FBA, also known as Functional Behavior Assessment, is a way to evaluate the client’s behaviors and determine the function or reason for their occurrence. The practitioner evaluates the client by observing them while gathering information from the client and others. Then the practitioner looks at the antecedent to the behavior (what triggered it), the behavior itself, and the consequence of the behavior (what did it do for the client). Knowing these steps helps to strategize different approaches.

Getting back to drug use, what might be the functions of it or the reasons a client may do it? Five functions of FBA can explain the behavior, as follows:

Connection – a teen may use drugs to feel part of a group, feel connected, to socialize. Teens that need connection will use drugs to be in a peer group, have something in common with other teens, and feel accepted by this group. The practitioner must work with the teen on their socialization and communication skills to change the behavior. Then directing and assisting the teen in finding other non-using friends will guide them to improve their social skills.

Escape – some teens who experience trauma use to run away from the inner feelings they have emotionally. Drugs numb them so they do not feel the trauma triggers. The practitioner must teach the teen how to cope with the emotions, find mindfulness skills to mitigate them and help them feel stronger by walking through their fears.

Control – teens who need control believe no one protects them, so they must be in charge. Using drugs makes them feel in control. In this case, the practitioner must get a support network around the teen so they do not feel alone and that others can help them with their problems.

Stimulation – because drugs put the teen in an altered state, they like the feeling compared to the pain and angst of growing up. It helps them with their moods and to feel more aroused or calmer. The practitioner can help them develop other physical or mental health activities that replicate these feelings. Sports, mindfulness, as with the Escape function, and sensory integration exercises are examples of interventions.

Access – when teens need independence, they turn to drugs. The teen may use drugs to be defiant to adults, feel the need to be free, and do something that adults disapprove of. The practitioner can help the teen learn social communication and other skills that give them freedom.

These are some examples of how learning the function of the teen’s drug use improves the strategies to work with them. FBA is an excellent approach to use with this challenge.

Behavioral Health RFPs: Follow the Money

Thu, 25 May 2023 17:59:56 GMT

Doing the financial work in an RFP first helps the behavioral health organization save time in determining whether to pursue the project.

Behavioral health organizations seek to grow their business, and one way to do so is through Requests for Proposals (RFPs). But many organizations are not successful in this endeavor. It is not because the organization lacks expertise or the capability to provide the requested services. It is also not because they require the staffing or the ability to recruit and hire.

The financial component is the one area that creates difficulties for most organizations pursuing RFPs. And this is crucial. With my clients asking me about applying for RFPs, we explore the finances first. One reason for this approach is that the funding does not support the company’s capabilities. For example, in the recent California Community Reinvestment Program (CalCRG), programs could only apply for a specific amount of no more than 30% of their total existing revenue. If an organization had a small revenue stream, this grant (although valuable) would be limited to a portion of its current volume. And some organizations fail to understand how a large influx of funding and operations could jeopardize their existing business.

The other factor is whether the finances make sense. An RFP may indicate a dollar amount to be awarded for services. But for an organization, can they make the dollars and cents work for them? They want to retain money and maintain their business to take on other programs. How do they explore the RFP and discover if it makes sense? The first step is to create a Pro Forma. The Pro Forma is a look into the future, a forecast of what the project will look like. It shows how the expenses, revenue, staffing, and profit work together.

The Pro Forma looks at the financial variables. The rate of pay (per client, a unit of service ), the expenses, the expected revenue, staffing, and other costs. Many RFPs are cost-based reimbursement. This means that the expenses must match the revenue to the penny.

Suppose a potential contract is $5 M for yearly behavioral health services. The Pro Forma determines the reimbursement rate per minute or hour to determine how many services can be provided. Then it reviews the number of staff, their full-time equivalents or FTEs, and which titles are to provide the services (clinicians, behavior specialists). The Pro Forma also looks at direct costs (for the actual program) vs. indirect costs (for overhead) and outlines the expenses. Once this is done, the Pro Forma can help the behavioral health organization to decide if the RFP is worth the application.

Doing the financial work in an RFP first helps the behavioral health organization save time in determining whether to pursue the project. Then once completed, it guides the narrative to know the who, what, where, how, when, and why in the narrative.

One Vital Diagnosis You Don’t See in the DSM-5

Fri, 19 May 2023 17:04:22 GMT

This disorder was proposed to be included in DSM-5 to capture the dysfunctions experienced by children and adolescents exposed to chronic traumatic stress.

When clinicians evaluate children for potential trauma, the DSM-5 gives them two choices. These are Post-Traumatic Stress Disorder (PTSD) or Unspecified Trauma- and Stress-Related Disorders. Neither of these disorders describes adverse childhood experiences . They leave out the one vital diagnosis that quantifies the behaviors in children that lead to consequences of functioning in adolescence and adulthood.

Dr. Bessel van der Kolk is a renowned psychiatrist and specialist in trauma for children and adults. In his book, The Body Keeps the Score , he discusses the concept of developmental trauma disorder (DTD). This disorder was proposed to be included in DSM-5 to capture the dysfunctions experienced by children and adolescents exposed to chronic traumatic stress. At the time of the DSM-5 publishing, the American Psychiatric Association indicated that not sufficient evidence existed to warrant it as a diagnosis.

However, for those clinicians who deal with children exposed to trauma, DTD is an essential part of their understanding of how trauma impacts someone at an early age. Among the criteria assigned to DTD are:

1. Exposure to episodes of violence or disruptions of caregivers

2. Affective and physiological dysregulation, such as the inability to modulate affect, regulate bodily functions, and diminished awareness of sensations.

3. Attentional and behavioral dysregulation as indicated by impaired coping with stress

4. Self and relational dysregulation is shown by lack of self-esteem, difficulty with separation, defiance, and other behaviors.

In Dr. van der Kolk’s study in 2019, he and others found that “DTD’s comorbidities overlap with but extend beyond those of PTSD to include panic, separation anxiety, and disruptive behavior disorders.”

As Martin Teicher in Scientific American indicated, “Research on the effects of early maltreatment tells a different story: that early maltreatment has enduring negative effects on brain development. Our brains are sculpted by our early experiences. Maltreatment is a chisel that shapes a brain to contend with strife, but at the cost of deep, enduring wounds. Childhood abuse isn’t something you ‘get over.’ It is an evil that we must acknowledge and confront if we aim to do anything about the unchecked cycle of violence in this country.”

For clinicians, these findings are significant to begin incorporating them into assessment and treatment. Although DTD cannot be used for diagnostic or insurance purposes, treating the child and adolescent becomes essential. Looking beyond the existing behaviors back to the original traumas can assist the clinician in finding the best approach to mitigate trauma triggers, re-traumatization, and their impacts on the child. Knowing their history and the events that shaped the child’s functioning or developmental delays at an early age, the clinician can shape interventions to mitigate trauma’s impact. In the future, DTD needs to be part of the existing training and discussion until DSM-6 includes it.

Foster Youth and Law Enforcement Needs Multi-Pronged Approach

dan.thorne@praxesmodel.com (Dan Thorne) — Wed, 05 Oct 2022 18:59:56 GMT

As a result, rather than simply buckling down on the youth to improve their behavior, a multi-pronged approach needs to occur.

The current view of foster youth is that they are more likely to be involved in law enforcement. While this may be true, it does not cover the reasons why. County child welfare agencies push foster family and residential agencies to keep foster youth out of trouble with the police and sheriff. This is because the time law enforcement takes with runaways or aggression at home removes them from more serious crimes. And the double-edged sword these agencies have is that they are being asked to take on youths with higher acuity but reduce the behaviors that intersect with law enforcement. Subsequently, the focus on the youth is that they’re the “problem” in this situation.

But it’s more complicated than blaming the child. Here are three reasons why:

1. Youths impacted by trauma respond may respond with violence. Dr. John Bowlby, a British psychiatrist and leading expert on attachment theory, found a strong connection between a youth’s abandonment and separation from family and acts of violence. He said in 1973, “The most violently angry and dysfunctional responses of all, it seems probable, are elicited in children and adolescents who not only experience repeated separations but are constantly subjected to the threat of abandonment.” Foster youths are ten times more likely to be arrested than the total youth population. If foster youths come from homes with violence and a lack of attachment to parents, these children have more risk factors for engaging in violence.

2. The behavior of resource parents impacts the youths. Most foster family agencies report that most of their time is spent handling family crises, many of which involve law enforcement. The resource parents may be overwhelmed, lack the training in crisis management, and feel they’d prefer to let the police handle the problem.

3. The intersection of the foster youth and law enforcement is not always positive. Many foster youths grew up in environments of crime and poverty. In these places, the police may have negatively treated them or family, leading to an adverse view of law enforcement. Consequently, many police have sensitivity and knowledge of foster youths, while others lack the knowledge of their circumstances and see the need to talk as “a waste of time.”

How can a youth who’s experienced trauma and violence, sometimes overlapping with the police, expect a positive understanding and be willing to work with the police?

As a result, rather than simply buckling down on the youth to improve their behavior, a multi-pronged approach needs to occur. Resource parents need training on preventive strategies to reduce the youth’s risk behavior (e.g., runaways, aggressive behavior, or harm to self or others). The youth needs crisis and safety plans that use their strengths to improve self-regulation. Finally, foster family agencies can bridge the communication gap between themselves, the resource parents, law enforcement, and youths. Educating all parties on their roles in their approach to foster youths, a shift in attitude occurs. Police understand the foster youth’s perspective on the youth’s fears and needs. In return, foster youth perceive law enforcement as a source of health and safety instead of punishment.

Value-Based Reimbursement and Its Counterparts

dan.thorne@praxesmodel.com (Dan Thorne) — Wed, 05 Oct 2022 18:55:01 GMT

Each of these methods can work in a behavioral health atmosphere, provided that data is used and the agency has alternative methods of approaching care vs. traditional psychotherapy alone.

For now, much of the talk in California and through CalAIM is that value-based reimbursement (VBR) will be forthcoming. Yet little is known about what VBR is or what it looks like. Before comparing it to its counterparts in the reimbursement world, it is helpful to understand the variables in payment:

Cost – the payors (in this case, counties) will decide how to pay based on different scenarios. Either per client, per episode, per diagnosis, or population.
Quality – payment may be contingent on the type of services and how the client improves due to those services.
Value – whether the client determines that the service benefited them through their symptoms or satisfaction.

With these concepts in mind, let’s discuss the five payment methods. These are not all-inclusive of every reimbursement system but cover most of the ones available now:

Fee-for-service – this is the most common type of reimbursement for services and is the traditional form of compensation for behavioral health. In this category, the provider receives compensation at a contracted rate for each episode of care. If a therapist sees a client for ten sessions, they are paid for them. There may be a limit on the number. But there is no requirement for the quality of the service or the value it brings to the client.
Pay-for-performance – in this case, the therapist may continue to see the client, but specific metrics or measures are used in conjunction with payment. For example, the therapist sees the client and is paid but receives an increase in reimbursement if the client achieves defined goals (reduction in symptoms, fewer sessions to improve outcomes, client satisfaction).
Value-based reimbursement – this term can also be known as bundled payments. The payor chooses a specific condition or diagnosis (e.g., attention deficit disorder) or service (outpatient care). The therapist or clinic then is paid an exact amount to help the client improve their symptoms. For example, if a clinic serves primary youth with attention deficit disorder, and the data shows their average length of stay in treatment is one year, the payor will pay a total of $8,000 per client for the service. Counties already calculate the cost per client, so they will, in the future, roll this data into their contract.
Case rates – this payment method is currently done in residential facilities, where the reimbursement is a specified amount per youth per month. This is done regardless of how much it costs for the youth to stay there regarding food, clothing, and other expenses such as replacing furniture. The agency has to calculate how to average the costs so that some expenses are less for specific clients than others.
Capitation – this form of reimbursement is more known in HMOs, where a company will manage the health of a population and be compensated per member per month. The company pays its providers and administrative services out of the funds received each month. While some call this “rationed care,” it is more about ensuring that those who need the services (hospitalization, intensive services) receive it while exploring less restrictive options if possible. Using this approach requires more proactive options, such as identifying those in the population with higher needs and surrounding them with services to avoid higher levels of care.

Each of these methods can work in a behavioral health atmosphere, provided that data is used and the agency has alternative methods of approaching care vs. traditional psychotherapy alone.

School-Based Mental Health Needs Better Solutions

dan.thorne@praxesmodel.com (Dan Thorne) — Thu, 15 Sep 2022 17:34:00 GMT

The hypothesis that state officials use to fix the problem is that they can increase the capacity of school counselors.

Two weeks ago, we covered an article about California's shortage of school counselorsThe article cited that the state ranks in the bottom five regarding the number of counselors working in schools. This shortage occurs despite initiatives by State School Superintendent Tony Thurmond and Governor Gavin Newsom to increase funding to hire counselors and pay education fees for new counselors , respectively.

Let’s look at what brought California to the school-based mental health crisis in the first place. COVID-19 created a perfect storm for this situation. Due to the shutdown of schools, students felt more isolated from their peers. Distance learning left many students disenfranchised and unmotivated to engage in school. Since students lived in a bubble at home, family stress increased, and fewer child abuse cases were reported. School counselors also felt their roles during COVID were confusing, complicated, and lacked leadership. Many counselors may seek a new environment with school returning and leaving for greener and perhaps less stressful pastures.

The hypothesis that state officials use to fix the problem is that they can increase the capacity of school counselors. What is occurring is that school districts lure clinicians from behavioral health agencies to fill their vacancies. While this approach solves the school counselor issue, it leaves other agencies ill-equipped to handle their youths. The concept of increasing student loans and funding for school counselors will take perhaps 5 to 10 years to be entirely achievable; it is not a short-term fix.

What can be done?

Telehealth services. Instead of using on-site counselors, telehealth agencies can be hired to handle the backlog of cases or referrals.
Behavioral Specialists. Having Bachelor’s level staff to work with the youths provides more strategic interventions. This currently occurs with Medi-Cal contracted agencies that provide school-based services that use Therapeutic Behavioral Services (TBS) as behavior modification for students on campus.
Parent partners can be employed to engage the parents. Many issues related to school mental health affect the parents and helping the parents will increase the student’s participation.
Virtual platforms. More students can be reached on and off campus using care coordination modules through the computer or mobile apps.

Schools need to be more creative in how they approach school-based mental health. And looking beyond hiring school counselors provides more cost-effective solutions and approaches to addressing the current crisis.

Behavioral Health Staff Will Pay for Treatment Strategies

dan.thorne@praxesmodel.com (Dan Thorne) — Thu, 15 Sep 2022 17:24:50 GMT

Behavioral health professionals lack the time and resources to help them improve their strategies with clients.

Despite the technology available with electronic health records and staff support, behavioral health professionals want more assistance with treatment strategies. They are even willing to pay for it independently versus having their employer pay it. This information comes from a survey conducted by Praxes Behavioral Health this spring. Over 5,500 mental health professionals from around the country responded to the survey, including 25% paraprofessionals, 44% with Bachelor’s degrees, 24% with Master’s degrees, and 7% with doctorates.

We first asked the respondents how they currently develop treatment interventions for their clients. They provided multiple options for which they strongly agreed or agreed they use, including:

Research – 85%
Past Experience – 71%
Talking to colleagues – 50%
List of interventions – 66%
Their supervisor – 50%
Internet searches – 66%
Their electronic health record – 66%

Here is a sample of other responses for which respondents strongly agreed or agreed:

1. It is challenging to create new and unique interventions: 70%.

2. Using the same interventions repeatedly for different clients: 66%.

3. Difficulty finding interventions for clients with serious emotional problems: 62%.

4. Lack of time to create unique client interventionists: 52%.

5. Difficult to take assessment information and generate interventions from it: 64%.

6. Challenge to tie the diagnosis to treatment interventions: 67%.

Then we asked the respondents if they would like a library of interventions available, to which 72% strongly agreed or agreed. Finally, we asked them if they would be willing to purchase our company’s treatment software Apogee for themselves, and 72% said it was very likely or likely that they would.

These responses indicate that behavioral health professionals lack the time and resources to help them improve their strategies with clients. With documentation requirements and productivity demands, together with high-risk clients, they don’t have the means to treat clients successfully. The lack of agency support is one reason professionals are leaving agencies to work at telehealth agencies or other environments where their burnout is less. If staff are willing to buy intervention software independently of the agency, perhaps the agency should look at it to improve their treatment efficiencies and outcomes.

Please contact us if you would like a link to the survey results.

Role-playing as An Intervention in Treatment

dan.thorne@praxesmodel.com (Dan Thorne) — Thu, 25 Aug 2022 21:48:40 GMT

The art and science of role-playing need more attention as an intervention in behavioral health treatment.

The art and science of role-playing need more attention as an intervention in behavioral health treatment. It is a technique that helps the client get “out of themselves” and pretend to be someone else. Yet it often is overlooked as an approach to use with clients. But its benefits help clients use real-life situations and create new pathways to success.

Role-playing is a technique that comes from the process of acting. The teacher asks students to portray different characters, emotions, and objects in a drama class. “Be a tree whistling in the wind,” “Pretend you’re an eagle in the sky, flying,” “In this scene, you’re going to tell your friend you don’t want to see them again.” When acting, a person has to become someone else. They have to move beyond the way they see the world and change. In his book, “The Body Keeps the Score,” Dr. Bessel van der Kolk talks about how theater provides opportunities for youths to deal with trauma. In his Actors Gang Prison Project, Tim Robbins teaches inmates how to use makeup and improvisation to deal with their emotions.

Most professionals do not find role-playing something with which they are comfortable. “It’s not logical or part of talk therapy,” they may say.

Yet to many clients, especially children in elementary school, role-playing fits their personalities. Children spend much of their time in play. They make up characters and scenarios when they play with their friends or alone. They conduct role-playing sessions daily, becoming princesses, superheroes, bad guys, or whatever they want to be. It helps them build their creativity. And, right-brain activity reaches the emotional part of the brain more directly than trying to talk to them.

Role-playing gives a client ways to improve how they see the world. Here is an example. Suppose a client has trouble with others who bully them. A practitioner can tell the client to walk away or tell them to leave the client alone. That’s one approach. But instead, if the practitioner role-played the bullies (or did a reverse role-playing and acted as the client), they could act out the scene. They can portray it vividly and make it real for the client. Help them deal with their anxiety in the event and, in a safe space, practice what to say and do. Role-playing provides times to be someone else and change who a client is.

A Sinker, A Swimmer, or a Flyer: Which is Your Organization?

dan.thorne@praxesmodel.com (Dan Thorne) — Thu, 25 Aug 2022 21:44:06 GMT

Only a few organizations dare to make changes rather than wait for others to make them.

CEOs and Executive Directors in behavioral health organizations always have essential decisions. They are managing employee productivity while retaining and supporting employees. They achieve budget projections, strategic goals, and continuous quality improvement plans. But COVID threw all operations into a perfect storm, challenging leaders throughout the country.

One question remains as we navigate the continuing uncertainty of whether WFH (working from home) remains the standard or whether agencies return to their previous operations. This question pertains to how each agency perceives its survival in the next three to five years:

Are you a sinker, a swimmer, or a flyer?

A 2020 study taken on by Open Minds showed that, within three years, organizations show different patterns. 9% are flyers. That means they take the disadvantages and challenges of the industry and learn to thrive. They look for new business opportunities or modify their agency to meet the new challenges. They don’t stand by idly and wait for new contracts; they seek out potential payers, new services, or ways to maximize their cash flow.

17% of the organizations in the study are sinkers. They are drowning in negative cash flow, reduction in the census, and increased employee turnover, and they don’t know how they will hang on. These symptoms often occur because the organization is short-sighted; they stick to one program or business philosophy while things change around them. We see it here in California with the old-time group homes, many of whom closed rather than become STRTPs. They didn’t want to change and, as a result, were gone or will be gone. And the concept of merging is possible for some agencies. But when an agency merges out of necessity, it’s like going to the bank when you need a loan. You’re in a desperate and non-advantageous position.

And the rest, 74%, are swimmers. They are still making it, but that could be treading water or swimming. Most behavioral health agencies take this stance because they are afraid to move forward. When employees, board members, or leaders are stuck in the same place, they can make changes, but these are too small to make a significant difference in the company’s bottom line.

One company Praxes worked with had this debacle. The president of their board of directors approached us to do a needs assessment. They were a residential facility becoming an STRTP, but they couldn’t see future opportunities ahead. The president wanted to identify other business prospects. He was a successful head of a business, and as he saw, businesses need to profit and grow to stay alive. Yet he kept butting heads with the staff leaders who wanted the status quo. We would describe them as swimmers; they would survive but always be the “one-trick-pony,” relying on one county’s referrals for youths and not wishing to expand. After our needs assessment, we recommended that they look at utilizing their existing beds for managed care residential services. We also suggested they expand into behavioral health outpatient and foster care services since they had a great relationship with their county. These ideas would have improved their success in the future. The board liked the idea, but the agency leadership wasn’t on board. So, in the end, they are still swimming instead of flying.

As your agency moves forward, ask whether sinking, swimming, or flying is more of what you want to do in the next few years. It takes courage to fly, but it can improve your long-term success.

Improving Family Engagement: Using Active Efforts Approach

dan.thorne@praxesmodel.com (Dan Thorne) — Wed, 17 Aug 2022 18:57:20 GMT

Despite existing approaches, agencies still have difficulty increasing family engagement.

With the implementation of the Families First Preservation and Services Act (FFPSA), family engagement is one of the critical components of improving care. This element is primarily focused in a congregate or residential setting. This type of placement, known as a Qualified Residential Treatment Program (QRTP), needs more family involvement. Approaches exist that point agency in the right direction to improve their strategies.

Yet, despite these methods, agencies still have difficulty increasing family engagement. As indicated in our article on Child and Family Team participation , agencies have challenges getting parents and extended family members to participate in treatment. If the FFPSA requires more families to take part in their child's treatment without new or modified approaches, it will not occur.

One way to re-think family engagement is to borrow a page from the "Active Efforts" concept used in the Indian Child Welfare Act. According to the Judicial Council of California , “Active efforts are described in the Indian Child Welfare Act (ICWA) as important steps in providing remedial services and rehabilitative programs to prevent the breakup of the Indian family.” The rationale for going beyond the conventional approaches in working with family members of Indian families was that the families felt shame and guilt and were afraid to participate. They did not want to, at times, admit their heritage or even bother to get themselves help. This hesitation was for many reasons, including isolation and historical trauma. The Bureau of Indian Affairs provides examples of these efforts.

Translated to the residential facility, other illustrations of these active efforts from a residential facility’s perspective are finding ways to get family members to the facility to participate in care, removing barriers to their participation, using Zoom and other approaches to help families meet with the youth, helping the family with their needs such as counseling or parenting classes, and general education about the process.

The one significant barrier for parents in family engagement is their guilt about their child being in care. Parents tend not to participate because they do not want the finger pointed at them as the "bad parent." Active efforts such as education, resources for the parent, and simply listening to the parents' needs make a difference in their receptiveness to care. To make parents feel more comfortable, the agency staff needs to have a "whatever it takes" approach rather than an "I tried, but it didn't work" mentality.

Using ICWA philosophy to help families may improve their understanding of care, remove their resistance to helping their child, and lead to better outcomes for all.

How to Name That Episode of Care

dan.thorne@praxesmodel.com (Dan Thorne) — Wed, 17 Aug 2022 18:53:32 GMT

Behavioral health organizations will need to shift their focus from “treatment based on fees” to “treatment based on outcomes and costs.”

With the advent of CalAIM in California, Medi-Cal treatment of behavioral health will be based on episodes of care. To further explain, the traditional approach of “fee-for-service” care allows a provider to treat a client as long as they deem necessary, without consideration of cost or outcome. The future will change this approach where counties as “health plans” will act as managed care organizations, determining the appropriate length of care for each client.

This approach can be likened to the old television show, “Name That Tune.” In the show, a contestant would receive information about a song and then guess how many notes they would need to guess it. Translated into the managed care world, a behavioral health agency will be responsible for the care of clients assigned to their agency. Based on geographic, company historical data, and diagnosis, they may be asked to project the length of stay for clients. This alone can cause nightmares for organizations, let alone their staff. But it isn’t as difficult as it may sound.

Currently, in California, STRTPs are conducting a particular form of Name That Episode of Care. The general length of stay for youth in an STRTP is around six months. When the youth arrives at the facility, the Social Worker or Therapist develop their treatment plans and gives an estimate of treatment scrutinized by county and state officials. If the staff believes the youth will need more time due to higher needs, they indicate it and may receive additional services to help the youth. Monthly, the Child and Family Team meet to discuss whether this episode length is realistic; if not, it is modified along with treatment plans.

The same can be done in an outpatient setting. The first step is identifying the client, their symptoms, acuity, and desired goals. Suppose a 16-year-old with a diagnosis of major depression and a history of psychiatric hospitalizations due to suicide attempts is assigned to a clinician. How long will it take for them to be in the program? How can they name the episode of care? As indicated above, they can look at their historical data on clients with a history of major depression and hospitalizations. They can also determine how stabilized the client already is. Questions such as, “What is the length of time since the last hospitalization?” Are they stable on anti-depressant medications?” Then based on this information, the clinician, in their assessment, can determine an estimated length of stay, the number of sessions necessary, and adjunctive services (therapy, medication management, behavioral modification). This estimate can then be calculated in time and the cost of services as a preliminary projection. Then as the clinician continues to work with the youth monthly, they can evaluate the costs, the progress, and whether their projection is realistic or needs reassessment.

Behavioral health organizations will need to shift their focus from “treatment based on fees” to “treatment based on outcomes and costs.” Naming the Episode of Care will need to be a skill mastered by all those serving the client. But this approach, although appearing to do a disservice to the client, holds all parties accountable for improving their care. Changing the emphasis from fees (how much do I get paid) to outcomes (how do I get this client better) improves all participants’ approaches to help the client.

A Pro Forma Should Tell You This 1 Crucial Factor

dan.thorne@praxesmodel.com (Dan Thorne) — Fri, 05 Aug 2022 17:50:34 GMT

Pro formas should be realistic, not pie-in-the-sky predictions.

Every behavioral health company wants to increase their business, or at the least stabilize what they have. Grants, RFPs, and possible contracts become available to an agency and seem enticing. These opportunities for new business offer an agency more services, high rates of reimbursement, or expanded capacity to reach more clients. Yet the most important question each executive should ask is: will it be profitable? If the program can’t pay the bills, it’s not worth approaching. In the non-profit world, agencies still need to know they can cover their costs and use the proceeds towards other services.

A pro forma is one of the best tools an agency can have. Most financial information, such as a balance sheet, cash flow, or profit and loss, are backward-looking statements. They reveal information about what already occurred, not what could occur in the future. The pro forma is designed to give an idea of what could be in the future. These financial instruments predict (as well as possible) how the program will perform.

But if a pro forma doesn’t show you the 1 most crucial factor, it is not doing its job.

A good pro forma starts with assumptions , based on the potential service or program, or historical information. Then it will develop the revenue and expenses associated with the potential program, plus other costs. For revenue, it will explain how it is generated through billing, services, the rates to be used, and other factors. For expenses, it will contain salaries (the highest cost of any venture), the overhead or administrative costs, leasing, purchase of any items such as computers, and other items. After all of this is calculated, the final bottom line of profit, contribution margin, or whatever figure shows a loss or gain after the program.

The one factor a pro forma should concerns the ramp-up to achieve full profitability. Many pro formas show a program starting at full capacity as if the program begins with all the clients coming in right away. In the real world, this does not happen. There are always glitches, problems, and pitfalls that occur at the beginning of any program. Call it Murphy’s Law or any other rule, but things happen. A good pro forma starts slow, knowing these hiccups occur and accounts for them. If your accountant or financial guru doesn’t allow for a slow start in the pro forma, it’s not realistic. Ask them to have lower expectations in the beginning and it will be more fruitful for your business.

3 Reasons Why Resource Parents Need to Know FBA

dan.thorne@praxesmodel.com (Dan Thorne) — Thu, 28 Jul 2022 23:00:47 GMT

Functional Behavior Analysis (FBA) teaches resource parents to be good observers.

Functional Behavioral Analysis or FBA should be in the repertoire of every foster or resource family. When foster or resource parents take in youths, regardless of their age, they bring in youth with existing difficulties. The problems are caused by trauma, including abuse, neglect, or being in multiple placements. While other problems are due to their own emotional and behavioral difficulties, beyond what a “typical” youth would have.

In any of these cases, the resource family may not be prepared for what will come. Although they have experience with their own children or other foster youth, children with higher acuity are being placed with more severe difficulties. As resource parents across the country start taking in the youths who used to be in residential facilities, these youths come with more difficult problems, such as fire setting, substance use, sexual offenses, running away, or commercial sexual exploitation.

In some states like California, the state provides more specialized services, like Intensive Foster Care Services (ISFC) which is designed to provide resource parents with the skills to manage their foster youths’ behaviors. Or Therapeutic Foster Care (TFC) where the parents are the mental health behavioral specialists and bill Medi-Cal for treating the youths.

How do they prepare?

Here are 3 reasons why resources parents should know FBA:

1. It teaches them to be good observers. To learn what the youth needs, they first have to know what the youth is doing. When? Where? How much? What happens before and after their behavior? Learn it from their own observations and from that of others such as social workers, teachers, and others who know the youth.

2. They learn the functions of the youth’s behavior. Do the youth need a mind-body connection? To feel safe? To feel part of the group? Or to have some control of their life? This last one is a very big deal with foster youth. Imagine being a youth who goes into a new environment. They can’t control their parents, their social worker, what school they go to, or anything else. Not even their clothing. They then need some control, which could be anything from wetting their bed to cutting themselves with a paper clip. Learning the behavior’s function helps to create targeted interventions.

3. They learn how to try specific strategies which work with youth. This is a collaborative effort between the youth and the family. First, it gets everyone on the same page. The parent wants to help and there can be incentives for the youth to change their behaviors. The parent and youth develop skills to deal with crises and also to prevent crises. But it’s a partnership. Which the foster youth has some sense of control. A win-win situation.

For more information, please contact us.

Lack of Parent Engagement in Child and Family Teams

dan.thorne@praxesmodel.com (Dan Thorne) — Thu, 28 Jul 2022 22:40:33 GMT

The results indicate that 50% of the parents of foster children are not involved in the CFT process.

Parents are not as engaged in the Child and Family Team (CFT) process as child welfare agencies would like, according to a new survey conducted by Praxes Behavioral Health. Having surveyed members of over 100 organizations, the results indicate shortcomings in the process. CFTs are a key component of the Integrated Core Practice Model (ICPM), used to help organizations work together. While it does create synchronization for the agencies involved with a child in helping them receive services, it still misses the mark in helping their parents.

Examples of results from the survey indicate:

· Parent involvement – of agencies surveyed, 50% of their clients’ parents attend the CFT meetings.

· Attendance – 50% of the agencies’ parents who attended did so regularly.

· Participation – 42% of the parents participated in verbal or written form during the meeting.

· Using teleconference media – 51% of the agencies used Zoom or other media to encourage parents to attend.

These results indicate that 50% of the parents of foster children are not involved in the CFT process.

Then we looked at the reasons for lack of attendance. The highest was work conflicts, followed by childcare, transportation, distance from the CFT meeting, and finally lack of interest. Also, the reasons for non-involvement were due to the parents’ own problems and stress, no interest to participate, intimidation by county officials, feeling it was a waste of time, and finally their lack of knowledge about the CFT process.

Lastly, we asked what could be done to help improve parent involvement. There were some suggestions:

1. Make the CFT process more family-friendly

2. Educate parents on the value of the CFT

3. Have a parent partner or advocate attend to support them

4. Help the parents feel treated with respect

5. Give the parents time in the meeting to discuss their hopes and desires and feel part of the team.

Based on this information, the CFT process is not entirely inclusive of parents. Although they are invited, the process does not cater to their needs. Meetings are held while parents work. Parents do not receive the knowledge about why the meetings are important and why their voice needs to be heard. While the meetings focus on the child, they neglect the parents who, after all, are the ones who will be reunited with the child. Better efforts are necessary to engage the parents, such as the Parent Advocates mentioned. This approach would not only support but also educate and train parents on improving their skills as a caregiver. Making the meetings accessible, understandable, and inviting will increase parent involvement.

For more information on our survey, please contact us.

Evidence-Based Interventions vs. Community-Defined Practices

dan.thorne@praxesmodel.com (Dan Thorne) — Wed, 15 Jun 2022 20:21:39 GMT

Balancing the use of community defined practices and evidence based interventions requires input from local agencies with the macro view of statewide stakeholders.

In California, the Children and Youth Behavioral Health Initiative (CYBHI) was created to develop improved systems to help children and their families improved behavioral health services. It has several initiatives it is developing. One of these is its Round 5 plan to scale up evidence-based interventions (EBIs) and community-defined practices (CDPs). The CYBHI is available for the public to participate in and listen to as interested parties. One of the challenges is to determine which practices should be used. Both EBIs and CDPs have their pros and cons.

EBIs can be defined as “practices or programs that have peer-reviewed, documented empirical evidence of effectiveness. Evidence-based interventions use a continuum of integrated policies, strategies, activities, and services whose effectiveness has been proven or informed by research and evaluation.” The key element for EBIs is that they have research studies, many of which use an experimental vs. control group to determine the effectiveness of the practice. Then the study is published and reviewed by other professionals or researchers to verify the information, while other institutions may replicate the study to determine its effectiveness. While EBIs have a sound research basis, they may not represent the desired population. In an article, BMC Medicine indicated six potential biases in evidenced-based medicine. Applied to behavioral health, the concern may be the subjects chosen may not reflect the desired population for the practice or the necessary interventions that may apply to them. The other factor of EBIs is to keep their use strictly confined to the practice’s parameters. As with medications that have a specific purpose, EBIs must adhere to their target population, fidelity, and be sustainable.

With CDPs, the approach is somewhat different. Rather than starting with the research and defining the population, CDPs or community-defined evidence begins with the population and discovering what works for them. One of the major reasons for using CDPs is that many EBIs are not researched with people of color. CDP practices are “developed specifically to address the unmet needs and strengths of a cultural group; they are rooted in the community’s worldview and its historical and social contexts.” While the practice does not necessarily have wide-ranging utility among multiple communities, it has specific benefits for its limited communities.

How does the CYBHI best balance the use of EBIs and CBPs when California is a culturally and geographically diverse state? Not only are many ethnicities present in the state (many of whom are underserved and need better access to care), but disparity also exists between rural vs. urban counties. One approach is to allow each county to determine the best mix of EBIs and CBPs. The disadvantage of a larger organization making these decisions is that they are doing so from a macro level of the state and may not understand the differences between Alameda vs. San Diego Counties, between Yolo and Modoc. When decisions are made at the local level, with guidance from the state, the balance of decision-making provides the best match of services.

Contact Dan Thorne

Cost Reimbursement and Fee-For-Service – R.I.P.

Wed, 15 Jun 2022 20:11:32 GMT

New visions, strategic plans, and thinking about how to make the organization “managed care friendly” are prerequisites in this new world.

With the California Advancing and Innovating Medi-Cal (CalAIM) initiative continuing since its inception in 2019, a drastically new landscape commences on how behavioral health services will be provided. Two main changes occur in the reimbursement phase as it relates to behavioral health organizations. Cost reimbursement and fee-for-service will soon become a thing of the past. These dynamics are occurring as a result of CalAIM’s Behavioral Health Payment Reform.

For cost reimbursement , currently, each county uses a system where organizations billing Medi-Cal are reimbursed based on their costs. For example, if an organization has a contract for $4 million, its billing rates are dependent on how many costs it has and how many units of service it provides. As long as it provides $4 million of services and also has $4 million of allowable expenses, its rates remain. So agencies ensure they have enough costs in terms of salaries, overhead, and other expenses to justify their operations. Reimbursement then is not based on care, but on cost. This system does not reward positive outcomes, only what agencies spent. In the future, counties will change this structure.

As for fee-for-service , the CalAIM initiatives are to replace the fee-for-service system with value-based reimbursement. As indicated on the CalAIM webpage, Medi-Cal managed care health plans (MCPs) … will provide incentive payments to providers for meeting specific measures aimed at improving care for certain high-cost or high-need populations.” This means that an organization will be paid based not on how many visits they have with the client, but on what outcome measures are achieved. The emphasis shifts away from volume to how well the client improves, in terms of symptom reduction, client satisfaction, reduced hospitalizations, or other factors.

To prepare for these changes, organizations need to look at the following:

How an organization compensates its staff. With two jobs currently available for each job seeker , organizations will need to look at how they can streamline their workflows and also retain employees. The good news is that CalAIM is also updating the reasons for recoupment and the documentation requirements . So with paperwork reduction, staff can spend more time with clients.

Treatment protocols and best practices. While many organizations use evidence-based practices, other approaches will need to be developed by diagnosis and age group. Higher intensity services for youths prone to hospitalization, incarceration, or losing placements will need to occur quicker and include the right mix of clinicians, behavioral specialists, and paraprofessionals. New digital technology, such as care coordination and client portals will ensure clients do not fall through the cracks.

Developing a new philosophy of care. Some organizations have gone along with the “business as usual” mantra for years and are unwilling to change with the times. New visions, strategic plans, and thinking about how to make the organization “managed care friendly” are prerequisites in this new world.

Contact Dan Thorne

Bullying Prevention: Becoming Calloused

dan.thorne@praxesmodel.com (Dan Thorne) — Wed, 01 Jun 2022 21:05:06 GMT

According to a survey, the number 2 reason for school violence was, “Other kids pick on them, make fun of them, or bully them.”

As part of bullying prevention, youths who become calloused to bullying and verbal intimidation develop better self-images and improve their social skills. In the wake of the recent shooting in Uvalde, Texas , it is beneficial to look at why youths use violence. According to a survey at Alfred University in New York , 87% of student respondents agreed the number 1 reason for school violence was, “They want to get back at those who have hurt them.” The number 2 reason was, “Other kids pick on them, make fun of them, or bully them.” Despite all the efforts schools use for bullying prevention , youths will continue to use bullying tactics. Individuals tend to engage in this behavior for social positioning, amusing games, social contamination, and other reasons.

One approach in bullying prevention is to teach youths a “calloused exercise”. Callouses are the overgrowths on the skin from too much work. Construction workers or guitarists get them on their hands. When it happens, they don't feel the pain of the friction of tools or guitar strings. Youth can do the same thing, with their mind. If they do the following exercise (can be modified based upon age and interests):

Have them close their eyes and think of a quiet and calm place they can go where they relax. Where nothing bothers them. Have them take a few deep breaths and first enjoy the calm.
Once they feel that calm, have them imagine that they're in outer space on a spacewalk. They have a spacesuit and meteors try to hit them. But no matter how hard the meteor is, it bounces off them. They don't feel it. Their suit is so powerful, and nothing penetrates it. Have them imagine this scene.
Then have them think of a place where people bother them. Maybe teens or peers at school. Somewhere when they feel "less than" or hurt. Have them imagine they're still wearing their protective suit. Whatever people say to them, no matter how hurtful, they can hear but it doesn’t emotionally affect them. It bounces off them like the meteors and doesn't penetrate them. Let them imagine this scene for a few minutes. Then have them open their eyes.
Have them repeat this exercise daily or as frequently as needed to build up their emotional callouses. It will help them feel empowered.

Because a youth being bullied is often a traumatic experience, the youth can shut down and experience hypervigilance or withdrawal. Bullying is recognized as one of the factors of the Adverse Child Experience Survey (ACES) and also has long-lasting effects . Developing skills such as the calloused exercise offer youths a coping skill they can use to reduce the trauma impact.

Stop Hospitalization Manipulation

dan.thorne@praxesmodel.com (Dan Thorne) — Wed, 01 Jun 2022 20:59:42 GMT

In some behavioral health outpatient agencies, the foster family, and residential agencies, up to 50% of all hospitalizations are the result of a youth manipulating the situation.

When your agency’s youths are being hospitalized, is it a case of hospitalization manipulation?

In child and family agencies, it is not uncommon for youths to have thoughts of harming themselves or others. When the thoughts turn to plans, the next step is to evaluate the youth’s need for inpatient psychiatric hospitalization. Just to stabilize the youth and keep them safe.

But what if youths are using hospitalization as a place to run away from life and escape for a while?

Hospitalization by manipulation occurs more often than most agencies recognize. In some behavioral health outpatient agencies, the foster family, and residential agencies, up to 50% of all hospitalizations are the result of a youth manipulating the situation.

Here’s an example:

At an agency in the Los Angeles area, a twelve-year-old girl was at school. We’ll call her Carrie to protect her confidentiality. She attended her classes without any problems. But around her 4 ^th school period, she instead went to the school nurse. She stated she was very upset. She planned to buy a bottle of pills and swallow the whole bottle.

The nurse called the local Mental Health Emergency Team. A social worker evaluated her and determined she needed an involuntary hold. Into the hospital, she went for seven days.

Two months later she repeated the same event at school.

When the agency’s department manager talked to Carrie’s therapist about this case, they looked at the antecedents to her behavior. Turns out she avoided going to her Math class and instead went to the nurse. Why? Because she didn’t like math and didn’t want to take the test scheduled that day.

A seven-day hospitalization at a cost of probably $15,000. All due to a Math test.

It’s common for youths to use suicidal or homicidal thoughts as a mechanism to avoid problems. At home, the school, or in the community. Family disputes. Abuse or violence. Or their own inability to manage stress.

And why not? At the hospital, they get meds. A cushy schedule. Avoid the pressure of life. Plenty of attention. A reprieve from life.

Many youths do face personal hardships in their daily lives. These exacerbate their symptoms and lead to behavioral and emotional problems. But they may be able to avoid hospitalization.

This requires the agency and therapist to do a review of all hospitalizations, the triggers, and antecedents that lead to the youth’s true or fictitious reason for inpatient care.

What does the youth avoid? Trouble at home? A test? Bullying? A girlfriend’s rejection? Or abuse?

What need does hospitalization fulfill for them? Safety? Stress management? Socializing with their hospital buddies?

Youths, like adults, do things with good intentions. It’s self-preservation. But their actions are misguided at times. Knowing the purpose, and the function helps develop strategies to intervene.

In Carrie’s case, a Math tutor helped her stop being hospitalized. Resolved her fear of Math.

Off-Label Prescribing of Psychotropic Medications

dan.thorne@praxesmodel.com (Dan Thorne) — Wed, 25 May 2022 22:45:15 GMT

Psychotropic medications can be used in an off-label prescription, but the psychiatrist’s lack of clinical knowledge on the medication may not justify the possible clinical benefit.

Off-label prescribing of psychotropic medications has become a common practice among children and adolescents in mental health. In a study conducted in Denmark , “32.3% of all prescriptions were off-label, and 41.6% of subjects received at least 1 off-label prescription. The off-label rates for each drug class were as follows: melatonin, 100%; antipsychotic agents, 95.6%; benzodiazepines, 72.5%; antidepressants, 51.1%; and ADHD medication, 2.7%.” While most medications match the diagnosis and behaviors, this is not always the case. Frequently, psychiatrists may treat youth with an off-label medication. Yet the youth, caregiver, and others may not understand the implications of their prescription.

What is off-label prescribing of psychotropic medications and how does it affect youths? The definition of an off-label prescription is that the psychiatrist uses the drug for a reason for which it was not clinically tested. For example, when pharmaceutical companies get FDA approval for medicines, they state the medication’s purpose. Examples are Adderall for attention problems, Lexapro for depression, or Lithium for bipolar disorder. Several phases of clinical trials occur to prove the drug is both safe and effective for the stated purpose. After approval, the drug is ready for a prescription.

But suppose a psychiatrist sees a paper in a journal that explains the effectiveness of a drug for another purpose. Or the pharmaceutical rep who visits their office gives them a brochure about new uses for the drug. The psychiatrist can use that drug for something else if they feel it is effective.

So is off-label prescribing of psychotropic medications helpful to clients?

The reason many psychiatrists use off-label prescribing is the time and expense of approval for an additional purpose. The pros to it are that psychiatrists in clinical practice may see treatments that pharmaceutical companies cannot. They’re “closer to the action” and know which medications work and which don’t. They can use medications now instead of waiting years for the FDA approval.

The cons are that without the rigor of clinical trials, psychiatrists don’t know the safety or effectiveness of medications or have the clinical knowledge of the medication. And many psychiatrists receive information about medications from pharmaceutical representatives, not from medical journals.

What is the final answer regarding off-label prescribing of psychotropic medications? Tell your caregivers to be informed, ask about off-label prescriptions and their effectiveness, and get second opinions if they’re not sure. They can work, but it’s best to have some hard data first.

Praxes offers an online course in psychotropic medications .

For more information about our training courses, please contact us.

Parent Training: Non-Birthparent Grief and Loss

dan.thorne@praxesmodel.com (Dan Thorne) — Fri, 20 May 2022 15:25:38 GMT

A non-birthparent experiences grief and loss differently about their child with mental health conditions than parents.

Parent training requires that both the parent and the non-birthparent deal with their grief and loss of their child’s mental health conditions. The child’s special needs bring extensive stress to their family situation, as it creates a loss for the parents . They have hopes and dreams for their child, in terms of school, relationships, marriage, and happiness. But when a child grows and has emotional difficulties, the parents can be devastated by the child’s lack of “normalcy”. Virginia LaFond, in her book, Grieving Mental Illness , discusses how unacknowledged grief can be emotionally exhausting for the parents if not addressed.

But for the non-birthparent who has a child, loss also exists as well. For the adoptive or foster parent who takes in a child because of their infertility, loss occurs. They have to go through the stages of grief and loss as it equates to a loss of the ability to have their own child. In addition, the child they adopt or foster may not live up to their expectations due to the child’s mental health needs. This can lead to extensive stress.

And for the grandparent who is the caregiver, the role of being a “parent” again brings with it mixed feelings. The grandparent thought they were going into their “golden years” and have freedom from work or raising a family. But due to the parent’s absence, due to drug use, incarceration, or other reason, the grandparent must step into their role. More than 13 million children are living in homes with their grandparents, who have some role in their upbringing. The more involved the grandparent may be, anger, frustration, and deference may be felt because their role in life changes. This is their example of grief and loss.

In parent training, the non-birthparent must first deal with their own grief and loss before they can concentrate on their child. Dr. Elisabeth Kubler-Ross discussed the five stages of grief (denial, anger, bargaining, depression, and acceptance). These all apply to the loss of the parenting experience as they want it to be. Most parents are in denial of these feelings and don’t want to admit it. “My child is fine, there’s nothing with her.” “Why should I feel any loss, I’m happy to have a child.” But inside, parents feel guilt and shame over wanting something different than their child and not accepting the child with mental health conditions. Through confronting the grief and loss they experience, whether they agree or not, the concept percolates for a while until it hits them. Then they move through the grieving process.

As with any grieving process, it is not a linear one. But in parent training, helping the parent achieve well-being comes before parenting skills.

Dan Thorne, the President of Praxes, developed the Intensive Parent Model training program. It has been used throughout the country by hundreds of professionals. It is available online or contact us to learn about a training program for your agency.

World-Class Quality Programs in Behavioral Health

dan.thorne@praxesmodel.com (Dan Thorne) — Wed, 11 May 2022 18:43:57 GMT

Mental disorders are common worldwide, yet the quality of care for these disorders has not increased to the same extent as that for physical conditions.

Behavioral health organizations (BHOs) need to challenge their assumptions of quality to become world-class quality programs. Because the payor environment is changing throughout the country, both private (managed care) and public (state or counties) will demand more accountability. The push for value-based purchasing is one initiative that requires a behavioral health organization to manage the care of clients by episode, diagnosis, or length of stay.

For BHOs to become world-class quality programs, it may take a page from the manufacturing industry. In an article from Quality Magazine in 2016, researchers surveyed these companies to determine the characteristics of world-class quality. The indicators mentioned included: quality as strategic and competitive; training employees, understanding performance through the customer, visible metrics on performance, and other markers. In their study, only 1.6% of their respondents had these qualities. Comparing these figures to behavioral health, BHOs need to have consistent measurements that match those of their customers (clients, stakeholders, and payors).

In an article published in World Psychiatry , Amy Kilbourne and her associates looked at how mental health is measured regarding quality. She said, “Mental disorders are common worldwide, yet the quality of care for these disorders has not increased to the same extent as that for physical conditions.” Some recommendations listed were for routine assessment of outcomes, and measurement-based care. She went on to say, “Measures are also lacking for mental health conditions commonly experienced in populations, such as anxiety disorders, and lacking in depth for evidence‐based treatments such as psychotherapy.” Improving not only the quantity of services but their effectiveness needs more precise measurements.

Moreover, the National County on Quality Assurance (NCQA) release its report in 2021 on Behavioral Health Quality Framework. In its report, one of its findings was, “BH (behavioral health) integration is inconsistently and insufficiently measured by current standardized measures. They recommend that measures must be aligned from the State and Federal governments to the managed care agencies and down to the facility level. With this level of coordination, then synchronicity of quality can occur.

In summary, for organizations to become world-class quality BHOs, they must communicate with their payors on the state and managed care level. Determining the measurements, practices, and treatments that are agreeable among all parties then coordinates the measurement of quality. Also, employees must be focused on how they impact quality. The clinician who sees a client and gives them an assessment before and after treatment needs to understand how their “paperwork” has significance to the client and the payor system.

3 Steps of the Trauma-informed Praxes Intensive Models

dan.thorne@praxesmodel.com (Dan Thorne) — Wed, 11 May 2022 18:17:01 GMT

For parents to be successful with their children, they must first confront their trauma histories.

Whether an agency trains their staff in the Intensive Parent, Youth, or Child Model , they each provide 3 steps towards trauma-informed care.

Trauma-informed care for children and youth focuses on the understanding that they have experienced trauma. That they had histories of neglect, abuse, and witnessed domestic violence. Had major accidents, deaths in their families, or life-threatening experiences. And when it happens, the trauma doesn’t go away. It stays within the body; the trauma lingers in the right side of the brain, in certain parts of the body, and the emotions of the trauma survivor. Working with youths requires an understanding of their perspective on the trauma.

This goes for parents as well. They also may have experienced their own trauma. They may be biological parents, foster parents, or adoptive parents. And they are on a day-to-day level imparting their views of parenting to the children. But many have not dealt with their own traumas, and then incorporate that perspective through to their children.

It’s seen all the time. Parents on one end of the spectrum are so afraid of their children that they abandon their role as the head of the household. They may work to pay the bills and provide food and clothing, but they can’t parent their children. When Roberta yells at her mom to buy her a cell phone, the mother’s trauma regarding loud noises causes her to withdraw and let her child boss her around. Or on the other end of the spectrum, the parent is so strict their child can’t be a child. If Jimmy laughs when he shouldn’t, the father’s abuse from his parents is repeated on the child. These parents may have grown up in past homes with violence or abuse and keep the pattern in the present.

But our Intensive Models for the Parent, Child, or Youth offer interventions that work with trauma-based behaviors. It’s not meant to be a trauma treatment. But it does take the first move forward in helping parents and children heal.

Here are 3 steps that it takes to accomplish this.

1. Stress Reduction. When parents or children experience trauma, it unsettles their body’s ability to manage stress. For most of us, when we are in a stressful situation, our body activates the sympathetic nervous system to respond to the crisis and then deactivates through the parasympathetic nervous system. But when someone has trauma, their bodies aren’t able to access the latter, leading them to a constant state of hypervigilance. But with the Stress Reduction session, the parent or child learns about how stress affects them. Practices relaxation exercises. Develops skills to circumvent stressful situations. Creates a plan for more exercise, better nutrition, and doing something fun for themselves.

2. Assertive Communication. Parents of children in trauma either overreact (aggression) or underreact (passive). Yet there is some midpoint where they can respect themselves and others through understanding assertive skills. The session teaches them how to stop avoiding conflict and ask for what they want calmly. Learning how to take criticism without withering. Being persistent without being pushy.

3. Family of Origin questions or intergenerational trauma . In each family, a child learns how their parent manages stress. Communicates. Handles discipline. And in families of abuse or violence, when the child becomes a parent, in many instances they repeat the pattern. The child also takes on those behaviors; a dad who was a bully creates a child who wants to be aggressive with others. Taking time to “hit the pause button” and look at their behaviors helps the child or the parent decide what they want to do differently. And how that can happen.

These are some examples of how the Intensive Models for the Parent, Youth, or Child help navigate the trauma-informed care road.

For more information about these training programs, please contact us.

Family Therapy in Child and Family Agencies

dan.thorne@praxesmodel.com (Dan Thorne) — Wed, 04 May 2022 18:34:19 GMT

Family therapy in child and family agencies can be improved and utilized more if the clinicians reduce their resistance and use these skills in their practice.

Family therapy , while practiced in the United States in different forms since the 1940s, is not a common mode of treatment in child and family service agencies. Some skills can improve their use, as long as the clinician is open to them.

The majority of clinicians that enter child and family agencies receive their master’s degree in Marriage and Family Therapy. Their goal during their work is to gather hours to obtain their license as a Marriage and Family Therapist. Yet the amount of work conducted in actual family therapy is sparse. For many clinicians, the idea of seeing a family in treatment worries them. When asked by a supervisor to treat the family as a whole, they might answer as follows:

“How do I get the parents on board?”

“What if they question my knowledge about being a parent when I’m so young?”

“What if they don’t want to attend?”

“They only want me to fix their child, not them.”

To remove the resistance the clinician might have, several steps should be taken to improve the utilization of family therapy in the child and family agency.

Recognize the resistance parents have to family therapy. Although it’s easier for them to blame the child for the family’s problems, parents know internally they play a part. They simply don’t want to admit it out loud. Parents can feel a sense of guilt and shame when children experience emotional and behavioral problems, which leads to internal stress. Using techniques like Motivational Interviewing can help the clinician feel at ease.

Determine the goal of family therapy. If a child has emotional or behavioral problems, does the clinician want to improve the child’s behavior, the family’s communication, conflict resolution, or a combination of these? Although the family will ultimately develop the goal per their needs , the clinician should be focused on it as well.

Form therapeutic alliances with the members . Clinicians know how to form these relationships with a child. But in a family therapy situation, the clinician must demonstrate to each member they believe them. Each member needs to feel validated and a contributor to the solution.

Finally, relax and enjoy the process. Clinicians may feel uncomfortable when family members participate together. However, the interactions are dynamic. The clinician can ask the family to describe a problem and see the problem’s causes and issues unfold before their eyes. The verbal and non-verbal communication occurring in family therapy creates opportunities for solving problems, being a mediator, and encouraging positive dialogue.

Family therapy in child and family agencies can be improved and utilized more if the clinicians reduce their resistance and use these skills in their practice.

Foster Family Agencies: Peace Between the Silos

dan.thorne@praxesmodel.com (Dan Thorne) — Wed, 04 May 2022 17:45:36 GMT

When foster family agencies have two sectors (social work and therapy) in their organization, a better understanding of their counterparts’ responsibilities leads to integrated care.

Foster family agencies with both social workers and therapists in their organization may experience a silo effect. The work they both conduct with youth can put them at odds with each other. While each role has value in helping improve the youth in the foster care system, they need to find an understanding of each other’s perspectives.

This issue of silos in foster family agencies comes into play in the area of confidentiality. Recently I worked with a foster family agency on law and ethics issues. The agency had a contract with a local county to provide mental health services for their foster youth. This meant each foster youth had a social worker and a therapist assigned to them at the agency. The therapists conducting mental health services were bound by client confidentiality unless issues of suicide, homicide, or child abuse arose. But the social workers did not understand or appreciate the therapist’s ethical duties.

When a youth at the foster family agency disclosed to their therapist they brought drugs to their school, the therapist was bound by confidentiality to not discuss this behavior with the youth’s social worker. The social worker was upset the therapist did not share this information. In their mind, had they known, they would inform the county social worker to evaluate potential placement change. The social worker also believed they should inform the school so they could intervene and confiscate the drugs from the youth.

I explained to the social workers and therapists confidentiality has different meanings for each discipline. Social workers and therapists cannot reciprocate the youth’s privacy. We discussed how the foster youth’s disclosure did not meet any requirements for breaking confidentiality. If the therapist discussed it with the social worker, they would violate the law, because no threat of suicide, homicide, or youth abuse was evident. However, had the youth brought a knife to school and threatened to harm another youth or teacher, this would be grounds for notifying the school. But drug possession didn’t meet the bar of breaching confidentiality.

Afterward, the social workers in the meeting appreciated the dilemma therapists have in hearing about risky behaviors but not being able to act on them. It creates more collaboration and cooperation between the two departments and a reduction of the silo effect between them. When foster family agencies have these two sectors (social work and therapy) in their organization, a better understanding of their counterparts’ responsibilities leads to integrated care.

Behavioral Health Training: Selecting The Priorities

dan.thorne@praxesmodel.com (Dan Thorne) — Wed, 27 Apr 2022 18:30:35 GMT

Organizations that succeed balance retention and morale with clinical and governmental essentials.

Behavioral health organizations need to put priority on training their staff. Having a well-trained workforce leads to reduced turnover, increased employee morale, and better-skilled professionals. Organizations may determine their training needs due to governmental regulations, such as management of assaultive behavior or trauma-informed care. Accreditation agencies such as COA and CARF also have mandatory training courses. Others use training courses that are required to access funding streams, such as prevention and early intervention , with evidence-based practices. But these training courses may not fit the overall needs of an agency. How does an agency prioritize what its employees need?

First, align the behavioral health training courses with your organizational leadership goals and plans. Each organization has a strategic plan, an instrument that provides the agency’s path in the next one to five years. Client functioning, higher productivity, and employee retention are examples of these goals. Evaluate the types of training that facilitate employees and the organization to achieve these goals.

Second, determine the areas of greatest risk to clients and the agency. What are the problems that clients experience that create the highest level of crisis or severity? Substance abuse, crisis management, domestic violence, dealing with running away, and medication adherence may be the topics of choice to reduce risk.

Third, assess the workforce’s strengths and talents. If your agency has less experienced staff, they may need the basics of behavioral health training, such as behavioral interventions. Topics such as suicide prevention, trauma-informed care, and documentation may be advantageous. Agencies with more experienced clinicians elevate to more clinical techniques for family therapy, individual therapy, and other topics.

Fourth, ask employees what they need. Develop a survey of your employees to explore what they want to learn more about. On the front line of care, they deserve to have a voice in what empowers them in their job. More employee involvement means more buy-in to the organization’s goals and better receptiveness to topics given.

Although behavioral health training is a function of the regulatory and funding needs, it should also be implemented with the employee’s requirements in mind. Organizations that succeed balance retention and morale with clinical and governmental essentials.

STRTP and QTRP Facilities: Current Challenges

dan.thorne@praxesmodel.com (Dan Thorne) — Wed, 27 Apr 2022 18:17:13 GMT

To meet these challenges, organizations will require more training, better policies and procedures, better hiring practices, and a different philosophy about the youths and their care.

STRTP and QRTP facilities, while still making a difference in youths’ lives, face critical challenges. Whether an organization has an STRTP (Short-Term Residential Therapeutic Program) in California or QRTP (Qualified Residential Treatment Program) throughout the country, the task of stabilizing a youth’s functioning is not getting any easier. In some cases, the work is becoming so difficult that more of these facilities are closing.

The treatment and guidelines are part of the Families First Preservation and Services Act designed to keep youths closer to their homes. Youths sent to these facilities display difficulty in traditional home environments such as with their family or in a foster family setting. 24-hour care, therapy, and programs are designed to help them improve their functioning. What are the challenges facing these agencies?

The higher acuity of youths. The youths now entering these facilities have more longstanding emotional and behavioral problems. Substance use, commercial sexual exploitation, fire setting, sexual offenses, runaways, and gang involvement are typical among the youths. The STRTP and QRTP having youths with more complex problems together can lead to increased dysfunction. For example, if one youth is heavily involved in sex trafficking for her “pimp”, she can encourage her housemates to join her. If they also have a history of sex trafficking, the group environment may embolden more to run away rather than less.

Reduced use of mental health services. The STRTP and QRTP may be required to hire mental health staff to provide onsite mental health services for the youths to help them with therapy, behavioral interventions, or other skills. Yet the staff can only bill for services the youth attends. If youths don’t want to go to therapy, they can’t be forced. Subsequently, the staff cannot bill, and the agency cannot receive compensation for the staff salaries. As a result, there is reduced use of the mental health services, and agencies lose money with staff who cannot treat youths unwilling to receive care.

Staff turnover. Traditionally, STRTPs and QRTPs have a 50% turnover rate of staff yearly. But with the higher level of youth behavioral challenges, together with COVID, many staff don’t want to work in these facilities anymore. Secondary trauma , together with dissatisfaction with documentation and regulatory demands makes it more challenging for agencies to hire and retain staff.

To meet these challenges, organizations will require more training, better policies and procedures, better hiring practices, and a different philosophy about the youths and their care. Therapy techniques need to be modified to meet the youth where they are at, walking a mile in their moccasins. Use of Motivational Interviewing , harm reduction, and behavioral strategies such as Functional Behavior Analysis are skills staff will need. The trauma-informed approach to youths and stress management skills are at the core and make significant differences in improving functioning. While STRTPs and QRTPs will continue to face uncertain futures, modifying programs to meet youth and regulatory needs keeps them at the forefront of residential care.

Secondary Trauma: Using Personal Strengths

dan.thorne@praxesmodel.com (Dan Thorne) — Wed, 20 Apr 2022 18:41:08 GMT

Through using personal strengths, the professional and their agency engage employees more in the work they love.

Although behavioral health professionals can suffer from secondary trauma , their personal strengths may also combat their work fatigue. Professionals working in the child welfare arena hear frequent stories of a youth’s trauma, which can affect their mental well-being and leave them wanting to avoid work. The current stress of COVID, as a crossover trauma , has had long-lasting effects on professionals due to changing work conditions and hybrid vs. in-person settings. Finally, the impact of greater demands to “do more with less” leaves workers wanting to leave the field.

For employers, training employees to evaluate their work-life balance and make changes leads to healthy work engagement. According to a 2017 article by Don-Jin Lee and M. Joseph Sirgy, workers can develop balance in their workplace and personal life by integrating using personal strengths from one area and placing them in the other. This concept is called spillover versus compensation. The idea is that the “work-life balance is achieved when “individuals experience spillover (positive affect from one life domain contributes to positive affect in another and vice versa) and compensation (negative affect in one domain may cause the individual to enhance positive affect in another domain and vice versa).” For example, take the concept of conflict resolution. Suppose a worker has expertise in their professional life handling conflicts. They are a therapist who deals with managing family conflicts throughout the day with their clients. Their ability to view both sides of the problem gives them a picture of how to do the same in their personal life. Thus, they can provide their professional perspective at home as a positive contributor to disagreements. This can reduce the stress and secondary trauma occurring at work.

Another area of difficulty Lee and Sirgy discussed is social relationships. It is common for workers to be socially interactive at work yet have difficulty making connections with others in their personal life. Sometimes this is due to their fears of meeting people and being hurt or manipulated. However, the skill of assertion (i.e., treating others with respect and as equals) as a personal strength at work also translates to the same skills in their private interactions with friends, family, and relationships.

Most importantly, the professional needs to increase those parts of their life that they find enriching personally and professionally. As an example, the electronic health record was supposed to reduce documentation for professionals, but this technology has not decreased the paperwork drain. Clinicians came into behavioral health to be with clients, not spend time on “paperwork.” Although it is necessary to document the details between client and clinician, the agency needs to find ways to assist the clinician in balancing their time through training, reducing forms, and simplifying the documentation process. Even paperwork can impact an employee's secondary trauma.

These techniques taken together can improve the quality of life for employees and lead to higher retention. Through using personal strengths, the professional and their agency engage employees more in the work they love.

Bundled Payments for Behavioral Health Organizations

dan.thorne@praxesmodel.com (Dan Thorne) — Wed, 20 Apr 2022 18:13:54 GMT

While the approach may be upcoming, it is not without its flaws.

The behavioral health organization’s ability to make bundled payments work will be a crucial tool as managed care integrates with behavioral health. Bundled payments existed in behavioral health for many years in other forms. Also known as case rates, these reimbursement structures are used for residential facilities. For example, a facility receives a monthly rate for each youth, regardless of the number of services they need. Another example is the Wraparound Approach Services program, which can offer monthly compensation for each youth’s service.

While the approach may be upcoming, it is not without its flaws. United Behavioral Health was sued in 2021 for denying medically necessary treatment due to its bundled payment policy. The concept of cost-sharing can be controversial if it reduces care for certain individuals. Also, in 2020, the law firm of Manatt, Phelps & Phillips , conducted a report for the California Health Care Foundation about their findings in payor models. In their report, they indicated that “the total cost of care model appears ill-suited for behavioral health providers for several reasons: the complexity of dividing responsibility for total cost of care across physical health and behavioral health providers, lack of capital and infrastructure to manage downside risk, the inability of behavioral health providers to influence the full continuum of care, and the lack of standardized managed care contracting templates for behavioral health value-based purchasing (VBP).”

If your agency is looking at the option of bundled payments for services, there may be plausible options. The first assumption to make is that not all client conditions are created equal. For example, the cost for an episode of care for a client diagnosed with bipolar disorder is different than one who has a social anxiety disorder. Therefore, developing a cost per diagnosis or cost per episode approach may be more feasible.

The other key component is data, data, data. Your agency needs to have specific data related to the clients in your geographic area. For example, if you are in Sacramento, California, you will have different treatment models and lengths of stay per episode or diagnosis vs. Los Angeles, California. The same applies throughout the country, If a managed care company comes to you with a request for bundled payments contracting, then you ask them to share their data or use your own. Without hard facts to calculate the costs (plus some cushion), your agency will either deny care to clients or lose money.

Finally, an extra option is to put into a contract specific conditions for exemptions. For example, if your agency contracts for bipolar disorder episodes at a certain rate, a condition can exist that if the client has more than 3 hospitalizations in a specific time, the bundled payments cancel and go to a fee-per-service rate. This allows flexibility to both the payer and the agency.

Many options exist in bundled payments, but behavioral health organizations need to tread cautiously in this area.

Parenting Stress and Child Maltreatment

dan.thorne@praxesmodel.com (Dan Thorne) — Thu, 14 Apr 2022 21:05:01 GMT

The effects of parenting stress on child maltreatment or abuse are well known. According to a study published by the National Institute of Health, “the intersection of parenting stress and maltreatment underscores the importance of understanding the factors associated with parenting stress among child welfare involved families.” For both families receiving in-home supervision or children in out-of-home care, “parenting stress was predicted by child mental health, a finding with critical implications for intervention to this vulnerable group of families.”

Parenting stress became more evident during the COVID pandemic. Before it, parents who exhibited signs of depression, anxiety, or stress were seen in medical clinics, schools, or community organizations. At these crisis points, they received services critical to improving their well-being and child management. But with COVID, these resources shrunk due to social distancing and isolation. According to research conducted by Drs. Wu and Xu , the Family Stress Model is one theory about how the pandemic affected parents. When parents had a positive perception of the stressor (COVID), plus strengths and resources, their parenting skills were stable. However, for many parents already without these skills or resources, COVID exacerbated their previous capabilities and created higher levels of abuse and child maltreatment.

Additionally with school closures and therefore lack of childcare, increased parenting stress levels and potential child maltreatment occurred. Dr. Kurata and their colleagues in their cross-national study indicated, “These results indicate the need to improve the mental health of caregivers who are at risk for higher levels of parenting stress during the COVID-19 pandemic in Asian countries as well as Western countries. These results indicate that there is a need to improve the mental health of caregivers who are at risk for higher levels of parenting stress during the COVID-19 pandemic globally.”

One approach for reducing parenting stress is to combine their well-being and self-care with the parenting approach. Many parenting programs tend to focus solely on the parenting approach. But with parents as indicated above who are too stressed to concentrate on how to structure their child, these programs may fall short. Parents who receive education about themselves and how to manage their stress can then be successful with their children. Integrating a strategy of learning parental coping skills along with knowledge about the child’s needs provides a comprehensive plan. This approach, similar to the Family Stress Model, offers additional strengths and resources to the parent. They perceive stressors as COVID with feelings of empowerment rather than failure and step up to life’s pressures. Through these approaches, parenting stress and child maltreatment are reduced.

With April being National Child Abuse Prevention Month , organizations need to find positive solutions to reduce the connection between parenting stress and child maltreatment.

Praxes offers its Intensive Parent Model for parents to reduce their stress and improve their child’s behavior. For more information about training for your organization, please contact us.

Effective and Efficient School-Based Mental Health

dan.thorne@praxesmodel.com (Dan Thorne) — Thu, 14 Apr 2022 20:55:04 GMT

The California Department of Education is calling for more mental health counseling at schools. To have value to the schools, parents, and students, the services must be effective and efficient. The challenge of recruiting, hiring, and training staff is only one of the obstacles. Accessing, receiving services, and integrating the counseling with the student’s family also need to be done.

Effective and efficient school-based mental health requires a collaborative approach. This exists from the mental health provider through to the school and their personnel. The first step is to get the school or the district’s buy-in to mental health services. Many school administrators are resistant to offering these services. Lack of space for confidential services, objections to taking students out of class for therapy, and other barriers exist. To provide effective and efficient services, the mental health advocate needs to explain the cost-benefit of mental health services. Schools receive funds based on attendance. When students do not function, they do not attend a class which reduces the school’s reimbursement. Since mental health is a key component of lack of attendance, school administrators need to see the rewards to their school. Also, shuffling a student from one school to another doesn’t alleviate their mental health difficulties. Administrators need to develop trauma-informed campuses where students are not punished for mental health behaviors but directed to proper services.

The next step is to educate the staff at school about the rationale for these services. Youths with academic, behavior and attendance problems have a higher likelihood of also experiencing mental health problems. Students reporting severe mental distress were four times as likely to report low academic self-efficacy and twice as likely to report delayed study progress compared to students reporting few or moderate symptoms of mental distress. Teachers already know the signs and symptoms of students with behavioral problems; this is what they are good at. Providing them a mechanism to refer youths for services ensures access to the youth.

The mental health agency also needs to accurately predict the number of staff for school-based mental health services. Projecting the number of referrals, the length of stay in treatment, and the percentage of students dropping out of services are all variables that create a staffing pattern. Plus working with a school requires collegial relationships with principals, counselors, and school staff. The mental health professional needs to consider themselves as part of the school team.

Lastly, school-based mental health services need family involvement. This participation may not occur at the school, but the mental health professional should include the parents or caregivers in the student’s progress. No therapy for a child that does not involve their parents will succeed; effective and efficient treatment occurs when the family participates.

Praxes provides consulting to school districts on implementing school-based mental health services. For more information, please contact us.

Ego-dystonic vs. Ego-syntonic: Personality Disorders Distinctions

dan.thorne@praxesmodel.com (Dan Thorne) — Fri, 08 Apr 2022 22:03:02 GMT

Clients who enter mental health treatment come in with either an ego-dystonic or ego-syntonic view of the world. Using this characteristic of abnormal psychology assists the clinician in evaluating for personality disorder or a mental disorder. Both refer to psychoanalytic terms about how the ego, or our rational minds, manages our thoughts, feelings, values, and behaviors.

The difference between ego-dystonic vs. ego-syntonic has to do with whether a client sees their world in harmony or not. When most individuals experience mental health problems, they undergo some form of emotional pain. They lose some part of their functioning in their relationships, their home life, or their school or work. And the client is aware that something is not right. A form of conflict needs to be resolved for them to return to their typical functioning level. These individuals live with ego-dystonic behaviors. They know there are problems and that the problems originate with them. In 2011, Drs. Louise Bradvik and Mats Berglund studied the effects of anti-depressant medication on suicide ideation with ego-dystonic and ego-syntonic clients. They found that the ego-dystonic clients had poorer responses to the medications and higher incidences of successful suicides. This evidence could conclude that ego-dystonic clients have more difficulties resolving emotional pain than ego-syntonic clients.

The client who has ego-syntonic traits does not see problems due to their personal behavior. For example, suppose you have a problem with someone with an ego-syntonic personality. You talk to them about your concerns. But by the time you finish and they respond, you may leave the conversation thinking that you are at fault, instead of vice versa. The client who has ego-syntonic traits believes that “You’re the problem, not me.” The person with an ego-syntonic personality may not view their traits as a problem; instead, they may view them as an asset. Dr. William Hart and his associates in 2018 examined subjects with personality disorders. They indicated subjects found their traits were useful to them and not causing them emotional pain.

In looking at the distinctions between the individual with ego-dystonic vs. ego-syntonic traits, the world is either in disharmony (ego-dystonic) or harmony (ego-syntonic). When clients with personality disorders enter treatment, it may be due to mental disorders such as depression or anxiety that are impinging on their personality traits. Whereas with mental disorders a client can recover from an acute episode, a client with personality disorders can only resolve the conflict yet continue with their traits intact.

Praxes offers training in personality disorders. For more information, please contact us.

A Trauma-Informed Level System: Don’t Swing the Pendulum

Fri, 08 Apr 2022 21:54:25 GMT

A trauma-informed level system is a controversial subject with behavioral health organizations (particularly residential facilities). Traditionally, on one end of the pendulum organizations used a level system to incentivize youths to improve their behaviors. Youths would start at the lowest level when they arrived in care, then work their way up to higher levels as their behavior improves. However, research and other findings proposed that these methods were not trauma-informed. The studies found youths lost privileges or were dropped a level due to behaviors created by trauma triggers. Therefore, the level system was proclaimed to be harmful to youths in foster care and recommended to be disbanded.

Then organizations moved to the other end of the pendulum. At the request of governmental child welfare agencies, they eliminated the level system. Subsequently, youths felt unmotivated to stop risky behaviors. Smoking, drug use, assaults, and other behaviors increased on residential campuses as well as in foster homes. And caregivers had no means to modify a youth’s behavior. Rather than be focused on their personal motivation for improved behavior, youths would be more influenced by the behaviors of peers. According to research , youths associating with peers who have the same behavioral difficulties can mirror those behaviors and increase, rather than decrease their pathology.

Neither approach seems to work because they do not address the adolescent’s need to address the risk vs. benefit of their actions. Because using a trauma-informed level system requires an understanding of how adolescents function. In Dr. Frances Jensen’s book, The Teenage Brain , she discusses how adolescents define their actions by how the risk of the event compares with the benefit. As long as the risk is worth it, they will engage in the action. This plays into the need for a motivating factor to help youths improve their functioning. They won’t do it on their own, but if the rewards of a better level in their home improve their life, then they will adapt their behaviors. Besides, if the level system works in the real world, why can’t it work in residential facilities? Employees start at an orientation phase and then have opportunities to receive higher levels of reward (benefits, salary increases, promotions, perks).

Creating a trauma-informed level system means using the principles of trauma-informed care and incorporating them into the platform. This means using the following:

1. Using reinforcements and consequences. When youths with trauma receive a positive interaction following their behavior, it leads to an increased repetition of that behavior. The same holds for consequences; it is based on their behaviors and is non-punitive. Even offering praise for youth returning after an AWOL for coming back lets them know they are valued and missed.

2. Get the youths’ buy-in and feedback about the plan. To make the level system work, hold monthly meetings about the incentives and reinforcements. When youths incorporate what they want, then they participate in collaborative decision-making. Teenage girls may like spa treatments like manicures and pedicures, makeup, and other hygiene incentives. Teenage boys may like access to video games, courses on how to get along with girls, and better clothing.

3. Establish levels based on achievable goals and prohibit youths from going down levels. The first level focuses on intensive services to help stabilize the youth. Then each level afterward is based on achieving goals or behaviors, along with additional rewards (allowance, curfew, use of electronic equipment, and passes). But the youths never go down a level; they only stay at a level if their behavior doesn’t improve. This approach lets the youth know they can only go up the levels, not down.

Praxes offers training on establishing trauma-informed level systems and consulting. For more information, please contact us.

Borderline Personality Disorder vs. Bipolar Disorder

dan.thorne@praxesmodel.com (Dan Thorne) — Wed, 30 Mar 2022 19:36:17 GMT

A borderline personality disorder is a common occurrence in behavioral health agencies. This disorder, according to the DSM 5 , occurs predominantly in females (75%) and between 1.6% to 5.9% of the country’s population. Yet it has many features that are common to those who experience bipolar disorder. So how does a clinician distinguish between them?

First, let’s look at the symptoms of borderline personality disorder . These are individuals who have difficulty with their interpersonal relationships, moods, impulsivity, and self-image. Some of the symptoms are efforts to avoid abandonment; suicidal behavior, gestures, or cutting; feelings of emptiness; low self-image. But a major component is what DSM 5 calls, “a pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.”

Bipolar disorder has two different categories. For bipolar disorder I, the client could have manic episodes plus either hypomania (less severe manic episodes), and/or major depressive episodes. For bipolar II, the client would have the hypomania episode and the major depressive episode. Either way, the client has a history of mood swings that usually are endogenous (biochemical) and exacerbated at times by stressful external events.

If a client experiences mood swings, how does a clinician determine if they should be treated as a client with bipolar disorder or borderline personality disorder? The difference has to do with the mood swing episodes themselves. Whereas a client with bipolar disorder will have mood swings that could last hours or days, a client with borderline personality disorder could have mood swings that last minutes. Also, borderline personality disorders tend to be functions of the environment and exogenous, rather than due to a biochemical imbalance. Finally, clients with bipolar disorder may have strong relationships that are tested during their mood swings, but the cause of the problems is due to the mood swings. Whereas a client who experiences borderline personality disorder continually has interpersonal relationship difficulties. Even if they are in a long-term relationship, it is tested due to their personality, not their moods.

Looking at the differences between borderline personality disorder and bipolar disorder requires the clinician to identify if the behaviors the client shows are long-term (personality) vs. acute (bipolar).

Praxes provides training in personality disorders for clinicians. For more information, please contact us.

Employee Length of Stay – 3 Recommendations

dan.thorne@praxesmodel.com (Dan Thorne) — Wed, 30 Mar 2022 19:18:49 GMT

The employee length of stay is a strong measure of a company’s employee retention, recruitment, and morale program. Briefly, the length of stay or employee tenure is a statistic similar to that of behavioral health clients. It looks at the average amount of time between an employee’s first day of onboarding to their last day of employment.

According to the Bureau of Labor Statistics, the average employee length of stay is about four years, which also applies to behavioral health. Traditionally, behavioral health employees view each agency as a stopping point in their career journey. Many are Bachelor’s level staff earning their Master’s degrees while working. Or they are Master’s level clinicians seeking hours for their licensure. Either way, they use the agency as a stop for experience while they attain their final goal (whatever that is).

The Great Resignation put a monkey wrench in this equation, possibly lowering the employee length of stay. Employees left their organizations due to wages, lack of recognition, no upward mobility, or burnout. But there are three ways to rectify this problem and regain employee retention.

1. Hire the right people. Joni Coccagna and David Murdock with Kaufman Hall and Associates discuss ways to improve the recruiting process. Along with their discussion, executives in behavioral health need to find the right person for the job. Jobs are more about the qualities a person has vs. their experience. For example, staff who work in the field need to be more independent, conscientious, and energetic. A candidate who does not fit these criteria, regardless of how long they’ve been doing the job, will not succeed.

2. Train employees. One of the major reasons for burnout is that employees lack the competencies to work with clients. And with clients having higher acuity of symptoms now than before, the need for skill-building doesn’t stop. Furthermore, documentation skills must also be a priority to ensure a longer employee length of stay. Because when their skills lack, they are frustrated and want to leave their job for greener pastures. Better knowledge of how to work with clients leaves employees more comfortable with their work.

3. Recognize employee achievements. In one company, when they had their monthly staff meetings for all employees, awards were given. Along with these awards were cash, gift cards, and certificates. The amount of these prizes was not large, mostly under $10. But the principle of acknowledging employees, especially when employees make an effort to improve, reaps huge rewards in loyalty, comradery, and longevity. And there are resources for these rewards.

Praxes provides employee retention and recruitment consulting services for behavioral health agencies. For more information, please contact us.

School-Based Mental Health – 3 Ways to Offer Services

dan.thorne@praxesmodel.com (Dan Thorne) — Tue, 22 Mar 2022 18:50:08 GMT

School-based mental health is now coming to the forefront as a location for children and adolescents to receive care. According to the Center for Mental Health in Schools , between 12 and 22 percent of school-aged children and youth have a diagnosable mental health disorder. Many advantages exist in providing services at the school. First, school personnel such as teachers and nurses are excellent observers of behavior patterns in a child act as the referent for service. Second, most schools have the space to provide a confidential office for therapy or other services to occur. Third and most important, having a child improve their emotional functioning also improves their attendance, citizenship, and grades. This is a winning result for the district, the child, and the parents.

Some schools may object to pulling a child out of instruction. However, agencies can argue that a mental health appointment is not any more disruptive than a dental or medical appointment. Plus, the services can be held onsite rather than needing transportation to go and return.

But school-based mental health is a luxury that many districts cannot afford. For example, the State of California is now recruiting 10,000 clinicians to become school counselors. In a time of the Great Resignation, salaries, loan forgiveness, and other strategies may not be enough to find employed therapists. Furthermore, with the COVID-19 pandemic, the emotional well-being of children at school has taken a hit due to social isolation and lack of educational continuity.

Behavioral health agencies have 3 opportunities to advance into the school-based mental health void, helping schools with their youths experiencing mental health challenges.

1. Medi-Cal services in the school. For youths with Medi-Cal, services that would be provided at a clinic or in the community can also be provided in the school. The youth’s treatment is paid for by Medi-Cal or Medicaid, depending on the state. The school thus can have the child seen for services and benefit from treatment without paying for their treatment.

2. Non-public agency. In California and Washington, as an example, behavioral health agencies can apply to become non-public agencies (NPA’s) which allow them to treat children whose Individualized Education Plan (IEP) requires mental health treatment. It can take several months to receive the certification, but it opens doors to agencies that do not have the resources to help children in need. For example, a school district in Los Angeles contracted with a behavioral health agency to avoid sending their students to out-of-state residential facilities, thereby reducing costs and also keeping students at home and functioning in school.

3. Managed care services. If a youth is covered by private insurance or managed care companies, the agency can begin the process of credentialing and contracting with these agencies. As with the NPA, the course of time can be lengthy but advantageous in the long term as it expands the flow of clients through the schools for services.

School-based mental health provides many opportunities for agencies to expand their service reach and also help the community. The more flexible an agency can be, the more likely they are to have a stable base of referrals and generate revenue.

Praxes offers consulting services to behavioral health organizations, including school-based mental health. For more information, please contact us.

The Media and Suicide by Contagion

dan.thorne@praxesmodel.com (Dan Thorne) — Mon, 21 Mar 2022 23:22:37 GMT

Suicide by contagion is one component of understanding suicide prevention. The Centers for Disease Control define contagion suicide as “a process by which exposure to the suicide or suicidal behavior of one or more persons influences others to commit or attempt suicide.” The concept is especially important for adolescents, who by nature are more pliable to suggestions from others. Along with the concept of contagion, suicide is “cluster suicide” which specifies that a cluster has occurred when attempts and/or deaths occur at a higher number than would normally be expected for a specific population in a specific area.

Along with the concern, parents have already about their teens is that suicide by contagion is also influenced by the media. Dr. Gould in her article presented studies that showed how exposure to media information about suicides led to a higher probability of an adolescent attempting suicide. Dr. Gould offered information that the reduction of information about suicide to adolescents may also reduce the likelihood of their attempts.

This information was brought to light in the media in 2017 with the release of the Netflix series, 13 Reasons Why . The article alone in Wikipedia about the show cited here has with it numerous studies conducted about suicide by contagion and the possible negative influences of the show. 13 Reasons Why was about an adolescent female who kills herself; she had mailed cassette tapes before her event to a classmate outlining her reasons for her actions. The show was successful but not without controversy.

On one hand, Dr. Jeffrey Bridge concluded that the viewing of the first season of the show resulted in a higher amount of suicides than before the show aired. However, Dr. Christopher Ferguson indicated in his study that no link exists between fictional media and suicide attempts or deaths. And Marco Scalvini indicated, “Fictional portrayals of suicide might empower vulnerable people in terms of normalizing mental health issues, preventing suicidal ideation or encouraging help-seeking. It has been suggested that appropriate portrayals such as those emphasizing negative consequences or alternative courses of action, could actually have a protective, or educative effect .” So the concept of suicide by contagion influenced by the media has both proponents and opponents.

What do behavioral health professionals do to reduce a youth’s risk of suicide? Adolescents will always have access to information about suicide, whether it is social media, television shows, or the news. Pretending it doesn’t exist does not help the professional, the parent, or the teen. But when a youth has a higher probability for suicide, preventive and reactive measures, such as a crisis and safety plans should be implemented. Discussions with the youth when a friend or someone they know attempts suicide should be done mindfully to help the youth distinguish between their emotional pain vs. someone else’s. Support, psychotropic medications, treatment such as Cognitive Behavior Therapy and Dialectical Behavior Therapy help to bring the youth into the present to deal with their thoughts and feelings, to avoid suicide by contagion.

Praxes provides training on behavioral health topics including a 6-hour course on suicide prevention for licensed CEUs. For more information, please contact us.

3 High-Risk Factors for Teen Suicide Prevention

dan.thorne@praxesmodel.com (Dan Thorne) — Tue, 15 Mar 2022 18:35:21 GMT

Teen suicide prevention is a major emphasis for behavioral health agencies. Before COVID, the pressures on youths were already high due to social media and cyberbullying drug and alcohol use, and violence. Many factors play a role in teen suicide.

But mixed in with these issues are three very high-risk groups. Where the likelihood of attempted or successful suicides jumps through the roof. And because behavioral health agencies treat these youth consistently, there needs to be more awareness, identification, and treatment. These youth tend to be more out of the mainstream. Left behind. And ones where the personal support systems don’t exist as much as they do for other youths. To advance teen suicide prevention, these three areas must be addressed when a practitioner meets with a client.

They are:

Childhood abuse or trauma. Youths with a history of abuse or trauma in their early years suffer more emotional and physical problems than other youths. The Adverse Childhood Experiences (ACEs) research indicates youths with these types of history have more difficulties. The experience of trauma, especially sexual victimization, affects a youth over the years. There is a sense of powerlessness. Hopelessness. The disbelief they have control over their life and environment. Along with this comes a sense of shame. They don’t feel bad. They feel that they are bad.

Studies also show a change in brain chemistry. Because of sexual abuse or other types of trauma, the youth’s ability to manage stress is compromised. Changes occur in the brain’s metabolism of serotonin, which can lead to higher levels of depression. They are in “ survival mode ”; always on guard. Hypervigilant.

Youths with a history of childhood abuse or trauma are twice as likely are other youths to attempt or complete suicide.

Youth in foster care. The nature of youth being in foster care starts them on the path toward emotional difficulties. Being taken from their home is the first factor. With witnessed abuse or neglect, the risk increases. And then if the youth themselves is the victim of that abuse or neglect, there are more risk factors for emotional problems. Then being placed in someone else’s home.

The uncertainty, the adaption to a new home, all lead to higher risks of depression, anxiety, or substance use. When youths are in foster care, they feel a lack of control over their lives, which leads to more depression and suicidal thoughts. These types of problems complicate their treatment. Especially if they already enter the system with behavioral or emotional problems. Take into account many of them are also survivors of childhood abuse or trauma, and that leads to more difficulties.

Youths in the foster care system are almost four times more likely to have attempted suicide than other youth.

LGBTQ youth. These youths have different experiences in their sexual orientation, gender identity, and expression. And are on the continuum from denying who they are to fully accepting it. And even along with that range, there are no guarantees how others, including family, accept them and their feelings. Consequently, they feel loneliness, depression, and a sense of hopelessness. That no one understands them. That others mock them for being themselves. It creates the fear to be themselves. Combating stigma, prejudice, and discrimination.

The rate of suicide attempts by LGBTQ youth is five times higher than that of other youths.

What do these youths have in common? The sense of loneliness. Lack of family support or the opposite, family estrangement. Feeling as outsiders. Unloved. Unneeded. Isolated and alienated. The same types of traits are seen in the population of youth who attempts suicide.

What can be done about teen suicide prevention? Develop means of inclusion. Support. Encouragement. Develop coping skills to help these youths. And an outlet so that when they feel down and moving towards suicidal thoughts, they feel or believe there’s hope. Something to live for.

PRAXES offers training for behavioral health agencies and their staff, including Suicide Prevention.

For more information on training for your agency, please contact us.

Behavioral Health Productivity for Professionals: The Plan B Option

dan.thorne@praxesmodel.com (Dan Thorne) — Tue, 15 Mar 2022 18:27:58 GMT

When the agency wants to meet behavioral health productivity standards, teach them the Plan B Option. Behavioral health agencies who bill mental health Medi-Cal face challenges with billing. Each agency receives a county contract for mental health services. Case management, mental health services such as therapy or collateral sessions with family, crisis intervention, and medication support. Other agencies treating foster family youth also use Intensive Care Coordination, Intensive Home-Based Services. And some provide Therapeutic Behavioral Services. Meeting the county revenue standards requires staff to bill a certain number of hours per week. Which ranges between 20 to 30 hours for behavioral health productivity. But it’s not always easy to reach these standards, because of the acuity of clients and other factors.

Why? Because clients cancel. No-show. Reschedule. Or things pop up where they can’t keep their appointment. Or the practitioner can’t make it. Plus with COVID and other factors, clients do not want to make their appointment.

This conflict between client engagement and agency revenue hits the practitioner who must meet their behavioral health productivity numbers or face possible ramifications. This requirement creates massive stress on the practitioner. “How do I have time for all my clients to meet them, document, and bill?”

To help them, let’s discuss the Plan A Option and the Plan B Option.

A clinician at an outpatient agency in the Los Angeles area found this problem. He noticed that every practitioner would plan out their schedule as if everyone would show up. That was the Plan A Option. They didn’t take into account that things would go wrong. They’d cancel or not be at their house when the practitioner came. And then they would have to make up all those hours somehow to achieve behavioral health productivity. Panic would set in.

This clinician used Murphy’s Law approach. Everything which can go wrong will go wrong. He found that if he planned, he would think of other ways, he could reach the client or someone else to discuss their services and move the case forward.

Suppose a client’s mother was supposed to come for a session. She cancels at the last minute. The clinician then would call her and speak to her instead and do the session over the phone. Instead of losing billing, the collateral service (talking with mom) went ahead as planned. Billing ensued and behavioral health increased.

Or a client was supposed to meet with the clinician. But she got sick and couldn’t make the appointment. The clinician spoke to the client’s teacher about her progress. About how she was doing in school and offered suggestions. Meeting the criteria for billing. Medical necessity (improving the client’s functioning) and benefitting the client (suggesting interventions). Problem solved.

With COVID-19 and the advent of telehealth services creating access for clients, the Plan B approach can work even more. Clients reticent to come into the office may be more willing to meet via phone or computer. Using a Plan A and Plan B approach together improves the behavioral health productivity for agencies and their staff.

Praxes helps behavioral health agencies with program development and operations.

For more information or a free assessment, please contact us.

Putting the Strategy in Strategic Planning

dan.thorne@praxesmodel.com (Dan Thorne) — Thu, 03 Feb 2022 22:34:06 GMT

Strategic planning should not be a task behavioral health organizations do only to satisfy regulatory concerns. True, agencies such as the Council on Accreditation (COA) and CARF require that organizations have a strategic plan. And as a result, many of these agencies do so, at the last minute. Six months, three months before, to fulfill their obligations for accreditation. But shouldn’t the purpose of having an organization, whether large or small, be to follow a path and purpose?

When a company engages in strategic planning, they evaluate the past, forecast the future, and develop the path forward. According to famous Harvard University Business Professor Clayton Christensen, "Most people think of strategy as an event, but that’s not the way the world works. When we run into unanticipated opportunities and threats, we have to respond. Sometimes we respond successfully; sometimes we don’t. But most strategies develop through this process. More often than not, the strategy that leads to success emerges through a process that works 24/7 in almost every industry."

Strategic planning can be done for one year, three years, five year periods, and upwards. But once a plan is put into place, it will need tweaking. For example, most organizations have difficulty forecasting the future. This is because they cannot predict all trends or outcomes, external or internal, that occur (who could have predicted COVID, or the rise in telehealth?). BetterUp discusses how “strategic planning is the ability to think through ways to achieve desired outcomes.” Forbes discusses its five-step approach. The best a company can do is evaluate what occurred in the past year and how their accomplishments and challenges compared to what they predicted. For example, if a behavioral health organization thought they would increase client access by 10% and it only was 5%, they can examine the causes for the shortfall. Was it unrealistic projections, barriers to incoming clients, lack of community outreach, or a combination? Then as the organization looks to the future year, they can look at how they can more accurately develop a picture of their plan.

For a Board of Directors or leadership team, strategic planning helps them to assess needed resources, purchases, or other program requirements. For example, if an organization will be getting a grant to work with migrant children who do not speak English, they will have to identify staff who are bilingual and bicultural in the children’s language. This means increasing recruitment, onboarding, and training efforts, along with possible bonuses to entice and retain staff.

Strategic planning doesn’t always have to do with growth. Some organizations want to keep their basic services but improve them. For example, a residential facility wants to reduce restraints, runaways, and special incident reports. They will identify the causes of these events and develop plans to improve training, resources, and other collaborations to improve their treatment outcomes.

Whatever your organization plans to do in the upcoming year, it should have a strategy, a solid approach that means something to everyone from the leaders to the line staff. When all levels of the organization know the results of strategic planning, they come together and work as a unified force.

Praxes provides consulting for organizations on developing meaningful strategic plans and preparing for accreditation. For more information, please contact us.

Gamifying Mental Health

dan.thorne@praxesmodel.com (Dan Thorne) — Thu, 03 Feb 2022 22:31:07 GMT

Using a game approach, or gamifying mental health treatment, maybe a promising strategy to improve the functioning of adolescents. Currently, the teenage population shies away from mental health treatment, although they are one of the most at-risk groups for these problems. By the time an adolescent seeks treatment, either through parents or through other sources (e.g., child welfare, school), they are turned off by traditional therapy. They tend to trust less, be less amenable to treatment, and have difficulties in opening up to therapists about their difficulties. In other words, their “engagement” in seeking help is minimal.

But put a typical teenager in front of a video game, and they will play for hours until the controls are pried from their hands. Or, as residential facilities find, become enraged if they are told to turn it off. The adolescent mind is primed for gamifying experiences, because they are novel, at times risky, require creativity, and quick decision making. So wouldn’t it be a good combination to blend a game-style approach to mental health treatment?

According to a study from the University of Hong Kong in 2016 , digital game-based learning (DGBL) shows promise in converting its educational opportunities into mental health approaches. The study took a game, Professor Gooley and the Flame of Mind, and asked the users to go through the different modules. The modules included topics such as mental health, automatic thoughts, self-esteem, procrastination, hope, communication skills, gratitude, problem-solving skills, and engagement. But instead of being traditional lessons, the user went through the game sequences to learn the concepts. The study showed that users improved their mental health as shown by the completion of different measures. Gamifying mental health can be a successful approach for adolescents.

In another study from Science Daily , “eQuoo [the gamified intervention app] was able to show that it not only had a significant and beneficial impact on the participant's mental wellbeing but that gamifying therapies counterbalances sky-high attrition rates most mental health apps struggle with, especially in the demographic of 18-35-year-olds."

How does an organization start to use gamifying mental health applications? Praxes is now experimenting with these applications, using its existing programs and interventions to create a client-centered portal. This portal would use some of the common traits of social media and games, such as avatars, badges, rewards, and other approaches to engage adolescents in their own mental health. When done with fun and challenge, Praxes believes these approaches will improve the work agencies are already doing.

To learn more about our new gamifying approaches, please contact us.

DSM 5 Diagnosis Training: Chicken or Egg?

Thu, 20 Jan 2022 21:56:07 GMT

If your agency trains your staff about DSM 5 diagnosis, one key point for them is the old question. Which comes first the chicken or the egg? Clients present with multiple problems, behaviors, and symptoms. The clinician must first take the information down about the length of these problems and how long they have experienced them. Then the client describes how frequently the symptoms occur, whether daily, weekly or occasionally. The intensity of the symptoms differentiates between whether the condition is mild, moderate, or severe. The clinician then determines whether the condition is affecting the client’s functioning. Does it affect their ability to work, go to school, be at home, or live in the community?

Then the question is what is the DSM 5 diagnosis? Out of all the behaviors, history, and conditions the client presents, how does the clinician make a decision? It’s not easy, since clients with a long history of problems present with an array of choices. One approach is to rule out possible diagnoses . This can be done by looking at all possibilities and then figuring out which doesn’t fit with the symptoms.

Then the next approach is to use differential diagnoses . These choices are listed in the DSM 5 diagnosis Manual for a specific condition. For example, with attention deficit disorder (ADD), other possibilities are oppositional defiant disorder (ODD), intellectual disability (ID), or autism spectrum disorder (ASD). Then the manual will discuss how the other conditions are characterized and differ from the selected one. In the case of ADD, it is an issue of organization vs. hostility (ODD), reduced cognition (ID), or social disengagement (ASD).

But how do the chicken and egg come in? Because a major characteristic of diagnosis is what generates the maladaptive behavior. What is the origin of the condition? For example, a client presents with anxiety, due to a traumatic event. The client experiences flashbacks of the event. Is it anxiety or post-traumatic stress disorder (PTSD))? Most probably PTSD, because the anxiety comes from the trauma. In the DSM 5 differential diagnosis, the manual would also examine the cause or source of the problem.

Suppose an adult client tells the clinician they have a long history of depression and anxiety. They explain they also have delusions and hallucinations, worry about people harming them, and have difficulty concentrating. From this brief description, the client could have four diagnoses; major depressive disorder, bipolar disorder, generalized anxiety disorder, or schizophrenia, not to mention others. The clinician must uncover the origin of the discomfort. Is it from moods, thoughts, or both? What do delusions and hallucinations look like? If the client is driven by their moods and thoughts, a DSM 5 diagnosis of schizoaffective disorder may cover most of the symptoms.

The clinician in doing their DSM 5 diagnosis must take out extraneous information and boil all symptoms down to a simple question: what problem or chicken/egg came first?

Praxes provides training on Diagnosis for behavioral health agencies. For more information, please contact us.

STRTP Mental Health Integration: Problems and Solutions

dan.thorne@praxesmodel.com (Dan Thorne) — Thu, 20 Jan 2022 21:15:48 GMT

California’s Short-Term Residential Therapeutic Programs or STRTP mental health integration progresses with positive results. Since 2016, when California’s Continuum of Care Reform law went into effect, STRTP’s as former group homes became mental health providers. No longer did STRTP’s need to refer out mental health services to other agencies. Now an STRTP could be a one-stop-shop, providing STRTP and mental health together at one site.

While California’s 58 counties all conduct services in different ways, the state’s STRTP Mental Health standards provide the structure for all services. Though counties are very supportive of the STRTP’s and their provision of mental health services, many problems exist statewide. Here are some examples of these issues and possible solutions:

1. High staff turnover – due to COVID-19, the Great Resignation , and the higher acuity of youths, agencies struggle to retain mental health staff. Especially with the Master’s level Head of Service, where employees at one agency for example last no longer than three months. STRTP’s must first be selective of their staff ( not hiring out of desperation ), then offer small rewards and recognition. When mental health staff feels part of the STRTP team, the STRTP mental health integration process moves smoothly.

2. Certification delays and inconsistency. STRTP’s must be certified by either the state Department of Health Care Services or their county for billing Medi-Cal (similar to Medicaid) services. Having programs approved can take months or years. Often, two clinical reviewers of programs will look at the same information and critique it differently. This process delays the STRTP’s ability to provide services. Also, some counties over critique the program service documents requesting infinite details. Thus, the end product seems more like a lesson in grammar than in STRTP mental health integration. The whole process should benefit the youths, not penalize STRTP’s. Consistent guidelines and a procedure-based focus will reduce these delays.

3. Lack of psychiatry resources. According to Active Medical Partners , reasons for a shortage of psychiatrists includes the aging out of professionals, burnout, and lower reimbursement rates. While STRTP mental health integration offers higher rates of compensation, few agencies can find psychiatrists willing to work with STRTP youths. Moreover, many telepsychiatry services won't contract with STRTPs because they lack the volume of youths needing services. To combat this problem, telepsychiatry companies can be more flexible in their pricing programs or bundle several agencies together to provide them with the services necessary.

4. Finally, Families First Prevention and Services Act (FFPSA) compliance. As a national law, STRTP’s, as well as Qualified Residential Treatment Programs or QRTP’s must meet the FFPSA standards. For programs over 16 beds, they lose funding because they are considered an Institute for Mental Diseases (IMD). Nursing services are required, along with CARF or COA accreditation. Also, a youth must receive an independent assessment from a Qualified Individual (QI) within 30 calendar days from the date of the referral or from the date the youth is placed in an STRTP or QRTP. While the FFPSA had good intentions to reduce out-of-home care for youths, it interferes with STRTP mental health integration. Further state and federal communication is required to find solutions that benefit the youth and their family, not politicians.

While STRTP mental health services are improving, many obstacles remain and will take time to be solved.

Praxes provides consulting services to STRTP and QTRP facilities in mental health integration. For more information, please contact us .

The Autism Spectrum: 3 Challenges with Autism Communication

dan.thorne@praxesmodel.com (Dan Thorne) — Thu, 13 Jan 2022 01:06:28 GMT

With youths on the autism spectrum, a challenge they all share is their autism communication. More interest, research and treatment is being focused on the youth on the autism spectrum. Whether a youth is silent and doesn’t function in school, or is a high achiever and a straight-A student in school, being on the autism spectrum gives them something in common. It’s their challenge with autism communication. In either diagnosing a youth on the spectrum, assessing, or treating a youth, the issue of how they relate to the world is an important characteristic which needs to be addressed.

For youths on the spectrum to function, to be part of the mainstream, they need to be able to communicate. Because autism communication is a symptom that is used to diagnose someone on the spectrum. It affects their functioning and ability to communicate with others.

What are the difficulties they experience?

Youths experiencing autism communication have deficits in social interaction. Here are three examples:

1. They can’t be involved in the give and take of conversation. When you meet a person on the street or in a store, you greet them and start up a chat about a topic. Fashion. Sports. Gossip. It lasts for a few minutes or so, maybe longer, and then finishes. But for the youth on the spectrum, the thought of conversation is foreign to them. Their inner world is more important to them. They may greet you, but don’t follow through with questions or statements. They need prodding, prompting to talk to. In some cases, with youths who are more non-verbal, this interaction doesn’t even occur. But they don’t have the skills to engage in talk, like a ping pong game where only one person hits the ball.

2. Their non-verbal behavior doesn’t match that of others. Being in their own internal world of pictures, words, and ideas, they don’t pay attention to how others respond. They may have the “autism stare” where they look through you but not at you. They might make facial squints, twitches, or other movements which are comfortable to them but seem out of place to conversation. If most people were to do that, you would think they were rude. But for the youth on the spectrum, don’t know that what they’re doing is not socially acceptable.

3. They have difficulty in developing relationships. There is more of a need to talk about themselves. They don’t have a connection to others. It’s not a matter of being selfish, just that they can’t know that other people may have different views than they do. If they ask questions or talk about a subject, it’s their subject.

How to teach families to improve the spectrum youth’s ability to reduce autism communication?

It takes a lot of structured time and effort. And it starts with the eyes. Remind youth to look at you (or close to your eyes). Ask them questions about themselves. Get them out of their cocoon. And role-play with them certain tasks you want them to do. Order at a restaurant. Play a game. Talk on the phone. Practice will help them develop the skills and positive reinforcement also helps. And if the youth is not verbal, help them with electronic devices to be their voice.

Praxes offers training on Interventions for Youths on the Autism Spectrum. For more information about our training courses, please contact us.

How to Hire 10,000 Clinicians for California’s Schools

dan.thorne@praxesmodel.com (Dan Thorne) — Thu, 13 Jan 2022 00:48:40 GMT

According to a press release from the California Department of Education , Superintendent of Public Instruction Tony Thurmond plans to recruit 10,000 clinicians to fill the mental health needs of California students. The plan calls for investing up to $25,000 per applicant in scholarships for future clinicians.

Locating 10,000 clinicians in mental health in California alone is a tall task, let alone hiring them to work in the public schools. Recent internet articles have indicated that a shortage already exists for mental health professionals. And this shortage doesn’t take into account how the Great Recession affected mental health workers already. According to a recent article from LinkedIn , the existing risk of secondary trauma, burnout, and other factors lead to mental health workers leaving their jobs. “When normal coping mechanisms break down, mental health workers (just like all human beings) often experience a “fight or flight” response. Simply stated, some may stay on the job and “fight” it out. Others shut down, burn out, and take “flight” by looking for less stressful employment.”

Hiring 10,000 clinicians is a positive yet challenging project. But it can be accomplished over time, using the following strategies:

1) Make schools a productive place for mental health clinicians to work. From my 20 years of experience in working with school-based mental health, I know that schools are a tough place for a counselor. They can be overworked, drawn into crisis management more than therapy, and lack support from school personnel. The school district and the Department of Education need a grassroots approach at the school level. This approach achieves buy-in from staff that the clinician is there to advance mental health. Moreover, resistance from teachers in having students taking out of class to receive therapy needs to be resolved. The benefit of healthy students needs to be prioritized over missing class time.

2) Use existing mental health agencies to provide school-based care. Historically, school districts with students having Medi-Cal referred students to the nearest county or county-contracted agency for services. But if the school districts fund the mental health agencies with Educationally Related Mental Health Services (ERMHS) for these students (since many of them qualify for special education), the shortage can be quickly resolved now while hiring continues.

3) Build in a system of pre-clinicians to assist in the workload. To achieve the 10,000 clinicians, the school needs a tiered approach. First, hire as many clinicians as possible (without draining other community programs). Second, develop relationships with Master’s level graduate programs to sponsor and supervise student interns. Graduate students can provide behavioral management services on their own and counseling under supervision. These students then learn the system and later can become future clinicians. Including psychiatric nursing programs in this phase can also help.

4) Use parent advocates as part of the “10,000 clinicians”. School-based mental health is only as good as the support and education the student receives at home. Clinicians can work with the student, but they still will face problems and barriers with their families. Parents are resistant to participate but can be encouraged through parent advocates or parent partners. Having these paraprofessionals with lived experience improves parent engagement and outcomes for the children.

Hiring 10,000 clinicians won’t be easy, but it can be done, with enough knowledge, planning, and community involvement.

Praxes provides consulting in school-based mental health programs. For more information , please contact us.

Don’t Abandon the Level System

dan.thorne@praxesmodel.com (Dan Thorne) — Fri, 07 Jan 2022 00:27:49 GMT

For years, residential facilities used the level and point system as a means of positive discipline. The concept was that each youth who arrived at the facility would start at the bottom level, say Level A. They were able to receive points for their positive behavior. When they spent a certain amount of time in the facility or they accumulated sufficient points, the youth was then promoted to Level B. Then depending on the agency, there were upper levels consistent with the time in the facility and increased points for good behavior. If a youth engaged in inappropriate behavior, they could have points subtracted. If the infraction was severe such as possession of contraband or altercations, they could be moved down a level.

The theory behind the level system was that getting points for the youth would incentivize them to improve their behaviors and reduce problems within the community. However, in the past twenty years, literature came out disagreeing with the level and point system. You can Google papers about the prior research conducted, which stated that it led to increased restraints, more staff injuries, and turnover. The research also indicated that it was not trauma-informed, which had some validity. For example, if a youth was penalized for running away due to a re-traumatization, they are punished due to their trauma.

In 2019, I wrote in a blog about other challenges, including that the level and point system was not “real world” based; adults do not have level systems at work (not the same as promotions) or points awarded to them. Plus, the youth entering always comes in at the bottom only because they’re new, giving them a clear disadvantage to benefit as others do. Finally, I wrote about how levels can stigmatize youths, that they are seen as an “A”, “B”, or another level rather than the person.

However, in a web conference in 2020 by the Association of Children’s Residential and Community Services (ACRC), several organizations presented how they work with commercially sexually exploited children and youth (CSECY). Most of them used a level and point system with their clients to help them move from living “the life” into a new self-perspective. This population has one of the highest incidences of trauma, yet a level and point system proved beneficial to them. This contradicts past research.

Fast forward to 2022. Many organizations are now rethinking their view of level and point systems. Those who abandoned them now see that their youth are having more difficulties instead of less. Increased AWOLs, physical and verbal altercations, substance use, and delinquent activities are reported by agencies. Executive Directors of these residential facilities I’ve spoken to express their frustration. “How can I keep the youths out of trouble when there are no consequences to their actions?” is a common question.

The answer is to keep the level system but use it more positively. Rather than move a client down a level due to negative behavior, they can stay where they’re at. They can’t move up until they engage in requested behavior, but they’re not penalized. Also, include earning points for treatment participation such as therapy, groups, family visits, and other services. Add these to the other ways the client can earn points such as chores, homework, and other healthy tasks. Setting up a level and point system combined with a therapeutic system increases their success rate.

For more information about developing these programs, contact Praxes.

Is In-Person Training Obsolete?

dan.thorne@praxesmodel.com (Dan Thorne) — Fri, 07 Jan 2022 00:23:11 GMT

In this current (and perhaps future) time of COVID, in-person training is not occurring as it used to. Two years ago (which seems like a lifetime), organizations would request staff attend training courses monthly or as needed. The trainer, either from inside the organization or someone hired, would conduct a course on trauma-informed care, therapy models, or other subjects. Attendees would get certificates and continuing education units if applicable. Hopefully, the participants would glean what they could from their training and use it in their everyday work.

But now with the ongoing issue of COVID, organizations are less likely to use the in-person approach. Due to social distancing concerns, hybrid locations (work and/or home), and new job requirements, getting staff in one room is not practical. So can organizations begin to change their thinking in the future about how they train staff?

If staff cannot be trained in person, the online training process can be a successful option. Although it lacks the closeness of having staff interact and do activities like role-playing, online training offers several benefits:

Staff can connect to the trainer regardless of their location. All they need is to use Zoom, Microsoft Teams, GoToMeeting, or other online tools to attend.
The training reduces costs. When an organization hired a trainer in the past to go to their location, that meant travel, meals, sometimes overnight stays. Now, the travel is gone and so are the extra costs.
Interaction can improve. In live training sessions, the vocal or extroverted members tend to do all the discussion while the quieter and shy staff keep in the background. This is due to the social constraints of operating in a large room. But when staff is in front of their computer, they can chat or talk with fewer fears of opening up.
Attention can be monitored. When you have a large room of trainees, it’s easy for them to sleep, talk to other participants, or check out their phones. Monitoring their participation is difficult. But when on screen, the viewer has to show themselves in the camera and be there to actively show they attend. And the trainer can call on them because they know all participants’ names to ensure engagement.
Most importantly, the training can be recorded. Unlike in-person sessions where video equipment is required, recording an online session is easy and takes one button on the video conference panel. And a recorded training can be available at a later time for those who missed the session. Moreover, when new staff comes in they can benefit from the video presentation at any time. Preserving the session becomes a valuable tool for the organization.

For these reasons, in-person training may become as extinct as dinosaurs while online training may improve knowledge and be more cost-effective.

Praxes provides live-streaming online training for its organizational clients. For more information, please contact us.

What’s the Status of Your EHR Marriage?

dan.thorne@praxesmodel.com (Dan Thorne) — Wed, 29 Dec 2021 20:56:48 GMT

It’s the beginning of 2022 and a good time to evaluate the relationship your company has with its electronic health record or EHR. Is it a success in terms of what it delivers? When behavioral health or child welfare agencies engage an EHR to provide services for them, it is in truth a marriage, for these reasons:

Compatibility. For the EHR company and you the customer, the reason your company signed a contract with them is that you shared common needs and resources. The EHR can offer electronic record-keeping, together with forms and templates, to standardize your staff’s documentation at a basic level. But is it offering what your company wanted, in terms of treatment planning, outcomes, reports, billing, scheduling, data sharing, and other needs?

Longevity. EHR’s are very time-consuming projects, with implementation, training, and ongoing issues. Once it’s put into place, it’s hard to change course. Data is stored, relationships are built between the EHR company and your company, and staff is used to a specific way of documenting in their system. Breaking it up and going separate ways is tantamount to a divorce, which can be messy and full of problems.

Unrealistic expectations. Like with marriage, what appears in the beginning to be the pros of a relationship between the EHR and your company doesn’t always work out as planned. Sybrid MD recently came out with an article on many of the problems that exist between the EHR company and the customer. Most of these are because both partners look at the best-case scenario yet succumb to the worst case. In a recent blog we posted, we discussed the results of a National Behavioral Health EHR Survey , as well as presenting how EHR’s at times may not do a good job of listening to their customers.

If you want the marriage of your company and your EHR to be successful long-term, you have to decide what is important to you. There may be times when the EHR cannot provide you with the data or tools you need. Does your EHR allow other vendors to integrate within their system? Do they use Applied Programming Interface or API to coordinate with other systems?

No EHR can be the “one-size-fits-all” vendor, and sometimes they need help to work with your company. This does not mean the marriage fails, but that sometimes other parts will help to make it work. That is something you and the EHR company need to communicate about, something that all good marriages have.

Praxes offers behavioral health software solutions that are compatible with EHR’s. For more information, please contact us.

Reducing Incidents in Child Welfare

dan.thorne@praxesmodel.com (Dan Thorne) — Wed, 29 Dec 2021 20:54:33 GMT

Special Incident Reports (or SIR’s) are the bane of a child welfare agency’s existence. Per state requirements, when a significant event occurs in a foster home or a residential facility, it must be reported to state and county organizations. Staff writes SIR’s for many reasons: runaway, drug use, refusals (school, medicine), aggressive altercations, and other events. While an agency may be stellar in its work, one SIR or event can lead to increased scrutiny by regulatory agencies. This extra layer of examination can then cause corrective action plans including staff training, changing of policies, even employee terminations or facility closure in some instances.

How can an agency reduce the number of incidents for youths in their care?

1. Identify the high-risk high-volume incidents. What are the issues that appear most with the youths, or lead to the highest consequences? Are there hospitalizations, calls to law enforcement, youth removals? Isolating the major problem helps the agency focus on what is the most important issue.

2. Use root-cause analysis . Using specific steps to ask “Why?” over and over again may lead to surprising answers.

3. Ask stakeholders to provide feedback. No solution will work without the input of all parties involved. This means staff, referral agencies, outside social workers, and other professionals. But most importantly, it means working with the youths and asking them for their assistance. Now some agencies will say, “talking to kids is like the fox guarding the henhouse,” meaning that they’ll say what makes life easier for them and more difficult for staff. However, youths have motivations and reasons for their behaviors. They also are inclined to adapt themselves when they have “skin in the game,” are active participants, and incentives are in place.

4. Try out the solutions as experiments, not fully-loaded initiatives. Not every action will work, but in many cases, there will be an improvement.

For example, if an adolescent female residential facility identifies their high-risk high-volume issue as physical altercations. The staff can look at all the variables that affect the fights, such as time of day, specific youths, precipitating factors, etc. Then they can use the root-cause analysis and ask why? Examples can be boredom, improper communication skills, lack of physical exercise, trauma triggers, lack of proper supervision, or lack of incentives to avoid fighting. The staff can then talk to the females and get their input for solutions. Maybe the youths need their own group time to work out their problems, with a staff member as a mediator. More exercise, meditation, or other activities to reduce stress. Maybe an increase in the allowance for avoiding aggressive behaviors. These and other ideas can be used to assist them in learning new skills.

Praxes provides consultation to agencies to improve the quality of care. For more information, please contact us.

Helping Foster Youth Navigate the Holidays

dan.thorne@praxesmodel.com (Dan Thorne) — Thu, 16 Dec 2021 00:22:26 GMT

As difficult as having holiday stress yourself, it tends to be worse for foster youths. Helping them navigate the holidays brings skills that they can use throughout the year.

This time of year brings stress to most of the population. Buying toys, whether it’s for Christmas or Hanukah. Preparing for parties or meals. Squeezing extra tasks into your already busy schedule.

But what about foster youth; how do they handle the holidays?

It can be complicated.

A foster youth, whether they live with a resource family or in a residential facility, are not with their biological family. Their contact with their family could range from consistent to sporadic to non-existent. Although families of foster youth lost their child due to abuse, neglect, or violence, they are still the youth’s family. Family holiday traditions, even if sparse, still are strong memories for the youth. When youths grow up, they associate love and holidays with their family. Even though they received abusive and traumatic experiences.

Foster youths tend to feel empty when the holidays come. They miss their family connections. And although foster family agencies have celebrations and spend countless hours rounding up toys, it’s still not the same.

Yet the holidays can be big teaching moments for youths if clinicians and support staff plan for it.

Foster youths tend to experience loss in general. Because they are away from families, unsure if or when they return, they have to address this loss. And nowhere does it show up more than in the holidays. Even if they get passes or visits, they still end up back in their placement.

This is why the holidays can tend to be a busy time for problems. Running away. Drug use. Aggressive behavior. Self-injurious behavior.

Rather than a practitioner putting on a happy face and ignoring the youth’s feelings, it is precisely their feelings that need to find expression. Allowing foster youth to feel the sadness, depression, anger at this time gets them to express their inner turmoil.

Options for the feeling of emotions depend upon the youth’s preferences. Sports enthusiasts need physical exertion through athletic activities and exercise. Artists use their painting, craft making, drawing, music, or rap poetry. A group process is a great place for youths to share and hear others in a similar place and also experiencing loss.

Even sitting with youth who’s visibly upset and letting them vent. Being there with them. Listening and not trying to tell them to stop. These skills the youth learns to teach themselves healthy means to express feelings.

The next time you see a youth storm out of a room at the holidays, they’re most likely expressing feeling something due to their holidays' losses. And being there to listen improves their skills in coping with trauma, grief and loss, and stress. Skills they will need throughout their life.

Foster Adopt offers five tips to help foster youth get through the holidays.

Praxes offer training courses for foster family agencies and residential facilities. For more information, please contact us.

Oppositional Behavior: Generating Interventions from the CANS

dan.thorne@praxesmodel.com (Dan Thorne) — Wed, 08 Dec 2021 22:18:39 GMT

Although the Child and Adolescent Needs and Strengths (CANS) provides resources for child welfare agencies, opportunities exist to be generating interventions in treatment for conditions such as oppositional behavior as well. The CANS is a measurement tool that is becoming more widely used in the United States and worldwide. Because it offers a communication-based approach, the practitioner together with a team of professionals provides the scores on the youth. The CANS’ ability to identify the specific areas of need offers a glimpse into the youth’s treatment goals and placement plans to ensure their stability and safety.

However, what the CANS does not do is provide treatment options or suggested approaches. The CANS is meant to be an evaluative tool and therefore leaves the approach to improve the youth’s functioning to the provider. Yet one challenge with the CANS is that so many items can arise it becomes difficult to decide which one to choose or what to do with the choices. It is not uncommon for youths in residential facilities, for instance, to have between 10 to 20 items that score a 2 (requires action or intervention) or 3 (requires immediate action or intervention), including oppositional behavior. As a result, the treatment staff must take these severe behaviors and create a treatment plan that improves the youth’s functioning.

Oppositional behavior is a set of behaviors that is difficult to treat. But generating interventions for treatment is possible. The practitioner can unpack the behaviors associated with being oppositional and work with the youth to assist them in meeting their needs. Youths who engage in anti-authority or anti-rules behaviors gave up on the traditional ways to get their message across and therefore use other methods to work. Three areas that a practitioner can work with them on are:

1. Their social ability to get across how upset they are with their state of life.

2. Their skills to be independent and self-reliant.

3. Developing a knack to reduce physically or verbally aggressive acts to others.

With these goals, if they are acceptable, the youth and practitioner can then start generating interventions work on role-playing different exercises. These events allow the youth to express themselves in a safe place without harming anyone, and then to shape through practice different approaches. Many youths with oppositional behavior learn what they’ve seen such as violence and conflict; through new methods, they reduce their behaviors to meet their goals of freedom and individuality.

CANS offers the “what” for the practitioner; it is up to them to develop the “how.”

For more information on Praxes’ software , please contact us .

LGBTQ+ Youth and Family Loss

dan.thorne@praxesmodel.com (Dan Thorne) — Wed, 01 Dec 2021 21:44:38 GMT

Every person has a sexual orientation, gender identity, and expression, or SOGIE. And many of us affirm our gender identity as our assigned sex. That is, we were born a man, and we feel that way when we dress, act, and live in the world. But for youths who have different SOGIE, such as lesbian, transgender, or bisexual, live in a parallel world. If they cannot express themselves in their family or their surroundings, they always feel tense.

“Coming out” for youth to their family about their SOGIE should be a warm and caring experience. Yet, for many youths, this is the opposite. Many families reject the youth who says they are gay or lesbian or identify themselves as neither male nor female but agender. These rejections lead to family conflict or kicking the youth out of the home. One study indicated that, while LGBTQ+ youths comprise 7% of the total youth population, they make up 40% of all runaway youths.

What causes families to reject their LGBTQ+ youths?

For some families, it is their cultural or religious beliefs. The rationale that is different and not like others is a sin, a transgression.

But other factors affect families. First, for the LGBTQ+ youth, a stigma exists similar to having a mental illness. It makes them feel different or less than others as perceived through the public’s eyes. This stigma, as with a mental illness, also affects the parents. The mothers and fathers of LGBTQ+ youths face the same discrimination and rejection from the community (e.g., “what’s wrong you with that your child is that way?”).

The other stressor for families is to deal with loss. As parents of children with mental illness grieve because their child is “different,” the same occurs with parents of LGBTQ+ youths. They go through the same stages.

Denial- “You’re not gay; it’s just a phase.”

Anger- “Why can’t you be like your brother and like girls?”

Bargaining-“Maybe if we take you to our pastor, he can help you not feel gay anymore.”

Depression-“I’m so ashamed of the job I did as a parent.”

Acceptance-“I’m not happy about how things turned out, but I can still love my son for himself.”

When working with youths, practitioners first need to understand the challenges families face when their children “come out.” This work takes time but builds family reconciliation.

The National SOGIE Center from the University of Maryland can offer resources to your agency.

Praxes has training courses in behavioral health topics such as SOGIE , and a recorded course as well.

For more information about our training courses, please contact us .

Proper Etiquette with Surveyors and Regulators

dan.thorne@praxesmodel.com (Dan Thorne) — Wed, 01 Dec 2021 21:13:42 GMT

Executive leaders meeting with governmental, or accreditation reviewers normally do so with a sense of decorum. The reviewer has substantial influence over licensure, payment, contracting, or other valued relationships. Yet in many instances, the executive creates an adversarial atmosphere that worsens their professional relationships.

Frequently, this problem occurs when the two sides meet over an evaluation of the behavioral health agency. This review could be for a regular survey, a problem with services, or a complaint. And the reviewer cites concerns about the current state of the organization. Examples could be lack of training, improper policies or procedures, or lack of sufficient documentation. Then the executive turns to them and argues about the findings.

Examples of this confronting behavior are as follows:

Arguing about regulatory or contractual changes.
Criticizing the evaluation methods of an auditor.
Disputing the results of a survey.
Citing how evidence of compliance exists.

In all these cases, the conclusion is always the same; the executive loses. The aggressive tone does not go over well with governmental or accreditation personnel and makes the process worse. It clouds future decisions about the executive’s agency and creates a hostile environment.

Why does this occur?

One thought is that the executive may have a fixed mindset. In Dr. Carol Dweck’s book, Mindset, she discusses how individuals approach life with fixed or growth mindsets. We discussed Dr. Dweck’s work previously. The person operating from a growth mindset is willing to accept problems and learn from them, while the person with a fixed mindset cannot leave their comfort zone and finds fault or blame in others. They cannot take criticism or accept complications that put their life in turmoil.

How can executives change their strategy with surveyors or reviewers?

To be positive in these situations, the executive must understand the perspective of the reviewer. They are hired to find problems and solutions. It is their job to hold an organization accountable to a set of standards. When the organization doesn’t fit the standards (which will always happen because no one’s perfect), the reviewer’s role is to advise them of it. The reviewer doesn’t have an agenda, although at times the executive may think differently. Instead of finding fault with the results, the executive needs to step back and know each problem has a solution. Turning around the situation and being positive, understanding, and discovering how to make the corrections as quickly as possible. This approach converts the adversarial relationship into a cooperative one.

Praxes offers consulting services for agencies. For more information, please contact us .

Competency Checklists in Behavioral Healthcare

dan.thorne@praxesmodel.com (Dan Thorne) — Fri, 26 Nov 2021 20:05:00 GMT

A job description is a requirement of all behavioral health organizations. Laid out with duties, responsibilities, and reporting mechanisms, the new employee has an understanding of their position. But how many organizations also have a competency checklist for each position?

The competency checklist is a worksheet with duties an employee performs to show they understand the position’s necessities. Most accreditation organizations require it as part of their survey process, yet behavioral health organizations do not. Although new employees are trained, how does a supervisor measure an employee’s readiness in their position?

Suppose your organization employs Master’s level therapists. You want to measure their proficiency in their first 90 days. First, you put down their job duties onto the list. Then you decide how to measure whether the employee demonstrates this skill. For example, if an employee must handle a crisis with a client when they express suicidal or homicidal thoughts. The employee may not have a client currently with a crisis and can’t show their skills in that manner. But by the supervisor reviewing with the employee company protocols on crisis management, the employee demonstrates this knowledge.

Then the supervisor can role-play a crisis with them portraying the client while the new employee shows how they would handle the emergency. These steps make the supervisor confident with the employee’s responses. Of course, because the therapist is under the supervisor’s purview, the therapist would still consult with the supervisor during the crisis. But the supervisor can document their beginning level of expertise.

The next steps are to expand beyond job duties. Beyond the job description, what other skills are required to demonstrate a competent therapist? Documentation, cultural competency, dealing with client resistance and countertransference, and the use of therapeutic interventions are some other tasks to list on the competency checklist.

Within the first 90 days, the supervisor should have an idea if the new employee can perform the duties the company requires of a therapist. And have documentation to prove it. And if the employee falls behind during their continued employment, the checklist can be revisited with retraining or additional skills to improve their performance.

Praxes provides behavioral health consulting to organizations in areas of accreditation and human resources. For more information, please contact us .

Collaborative Documentation: Bridging Engagement and Technology

dan.thorne@praxesmodel.com (Dan Thorne) — Fri, 26 Nov 2021 20:01:56 GMT

Collaborative documentation, or client-centered treatment planning, is an excellent tool to improve the effectiveness and efficiency of behavioral healthcare. While more county and state organizations are implementing it, still many organizations have some hesitancy.

What is collaborative documentation? As defined by Bill Schemelter of MTM Services, “Collaborative Documentation is a clinical strategy in which the clinician reviews the session with the client as they document this in the record (e.g. goals and objectives addressed, interventions provided, progress in meeting goals and objectives, clients response to the sessions today, and the plan/recommendations for things the client and if applicable the clinician will do prior to the next session). It replaces the clinical “wrap-up”, using a written medium to reinforce the above important aspects of the session/interaction.”

Why is collaborative documentation so vital? According to a presentation by Katherine Hirsch , LCSW from MTM, the following challenges currently exist:

1. Documentation has become “The ENEMY”

2. Clinicians report that documentation competes with time spent with clients

3. Clinicians count on “no-shows” to complete paperwork and catch up

4. High documentation to direct service ratio reduces number of scheduled appointments in clinic and in community (negatively impacts service

capacity)

5. Clinician’s paperwork is divorced from their clinical work

6. Clinician’s quality of life is affected!

Ask any clinician about their number one frustration with their work and they will most likely tell you that it’s documentation. Any number of clinicians will complain about how tedious and painstaking the process can be, leading to late evenings and weekends spent on the computer instead of with family. At this time of the Great Resignation , where employees are seeking work that improves their mental health, documentation shouldn’t be one of those tasks that worsens it.

Collaborative documentation simply means that, during or at the end of the session, the clinician writes the notes about the session and asks for the client’s input. The client may see the note or the documentation. It can be done at any time during treatment, such as assessment, treatment planning, progress notes, or transition. With so many clients resistant to treatment and feel like they are non-participants in their care, collaborative documentation can be a way to reverse these trends.

In an article in 2013, researchers used the collaborative documentation approach in community mental health centers, or CMHC’s . What they discovered in comparing this approach vs. the traditional approach of documentation was that medication adherence increased and more engagement (as measured by reduced no-shows) occurred. When clients have more of a sense of control in their care, they participate at a higher level.

Technology programs that advance this process, such as clinical decision-making and electronic health record applications, are valuable in making the clinical session more client-friendly.

Praxes provides consulting and behavioral health software to organizations. For more information, please contact us.

The 90-Day Accreditation Preparation

dan.thorne@praxesmodel.com (Dan Thorne) — Fri, 12 Nov 2021 20:50:09 GMT

W hen behavioral health organizations become accredited, they use Joint Commission , the Council on Accreditation , and CARF as the survey agencies. The purpose of accreditation is to receive government or managed care contracts. Accreditation acts as a “seal of approval”, like the Good Housekeeping Seal . But most agencies do not honor their accreditation as they are supposed to.

These accreditation agencies usually give 3-year accreditations. This means the agency has sufficiently shown its competence in its administration and programming. Although recommendations or corrections may be necessary, the agency passed its survey with flying colors. However, when the survey report comes and the corrections are made, most agencies take their policy manuals and work and put it in their basement for another 3 years. It’s treated like a Thanksgiving dinner; clean the house, get all the preparations ready, have the meal, and then let the house go until the next year.

Accreditation agencies want behavioral health organizations to continue the same type of services for the next 3 years as they did right before the survey. They want to see that the organization keeps up the same standards during the entire 3 years. For example, CARF asks organizations to provide annual conformance to quality report . Some organizations do this annual evaluation while many do not.

As a result, the survey process usually consists of an organization frantically running around three to six months before the actual visit. Because organizations do not have a designated person to handle their survey employees add extra workload to their already busy schedule. Is there an easier way?

If your organization is going to wait until the last minute, here are some steps you can take to be ready in 90 days:

Look at your prior survey results. Any recommendations from that survey should be corrected and part of the new way of operating. If they aren’t, your organization could be in trouble; not fixing prior problems signals to the surveyors that you aren’t keeping up.

Look at the new accreditation manual and any changes from before. Some agencies like CARF will give updates on changes made. Sections are deleted, modified, or consolidated. Knowing what changed allows you to modify practices and policies.

Get charts and staff ready. Accreditation agencies like to look at open or closed charts which they let you pick, so go over them meticulously. Tell your staff about the survey and pick some who the surveyors can talk to. Also, identify clients or referral sources to who the surveyors can speak.

Spruce up your policy manual. If the manual is three years old (or older), it’s time for a review. Whether it’s a major overhaul or simply some minor corrections, surveyors want to know you’re keeping up.

Last, and most importantly, be prepared. Have all documents marked or ready to go. First impressions are vital with surveyors. If your organization makes it easy for the surveyor to find what they need at the beginning, then the survey goes well for you. The reverse is unfortunately also true.

In conclusion, although your behavioral health organization should always be ready for an accreditation survey, you can do it in 90 days. Just don’t tell the surveyors about it.

Praxes provides consulting to behavioral health organizations, including accreditation. For more information, please contact us .

Why Diagnoses Aren’t Always Accurate

dan.thorne@praxesmodel.com (Dan Thorne) — Fri, 12 Nov 2021 20:27:05 GMT

When behavioral health clinicians develop treatment plans, they usually work from the diagnosis. This clinical finding comes from the assessment of the client, their symptoms, and what the group of behaviors appears to display. However, in many cases the clinician’s diagnosis is inaccurate, leading to improper treatment. While the diagnosis is valuable for billing and documentation purposes, it should be in sync with the client’s behaviors. And this process can be difficult. For example, in a list of the top 12 diagnoses for children and adolescents, the symptom “irritability” is listed for anxiety, bipolar disorder, eating disorder, oppositional defiant disorder, post-traumatic stress disorder, and reactive attachment.

Here are some reasons a client’s diagnosis are inaccurate:

1. The clinician falls in love with a diagnosis and makes the client’s behavior stick to their clinical conclusion. For example, if a therapist specializes in anxiety in the treatment of adolescents, they may see every child through a closed lens. Many children experience difficulty in fears and worries, but other factors can impact their symptoms besides anxiety, such as depression, substance use, or trauma.

2. Lack of knowledge. In a study published in 2008 , a psychiatrist reviewed over 200 psychiatric consultations and found that the “accuracy of psychiatric diagnosis was the highest for cognitive disorders 60%, followed by depression 50% and anxiety disorders 46%, whereas the accuracy of diagnosing psychosis was 0%.” Not knowing the proper symptoms or signs of a condition can lead to misdiagnosis.

3. The diagnosis of the decade. Every 10 years it seems that clinicians find a diagnosis and stick with it rather than objectively see if it applies to a client. A real case example illustrates this problem. A child born in the 1980s was first diagnosed at age 5 with attention deficit disorder and given Ritalin to help them with their inattention. Later in the 1990s as an adolescent, they continued with behavior problems and then were diagnosed with bipolar disorder. Finally in the 2000s, with prolonged problems, the now-adult was diagnosed with intermittent explosive disorder.

4. Lack of understanding of differential diagnoses. For example, trauma and attention deficit hyperactivity disorder (ADHD) have several symptoms that overlap. Concentration, distraction, lack of listening, restlessness, and difficulty sleeping are behaviors clients with either condition have. Yet ADHD is a disorder of organization because the client lacks the internal structure to keep their lives manageable. But trauma is a disorder of stress because the client’s stress response does not function properly, causing their behaviors to range from withdrawal to rage.

When clinicians decide on a diagnosis, it has to be based on the cluster of behaviors that occur and how to differentiate between different conclusions.

Praxes offers treatment intervention software, Apogee . Coming in 2022, it will have a diagnostic decision tree for its users.

Integrating Assessment Measurements and Treatment Planning

dan.thorne@praxesmodel.com (Dan Thorne) — Fri, 05 Nov 2021 21:27:26 GMT

Behavioral health practitioners use assessments and treatment planning functions throughout their clinical services with a client. It happens in the beginning when a client first enters care. The assessment process consists of interviews plus the use of measurement tools to gather precise information about the client. Then with this knowledge, the diagnosis is acquired and the practitioner moves on to the treatment planning, continuing to re-assess and update the treatment plan.

However, most practitioners consider the assessment and treatment processes as two separate phases rather than as one. Measurement tools such as the Beck Depression Inventory or the Child and Adolescent Needs and Strengths (CANS) provide valuable data for the practitioner about the client’s functioning. But why is there no connection between this data and the treatment options? And if there is a connection, why is so much left up to the practitioner’s knowledge and why does the tool’s result directly integrate with the treatment?

For example, suppose a youth enters treatment who has a history of trauma. The practitioner administers the UCLA PTSD Reaction Index (PTSD-RI) to the youth. Through the measurement tool, the practitioner then may use it to develop a diagnosis of Post-Traumatic Stress Disorder (PTSD) and that the youth’s functioning in school or at home is impaired by their trauma memories. Now when it comes to treating the youth, they may turn to different modalities of treatment. Trauma-Focused Cognitive Behavioral Therapy , Eye Movement Desensitization, and Reprocessing , or Seeking Safety are some of the more popular evidence-based treatments.

However, when a practitioner develops their treatment plan, all they may put into the interventions are, “Use TF-CBT with the client.” “Provide coping skills with Seeking Safety.” The client does not necessarily get their specific issues dealt with. As an example, in the PTSD-RI, one of the statements is “I have trouble going to sleep, wake up often, or have trouble getting back to sleep.” How are the treatment modalities going to specifically deal with that behavior? There is an assumption that sleeping will improve once the trauma is dealt with, but that doesn’t always happen. Shouldn’t there be a connection between the problem (sleeping) and the solution (ways to remove barriers to sleep)?

By having an integrated system that takes the answers from a measurement tool and then turns them into treatment interventions, the practitioner directly engages the client in the problems that are of most concern to them. This approach leaves less guesswork to the client and more success in treating them.

Praxes’ treatment software, Apogee , generates treatment interventions from assessment measurements such as the CANS and the Pediatric Symptom Checklist. For more information, please contact us.

Behavioral Health Budgeting in 4 Easy Steps

dan.thorne@praxesmodel.com (Dan Thorne) — Fri, 05 Nov 2021 21:21:33 GMT

Budgeting for behavioral health organizations can be unlike other financial forecasting activities. This especially is true when working with governmental agencies. Most budgets only focus on expenses and revenue, which is pretty clear cut. But when a behavioral health agency contracts with a State or County entity and government funds such as MediCal/Medicaid or Medicare are used, then the budget is a cost-reimbursed one. Most budgets focus on reimbursement based on a fee schedule. For example, a provider sees a client, and then they are paid a fee for that service. The contract then outlines the payments based on the services provided.

A cost-reimbursed budget has three moving parts:

1. The revenue or billing that the behavioral health organization expects to conduct during the contract period, say a year. The budget will have a total amount of revenue that can be billed for the year.

2. The revenue will also have a rate per unit (minute hour), depending on the governmental agency’s requirements. In behavioral health, the rate for mental health services could be $3.00 per minute or a total of $180 per hour.

3. Then there are the expenses for providing that contract over the year. This area includes salaries, administrative overhead , building lease, office expenses, and other areas.

When an agency gets a contract amount, the costs have to equal the revenue, so that there is a balance of services and expenses. For example, if a contract is for $1 million, then the agency should bill that total and also have that amount of expenses. And in using the rate per minute, they need to serve the number of clients the contract wants. At the end of the contract year, the behavioral health organization does a cost report showing their costs and revenue. Depending on the results, the organization could owe the payor money or vice versa, which neither side wants. So getting the budget right is critical.

So how does an agency work all these moving pieces?

1. Start with the revenue. If your agency has a $1 million contract, you figure out your rates per minute. If, as above, all your services were $3.00 per minute, that’s $1 million divided by $3.00 or 333,333 minutes; then divided by sixty it’s about 5,555 hours of people power to bill that amount.

2. How many staff to bill? If your staff do 20 hours per week in billable hours for 48 weeks of the year (take out 4 weeks for vacation, sick, and holiday time), that means each staff bills 960 hours per year. That figure divided into 5,555 means 5.79 full-time equivalents or about six staff.

3. Add expenses. Now you can calculate the staff salaries, benefits, and the other expenses as above. And it should add up to a total of $1 million.

4. And adjust. Budgets never calculate accurately the first time. Here is where you change staff hours, positions, and expenses. Then when you’re done, everything will work; you’ll have the staff needed to bill the $1 million and the expenses to equal that amount.

Praxes provides consulting services including budgeting and forecasting. For more information, please contact us.

Growth or Fixed Mindset in Leadership

dan.thorne@praxesmodel.com (Dan Thorne) — Thu, 28 Oct 2021 21:04:04 GMT

With the ever-changing climate in behavioral healthcare, leaders need to develop growth mindsets. This means changing the way they see the world, its challenges, and its shortcomings.

Dr. Carol Dweck, a professor at Stanford University, published her book, Mindset, The New Psychology of Success in 2006. Her premise was that individuals develop different perspectives of the world, either fixed or growth. Those who professed a fixed mindset were not risk-takers and preferred to keep the status quo in their companies. They limited themselves to what they knew. Moreover, when problems occurred, they blamed others and took little self-responsibility for their actions. In reviewing company leaders, her book listed those (including Enron Energy from the early 2000s) as examples of people unable to change or those who gave up.

We see this attitude in many behavioral health companies. Through regulation changes and COVID, we hear of leaders complaining about how unfair it is to adapt. In one webinar I recently heard, an executive stated, “We were told in the past that we were responsible for aftercare; now it’s being taken away from us. Why can’t anyone make up their minds?” It’s a common theme in meetings and conferences. Listen to those who, instead of embracing change, criticize it. That behavior is the sign of someone who wants to live in the past when healthcare will always be rapidly shifting.

In the article in the Harvard Business Review in 2016, Dr. Dweck wrote,

“Individuals who believe their talents can be developed (through hard work, good strategies, and input from others) have a growth mindset. They tend to achieve more than those with a more fixed mindset (those who believe their talents are innate gifts). This is because they worry less about looking smart and they put more energy into learning. When entire companies embrace a growth mindset , their employees report feeling far more empowered and committed; they also receive far greater organizational support for collaboration and innovation. In contrast, people at primarily fixed-mindset companies report more of only one thing: cheating and deception among employees, presumably to gain an advantage in the talent race.”

What can the behavioral health industry take from this point of view? Growth and change in organizations need to be evaluated, studied, and planned for. Mistakes will be made. Look at all the companies that are frustrated by their difficulty in hiring new talent. But through any change, those with growth attitudes keep trying and make progress rather than whining about the past.

Praxes provides consulting to behavioral health organizations in areas such as employee performance and change management. For more information, please contact us.

What Providers Want From an Electronic Health Record

dan.thorne@praxesmodel.com (Dan Thorne) — Thu, 28 Oct 2021 21:01:33 GMT

Are most behavioral health organizations happy with their electronic health record system (EHR)? Recently, Open Minds conducted a National Behavioral Health EHR Survey . They asked over 8000 behavioral health provider organizations, including small ($1-5M annual revenue) organizations as well as large organizations (over $5M). The four areas they reviewed were the clinical, scheduling, billing, and reporting/analytics functions of EHR's. Their results were broken into four categories:

1. Above 25% of providers were going to purchase an EHR soon, including 21% who wanted to switch their EHR. Of those agencies that had not purchased an EHR yet, the main reason was that it was too expensive.

2. Of those who had an implemented EHR, almost 2/3 of the responders stated it took between 3-12 months to fully implement their EHR systems. The main reason that those systems were not fully implemented was that the EHR's functionality was not what the customer needed.

3. While over 53% of the organizations stated have stayed with their current EHR because it meets their needs, the rest found other reasons to not change. 25% of companies stated concerns with implementation challenges, such as more cost and staff time.

4. Organizations stated that the functionality of their EHR was not meeting their company’s needs.

The major concerns in this area were the EHR's ability to have client portals, mobile functionality, value-based reporting, electronic visit verification, and telehealth capabilities. While the systems met companies’ clinical, scheduling, and billing needs, reporting and analytics still needed improvement.

Why the dissatisfaction with EHR’s?

There is a trend among EHR's to decide what is important to behavioral health organizations. For most EHR customers, offering the basics of documentation, scheduling, and billing gives them the primary tools they need. But when it comes to analyzing the data, making sense of the customer’s population, and running reports, EHR’s fall short. One large county currently in California can’t run reports because its nationwide EHR can’t run them, hasn’t been able to for months, and doesn’t see a timetable for correction. Another EHR is asked frequently by its customers to assist with obtaining data and is told, “We just can’t do that.” And finally, when customers want to add functionality to their systems, such as clinical decision making or treatment software capabilities, EHR's simply aren’t listening.

The EHR industry seems to be dictating what customers need, rather than the other way around. But changing an EHR is liking moving; too complicated and hard to find another home. Should a customer be satisfied with an inept EHR? Hopefully, more behavioral health organizations will demand changes to their existing systems or look elsewhere. Otherwise, surveys like the one from Open Minds will continue to show how the EHR business doesn’t meet their client needs.

Praxes offers treatment software for its clients, for more information, please contact us.

Are You a Controlling Boss?

dan.thorne@praxesmodel.com (Dan Thorne) — Fri, 22 Oct 2021 19:57:39 GMT

The Great Resignation is the chief headline in the news today about employee retention and performance. According to the Harvard Business Review , employees between the ages of 30 and 45 have the greatest increase in resignation rates. That is the prime age for behavioral health staff, those who finish their undergraduate or masters’ programs and start their careers. While many employees quit due to the need to reexplore their health and careers, one can’t help but think if it’s the boss that is the reason.

Managers and supervisors’ primary job is to improve the performance of those under their tutelage. They get the credit and the blame for their subordinates. For most managers, it would be wise to empower employees , because a Gallup study found “when an organization focuses on individual strengths, employee engagement increases from 9% to 73%”.

However, many bosses can’t do that. They have a problem with control. It’s got to be their way or the highway. They can’t let go of their organization. Or they set up situations where the employees are offered the illusion of independence and decision-making, only to put them in positions where it is taken away from them.

According to LifeHack , here are 10 signs your manager is controlling:

· They Use Fear To Achieve Their Goals. ...

· They Think They Know Everything. ...

· They Treat People As Pawns. ...

· They Dominate Meetings. ...

· They Take A “My Way Or The Highway” Approach To Conflict. ...

· They Ignore The Competition. ...

· They Never Practice Active Listening.

· They Focus on The Short Term

· They Never Inspire People with Their Own Example

· They are Unable to Work through A Crisis

Why does this happen? As pointed out above, they can’t let go of responsibilities that belong to other people. Here’s a real-life example:

Company ABC, which I consulted, has an executive director who wanted to have their employees become more independent. They complained that everyone came to them for answers to questions when they should have learned their tasks through training or asked others. They requested help to get employees more independent, through training and engagement in developing new policies. However, during work with the executive director, it became apparent that the employee improvement wasn’t going to happen. Because the executive director wanted to “micromanage” any changes to policies and procedures. Moreover, they eavesdropped on employees’ responses during training videos, showing a lack of trust in employee feedback. The executive director had good intentions, but they were unwilling to let employees make mistakes and learn on their own. As a result, leadership positions at the agency were a revolving door because they couldn’t take the extreme oversight of their boss.

If you show signs of the controlling behaviors above, it might help you discover what causes you to act this way and whether you need to do some self-examination. If not, your company suffers and so do your employees.

Praxes offers training and consulting services for behavioral health organizations on improving performance. For more information, please contact us.

College Readiness, Foster Youth, and MI – Partners in Success

dan.thorne@praxesmodel.com (Dan Thorne) — Fri, 22 Oct 2021 19:54:19 GMT

Foster youth face significant obstacles in developing college and career opportunities. But some of the major barriers are their own perceptions of their future. Can Motivational Interviewing (MI) help them?

According to Honoring Emancipated Youth (HEY), the following statistics apply to foster youth:

• Foster care youth’s overall developmental delay is 6 times greater than the general population.

• 2/3 of young women formerly in foster care are mothers within 5 years of leaving foster care.

• 25% of emancipated youth are homeless.

• Youth with early unemployment are more likely to have lower future earnings and repeated joblessness.

• 80% of foster youth did not earn enough to be fully self-supporting 4 years after leaving care.

Although many programs exist to help foster youth, such as the Chaffee Grant and other services, this may not be enough for the youth. Many youths come from families where no one graduate high school, let alone went to college or a trade school. From years of abuse, trauma, and multiple placements, their self-view is not one of a positive future. When a foster youth doesn’t want to face the future, hasn’t positive attitudes about a career, how can a social worker get to them to even talk about opportunities?

One option is to use MI techniques, such as “Change Talk. There are four elements that a practitioner can apply that reduce a youth’s resistance to change and discuss their career-building skills:

1. The Status Quo – at the moment, many foster youths may be unhappy with their lives, but don’t want to change or make efforts. Talking to them about the disadvantages of their current beliefs, their worries, concerns, and the consequences of these actions aid them in being ready to adapt their beliefs.

2. The Advantages of Change – pairing the disadvantages of doing nothing, the practitioner talks about what happens if the youth tours a couple of community colleges or seeks a career. They also discuss what they want life to be like in 5,10, 20 years.

3. Optimism for Change – the practitioner asks the youth about times in their life where they made changes for the better. Recalling past successes bolsters the youth’s ability to see change as possible.

4. The Intention of Change – ask a youth on a scale from 1 (not at all) to 10 (extremely) how likely they are to have a career or go to college. Once there’s a number, the practitioner can ask why they choose it and what it would take to increase it to improve their intent to change.

Praxes offers courses such as College and Career Readiness and Motivational Interviewing. For more information, please contact us .

Policies and Procedures: What’s In Your Manual?

dan.thorne@praxesmodel.com (Dan Thorne) — Thu, 14 Oct 2021 19:20:04 GMT

Policy and procedure manuals are like trophies: people collect them, and then after a while, they simply take up space. If a person walked into your office or saw you in a Zoom meeting, how many policy manuals would they see behind you? It’s common to have 10, 20, or 30 manuals, all addressing different topics or departments.

Having a lot of policy manuals may make a leader feel important or valuable, but they are no longer necessary. But here are a few questions to ask yourself about your manuals:

1. Is it valuable if the information is outdated by months or years and gathering dust?

2. If no one is going to look at the manual, whether they be the leader, an employee, or a regulatory agency, why is it there?

3. If someone is going to look at it, is it concise and organized?

4. Can it be streamlined, uploaded to a server, or consolidated with other manuals?

5. If someone important (regulatory or accreditation-based) looked at it today, would you receive deficiencies due to inaccuracy or missed requirements?

If your organization is part of a large corporation that requires you to have certain manuals for Safety, Human Resources, Infection Control, etc., then it might be out of your control. But it couldn’t hurt you to suggest that the powers that be that killing all the trees for paper is not necessary and they can be stored on a server. The only time many organizations need the manual is when a surveyor is there, and then it can be printed out for them. Otherwise, the manual can be stored in a cloud or the server.

Suppose your office has a manual for Medi-Cal or Medicaid; a manual for an accreditation agency such as Joint Commission, CARF, or COA; and a manual for the staff. Shouldn’t they somehow be put together? There are common threads between the different requirements. Rather than having two policies for treatment plans, couldn’t your organization take the verbiage that both CARF and the County or payor need and combine them into one?

Most organizations look at this work and decide to put it off. Until they need it and it’s way too late. But if you do a little at a time, just work on one section a week, it can make a difference. It’s like when your child or teen’s room is very messy and tell them to clean their room. They look at you and wave their hand (or worse) and don’t do anything. But if you work with them doing one part of the room today, another part the next day, it doesn’t end up a huge chore.

What’s in your manual? Is it information you and your staff need? The adage is: if you haven’t read it in a year, and no external agency needs it, toss it. It’s not necessary and no one will miss it. When you’re ready to educate your staff about the manual’s contents, they will be happier to use it if it’s informative, helps them do their job, and avoid making mistakes.

Praxes provides consulting on policy and procedures as part of its consulting services . For more information, please contact us .

Learn about Cultural Diversity from a Culturally Unified Organization

Thu, 07 Oct 2021 22:57:59 GMT

Behavioral health organizations have difficulty implementing cultural diversity and inclusion plans. Business magazines report daily on how to create this type of environment. Hire more persons of color. Be more inclusive putting people in leadership from different cultures, sexual orientation/gender, or intersectionality. But the more the print media makes suggestions, the less likely things change.

On this Indigenous Peoples’ day of 2021, I thought it would be beneficial to back away from the pressure of cultural diversity and explore the converse principle. Instead of looking at cultural awareness of different cultures, what would it be like to work for a culturally unified organization? At Praxes, we currently work with a Native American tribe. The tribe’s council is setting up a behavioral health clinic to provide services for tribal members. Praxes is helping them become CARF accredited and Medicaid providers in their state. One task in our project was to write a cultural competency plan for them.

Developing mental health services for Native Americans is a large undertaking. They have a higher percentage of unemployment, incarceration, poverty, violence, historical trauma, substance use, and other mental health problems than any other cultural group. Yet for them to achieve their mental health requires a blend of traditional mental health approaches coupled with the customs, legends, and traditions of their tribe.

Doing a cultural plan for the tribe is about diversity and unity simultaneously. Because everyone, although they have differences, will be from the same culture, heritage, and ancestry. So their plan, as a homogenous group, does away with the differences between people and focuses on their similarities. So that the plan includes the following areas:

1. Hiring people who understand the culture and needs of the tribe.

2. Having leadership who belong and participate in the tribal community.

3. Treating everyone with respect and understanding of the tribe’s customs and traditions.

4. Working with community organizations and partners.

5. Participating in or supporting cultural events.

6. Training staff to understand the culture.

7. Helping clients connect to their tribal values, land, and family.

If you review these principles, they work well for the employees, clients, and community of the tribe and their council. But if you extrapolate these principles to diverse populations, you will see they also apply. Because an organization cannot be culturally diverse unless it is culturally united in its values.

Praxes provides program development and accreditation as part of its consulting services . For more information, please contact us.

Documentation – The Ends Justify the Means

dan.thorne@praxesmodel.com (Dan Thorne) — Thu, 07 Oct 2021 22:23:24 GMT

At Praxes, we just finished conducting training for an organization in Southern California on conceptualizing and formulating documentation. In doing so, we helped the attendees improve the ways they viewed a case, how they perceived the problems, goals, and interventions, and what goes into a clinical record.

Along the way, we explored what should or should not be done in a treatment intervention. This goes to the old adage, “Do the ends justify the means?” In other words, can a practitioner do anything they want with a client during a treatment session and still bill it as a service?

The answer is yes (with one notable exception), as long as the outcome of the session is to cover a client goal originating from their assessment and treatment plan. To justify medical necessity, the practitioner must show that they are working to a) improve the client’s functioning, b) prevent deterioration of the functioning or c) help the client progress developmentally. This comes from the Los Angeles County Department of Mental Health’s Provider Manual of 2020.

Let’s give an example of two options:

Option A: Andrew takes Josh to the park where they play soccer.

Option B: Andrew wants to improve Josh’s frustration level. He stands about ten feet away and kicks the ball to Josh, who has to kick it back. Every third or fourth time, Andrew kicks the ball away from Josh, so Josh has to move to get it (within a reasonable distance). Josh learns how to move and improve his frustration level.

I s either of these billable services and why?

The answer is that Option A is not billable and Option B is. Although they are engaged in physical activity, Andrew the practitioner has a goal in mind. He wants to decrease Josh’s (the client’s) frustration level. Perhaps since Josh learns by moving around and likes to play soccer, Andrew is using a soccer ball as the means to help Josh tolerate being annoyed and irritated. He kicks the ball to Josh a couple of times, then mixes it up where Josh has to move around or chase the ball to retrieve it. This maneuver is Andrew’s intervention. Then Andrew observes what Josh does when he has to get the ball. If he gets angry, how does he manage that anger? Hopefully, over time, Josh will not be as upset and calmer, knowing that things don’t always go his way (literally). When done, Andrew sees if the approach works, and can even count the number of times Josh is upset or the intensity of these events. He evaluates the intervention and can use it again or try something else.

Kicking a ball, playing a game, any sort of activity (except watching a movie or television show) can be an intervention, as long as it is conducted with a purpose or goal to reduce or increase specific behaviors. Being creative with treatment strategies can improve client engagement and treatment outcomes.

Praxes provides training in Documentation. For more information about our training courses, please contact us.

High-Risk Behavior Management for Office Staff

dan.thorne@praxesmodel.com (Dan Thorne) — Thu, 23 Sep 2021 20:08:53 GMT

Does your office staff know how to handle high-risk behavior?

Here are some examples:

A youth runs out of the waiting room, ready to walk into a busy street.

A distressed parent calls on the phone because a therapist filed a child abuse report on them.

A child yells because her mother isn’t at the office yet for their visit.

A homeless woman enters the office and without talking proceeds to pick up and drop magazines on the floor.

Your agency’s mental health clinicians are trained to handle these types of situations. They go through school to learn how to handle crises. They have the skills to calm down clients.

But does your receptionist? Your billers? Quality assurance? Other office staff? Those without the training? What do they do?

The best way to help them is by giving them a lesson in customer service.

Think about the best and worst people you’ve experienced in customer service. On the phone or in person. How did they speak to you? What was their demeanor? What did they say? Were they humble or arrogant?

How people handled you at a time of crisis (albeit maybe not psychological) made a difference in how you responded. A calm and reassuring person who listened to you and tried to help as quickly as possible. Someone who made you feel heard and important. Who apologized and took responsibility for mistakes.

These are all the qualities you want your office staff to have when trouble happens.

Our clients come to social service agencies mostly when their life is in shambles. The child has trouble in school, at home, in the community, with the law. The family may be turbulent, involved in violence, or other aggressive behavior. Their home lives may be tumultuous. But even so, getting help from a counseling clinic, foster family home, or other agency is up there with going to the dentist. Admitting mental health problems makes families face the stigma of illness. They also have their home problems brought to the agency. And their difficulties managing stress.

Staff sees them at their worst. When they face the ordeal of getting treatment. Therapists understand this and work with the families using therapeutic techniques.

The office staff is not taught those skills. But they can learn.

By being calm and using a soothing voice. By meeting the client where they’re at. Acknowledging the client’s troubles. That they’re upset. That they need answers quickly.

Just as we teach our staff Motivational Interviewing techniques such as affirmations and reflections (i.e., rephrasing what the client is saying, acknowledging their emotions, etc.) we can teach our office staff the same. Meeting the client where they’re at. Not downplaying or denying the client’s pain or trouble. But trying to help them get answers.

And doing their best to make it happen. Keeping the client informed every 15 minutes if there’s a delay.

Teaching office staff to handle crises helps to keep harmony with clients and families. It also reduces their burnout and frustrations, making them feel part of the treatment team.

PRAXES offers many training programs, including High-Risk Behavior Interventions for Office Staff.

For more information about a specialized program for your organization, please contact us.

3 Myths about the Autism Spectrum

dan.thorne@praxesmodel.com (Dan Thorne) — Thu, 23 Sep 2021 20:01:06 GMT

Despite all the new information about the autism spectrum, there are still a lot of myths and misunderstandings about the condition.

With the 2013 version of the Diagnostic and Statistical Manual of Mental Disorders, the three categories of “Autism”, “Pervasive Developmental Disorder”, and “Asperger’s Syndrome” were erased. The new perspective in reviewing those individuals with extensive difficulties in communication and behavior is that their behavior ranges in severity. Which is a good thing for agency professionals working with those on the autism spectrum, as each person has individual needs and solutions.

Because each youth or adult on the autism spectrum is like a combination lock. Each lock has different numbers which, in combination, allows one to unlock it and open it.

In the same way, each youth or adult on the autism spectrum perceives the world differently. One may be fascinated to the point of perseverating about cars, another about machines, another about newspapers, etc. To have a boilerplate approach to them won’t work. It helps to have a structured approach such as applied behavior analysis, which focuses on which behaviors create problems for the person and which to resolve.

To help with the public and professional concepts of autism, the here are some myths on autism. Here are three of them:

People with autism can’t understand the emotions of others. Those on the autism spectrum have difficulties managing their own emotions and at times don’t understand the communications of others. There are certain things they don’t comprehend, like non-verbal language. It’s hard for them to grasp sarcasm, a shrug of the shoulders, a joke, or a heavy sigh. But when someone gives them direct communication, such as crying and feeling sad, or laughing, this is understood. This helps when professionals and parents work with the person to make sure they are looking directly at them and conveying their words and mannerisms in sync.

Autism is just a brain disorder. It is common for people with autism or on the autism spectrum to also have other health conditions. For instance, gastrointestinal disorders such as acid reflux can occur. In addition, food or other allergies may affect them as well. Sometimes those on the spectrum also may have seizure-type disorders and need medication. When evaluating a person with autism, it is important to also know their medical health and coordinate care with their physician.

People with autism are like Freddie Highmore’s character in The Good Doctor . The idea of a spectrum now means that each person has their behaviors, perspectives, talents, and characteristics. This actor portrayed someone with autism who also has what’s known as savant syndrome, which means that they display certain capabilities (in this case, medicine) far more than the average person. While some on the autism spectrum may have some remarkable abilities, it does not apply to each person.

The key to all these myths is that each person on the spectrum should be considered as an individual. Treated as one and have their special plan which may work for them and not necessarily for others.

To get information on other myths, here’s an article from Nevada’s Department on Aging and Disability Services.

If your organization would like more information about PRAXES’ training, please contact us.

Why Sexual and Reproductive Health is a Priority to Foster Youth

dan.thorne@praxesmodel.com (Dan Thorne) — Thu, 16 Sep 2021 21:53:53 GMT

When youths turn the corner of adolescence, physically and emotionally they start the path toward relationships and sexual health. How prepared they are to have discussions about these topics depends on many factors. According to the World Health Organization , “Sexuality is influenced by the interaction of biological, psychological, social, economic, political, cultural, legal, historical, religious and spiritual factors.”

For most youths, their families and surroundings guide their conversations about sexuality and reproductive health. But for foster youth, barriers exist to these communications. Due to experienced trauma, multiple placements, and lack of consistent adults in their lives, these youths don’t have the same discussions as other youths.

Here are some reasons why sexual and reproductive health are priorities to foster youth:

1. Pregnancy. In a report by Chapin Hall at the University of Chicago , 71% of foster females experienced pregnancy by their 21 ^st birthday, compared to 34% of non-foster females. 49% of foster males indicated they had gotten someone pregnant by age 21 vs. 19% non-foster males. Putting youths in the position of early pregnancy creates significant stress for the expectant mother, making life decisions at an early age of keeping a child, abortion, or giving the child up for adoption.

2. Unintended Pregnancy. The same Chapin Hall report indicated that, of the foster youths that experienced pregnancy, 70% of foster females and 66.3% of foster males stated the pregnancy was not intentional. This shows that many foster youths have irrational beliefs that, “It can’t happen to me,” or lack the knowledge and resources for birth control.

3. Sexually Transmitted Infections. According to several reports for the Centers for Disease Control (CDC), by the time they are 26, 44% of foster females contract sexually transmitted infections (STIs) vs. 23% of non-foster females, and 18% of foster males contract STIs vs. 11% of non-foster males. Foster youths who are sexually active are not aware of the infections that can occur and how to protect themselves.

Communicating to foster youths about sexual health is not an easy chore. Because of their family and cultural backgrounds, discussing sex may be taboo or bring shame to them. Moreover, youths with trauma, especially sexual abuse may be triggered by the discussion of sex. Staff working with foster youths need to work in concert with caregivers and the youths in providing them information, resources, and guidance. Helping youths develop a healthy understanding of relationships, love, and consent increases protective factors to reduce violence and further abuse.

Praxes provides a course on Sexual and Reproductive Health. For more information, please contact us.

A Long Term Approach to Child Welfare Care

dan.thorne@praxesmodel.com (Dan Thorne) — Thu, 16 Sep 2021 21:39:43 GMT

Child welfare care in California is a tale of how governmental agencies tend to look at the short-term solution rather than the long-term plan. Here is an example:

In 2015, Governor Jerry Brown signed AB 403 into law. Known as the Continuum of Care Reform, the goal was to reduce the number of placements a child would have in the foster care system. Also, the bill wanted the child and their family to have as much of a voice in the process.

These principles were not new, but how the State of California administered them changed. As part of the Continuum of Care Reform, group homes for foster youth were to be converted into Short Term Residential Therapeutic Programs, or STRTP’s. Instead of warehousing youths for years who could be better served in foster homes or with family, the new STRTP’s would take youths with more severe emotional problems. Each facility had to develop new guidelines for its programs. All facilities, regardless of size, were to be considered for a new license from the Department of Social Services. However, many facilities decided to close or were denied their licensure. As it turned out, most of these facilities were small, 6-bed homes. As these small homes, they lacked the resources and clout of larger facilities who were handed their new STRTP licenses. Subsequently, many good programs closed altogether or sought different licensures.

Turn to 2018. The Federal Government passed the Family First Prevention Services Act (FFPSA). In it, the federal government, as with AB 403 above, required youths to be placed with their families and avoid being in the foster care system. But with this new legislation came the guideline for the Qualified Residential Treatment Program (QRTP). While similar to the STRTP above, it has one major distinction. If a facility has over 16 beds, it can be classified as an Institution for Mental Disease (IMD) by the Federal Centers for Medicare and Medicaid Services. If it is classified as an IMD, it may not be eligible for Medi-Cal funding which could jeopardize the care its youths receive.

The point here is that six years ago, larger STRTP’s survived as a result of the State’s unintended consequence of emphasizing larger programs over smaller ones. Now in 2021, this priority has turned out to limit these large facilities and favor smaller ones. If residential facilities are to be successful as placements for youths who cannot thrive in a home setting such as their parents or a foster home, more effort and thought must be given about what these homes will be in 10 to 20 years.

Praxes provides consulting and program development to behavioral health organizations, including STRTP’s. For more information, please contact us.

Employee Retention - What Are Your Employees Worth?

dan.thorne@praxesmodel.com (Dan Thorne) — Fri, 10 Sep 2021 17:17:06 GMT

If you’re the head of your organization, keeping your employees happy and engaged leads to higher retention.

Social service organizations, like other healthcare firms, cannot afford high turnover. Not only does the turnstile of unhappy employees create higher levels of anxiety and stress for those remaining, there’s also a cost factor. Some organizations take it seriously, identifying the causes of employees leaving, while others shrug their shoulders and say, “It’s the nature of the business.”

If you’re the one who’s counting the dollars and cents, it helps to look at the financial drain on your organization if you have high turnover.

An article by Christina Merhar on the website PeopleKeep outlined “The Real Cost of Losing an Employee.” In it, she talks about the how satisfied employees help organizations to thrive. But that “voluntary turnover has a negative impact on employee morale, productivity, and company revenue.” This is because finding new employees requires a great deal of effort.

Merhar also discusses where the costs for hiring go:

Recruiting - the time it takes to run an ad, either in the paper or online, or find a recruiter to help. Then the countless resumes, interviews, second and third interviews. Not to mention background checks, references. And then agreeing on a salary (if what you offer is agreeable to the candidate). Especially in today’s labor market where unemployment is low, candidates can afford to compare offers and hold out for a better salary. It’s definitely a “candidate’s market”, not an employer’s.

Training- there is the time which is required to help employees learn all that is needed. The orientation to the organization, the policies, their department, their job and duties. And then there is shadowing which may be required as they learn the ropes from others. Not to mention ongoing training and re-training. Businesses invest 10-20% in training, and in many social service organizations, it’s more because of contractual requirements (evidenced based practices, special programs).

Lost productivity- thinking about the amount of time it takes an employee to reach the level of productivity of an existing person. Depending upon the job, it takes an average of 6 months for an employee to feel they’ve got the job understood.

Lost engagement - other employees are influenced by those who leave. They tend to lose interest, be less involved, and this lack of engagement leads to less productivity Especially in jobs where teams are involved, because the employee doesn’t feel they have a “go-to” person they can trust.

Back to the costs.

According to the website Enrich , when a business replaces a salaried employee, that costs between 6 to 9 months of salary. If a manager or supervisor makes $60,000 per year,, that means it could cost the organization between $30,000 to $45,000 in both recruiting and training costs. The higher in salary and responsibility the higher the costs, such as even twice annual salary.

For low paying jobs, the costs are less, probably around 16% of an annual salary. So if you have an employee making $15/hr. , the costs are about $5,000.

What can you do?

Look at why people are leaving. Do exit interviews.
Involve employees in the workplace environment. Ask what they need to be productive. And if it’s due to administrative problems or interpersonal issues with managers, fix the problem.
Sometimes it’s a simple as more employee recognition. A “thank you” or “good job” can be as satisfying as extra pay (well, almost).
Provide more training. Employee burnout leads to unsatisfied employees who want to go elsewhere.

Put the costs on your side; find ways to keep your employees retained.

PRAXES offers consulting services to social service organizations, including human resource management.

For more information, please contact us.

Shaking Off -Teaching Children How to De-Stress

dan.thorne@praxesmodel.com (Dan Thorne) — Fri, 10 Sep 2021 16:43:47 GMT

Children at the elementary school age have as many problems with stress as their older counterparts. Because for them, like us as adults, stress is any situation that creates a significant change for them from what they normally expect. Getting bullied, losing a game, getting poor grades are some examples. And for other children, it can be more severe leading up to traumatic-based stress. Parents arguing, violence, abuse, or a lot of uncertainty can affect their ability to manage their lives.

Because children cannot verbalize their stress like their older siblings or their parents, their chief solution is to somaticize their emotions. Stomach aches, muscle tension, getting sick more frequently are some of the symptoms of their stress. If the child does not have the tools to manage their stress, they may start feeling more depression or anxiety inwardly. Or they may start to act aggressively towards others, getting in verbal or physical fights. All are ways to deal with problems, but not in healthy manners.

Talking to children about stress at this age can be difficult. But one way to help them is to teach them how to “shake off”. If you’ve ever watched dogs or other animals, they use shaking as a way to regroup or ground themselves after fighting or a stressful moment. They shake themselves back and forth to re-establish an equilibrium.

For a child, they can learn to stand up with their legs slightly apart. Then they can start to take their arms and shake them up and down, back and forth. After this, they can do the same with their torso, legs, and their whole body for a few seconds. The sensation of shaking works as a way to tense and relax the muscles in the body simultaneously. And this is an activity a child can do almost at any time they’re upset.

For another example, watch Qigong expert Lee Holden show ways to Shake Off Stress.

Praxes provides training on its Intensive Child Model, designed to reduce stress and improved behavior for elementary-age children. For more information, please contact us.

3 Ways to Deal with the Great Resignation

dan.thorne@praxesmodel.com (Dan Thorne) — Thu, 02 Sep 2021 18:21:05 GMT

Last week, I was participating in a Zoom mixer with Associate members of the California Alliance of Child and Family Services. While discussing the challenges of hiring employees, one of those attending indicated that recruiting and retaining employees will take a hit in the next year. He mentioned “The Great Resignation” as a major factor with employees.

Not having heard of the term, I decided to do some research. And what I discovered should make leaders very concerned. The Great Resignation is now a term to describe the impending aftermath of the pandemic. Here’s an article from Forbes that goes into further depth.

How does the Great Resignation affect the behavioral health field? According to an article from Microsoft , 40% of the global workforce is considering leaving the employer in the next year. Why? Since 2020, employees working from home or laid off from jobs began to re-evaluate their lives. They looked at their work, the stress of traffic, documentation, long hours, and lack of support from leadership. These individuals found that, although making less money, their lives were more enriched while being away from the pressure cooker of working with clients. Subsequently, they will be making decisions about future employment with little loyalty to their current job site. Values such as job and personal development, along with opportunities for advancement, will keep employees at their desks, be it at the office or the WFA (Work from Anywhere) desk.

The behavioral health field has a long reputation for high turnover of employees even before the Great Resignation. For all the reasons mentioned above, employees wanted a place where their work had meaning, and they were valued for their achievements. To keep employees at their job, leaders need to take a look at the following:

1. Employee goals. What do individuals want from their job? Security, learning, the chance to make a difference with clients. In the past these were true, but now leaders must look at how employees will change their goals. Location, less stress, flexibility will even be more important. But most employees want to advance, either in position, degree, licensure, or recognition. And loyalty is at the bottom of the list. Companies that want to keep their employees need to listen and find initiatives to help employees. Consider that a Gallup poll of millennials and Gen Z found 87 percent “highly value” growth and development opportunities. Sadly, just 39 percent of young employees felt that they had “learned something new on the job in the past month.” Giving them a path to achieve these opportunities will make them want to stay.

2. Training. Employees who aren’t learning or feel overwhelmed by clients tend to leave organizations. This is why giving employees clinical training, knowledge, and the skills to help them with their clients creates value for them in their work. The more they feel they’re helping, the more engaged they become with work and feel a sense of success. Nothing is more satisfying to a clinical worker than having clients stay in treatment and see results.

3. Change the emphasis on documentation and productivity. Although this seems counterintuitive to agency survival, these demands will lead employees to avoid returning to work. Behavioral health professionals come to the field to help people, not feel like they’re constantly having to justify their billing and what they do on paper. Employees feel the pressure of performance, and with the pandemic, more will say, “Why am I doing this?” Companies that focus more on the mission of healing will keep employees.

Praxes offers behavioral health solutions in consulting , training , and treatment intervention software . For more information about our services, please contact us.

Balancing Work-Life in an Unsegmented World

dan.thorne@praxesmodel.com (Dan Thorne) — Fri, 27 Aug 2021 19:12:20 GMT

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Want Better Documentation? Tell a Story

dan.thorne@praxesmodel.com (Dan Thorne) — Fri, 27 Aug 2021 19:09:30 GMT

Many behavioral health professionals find it troublesome to develop clear and concise documents. Assessments, treatment plans, and progress notes take a long time, are ambiguous, and don’t flow. Subsequently, the staff runs into trouble when treating the client and billing for services.

Rather than focus so much on the paperwork, professionals should look at the story the client is trying to tell through their actions and their life. By looking at their lives as a story in a book or a movie, the professional has the foundation for the client’s plan. Since most everyone is familiar with the movie The Wizard of Oz (or its other forms, the Wiz or Wicked), here is a story that shows how Dorothy behaviorally achieves her goals.

Once upon a time, a girl named Dorothy lived in Kansas with her aunt Em and Uncle Henry (family history), along with their farmhands Hunk, Zeke, and Hickory (informal supports). She liked to sing and walk with her dog Toto (hobbies), but she wanted to get away from the troubles caused by her dog going into Ms. Gulch’s yard and decided to run away (problems). But as she tried to do so, a tornado started to touch down (stressor).

While seeking cover, she bumped her head, went into an altered state, and dreamed of a colorful world called Oz (trauma). In Oz, her house hit the Wicked Witch of the East, which created many happy Munchkins (support system) but an evil Wicked Witch of the West (communication conflict). Dorothy felt alone (fears) and only wanted to go back home (goal). Guarded by Glenda, the Good Witch (support), Dorothy was given ruby slippers (intervention) and told to follow the Yellow Brick Road (treatment plan).

While on the road, she was frightened by the animals and characters, but she made friends (objective) with the Scarecrow, the Tinman, and the Cowardly Lion (informal supports). The Wicked Witch of the West tried to poison Dorothy with poppies (stressor), but Glenda stopped this effort by making it snow to wake Dorothy up (intervention). Once at Oz (achievement of goal), Dorothy met with the apparition of the Wizard, who told her and her friends that she could go back to Kansas only if she brought back the broomstick of the Wicked Witch of the West (new objective).

Terrified but brave (stressor), the four companions went to the Witch’s castle (intervention), only to have Dorothy captured by the Witch (stressor). Her friends were able to get into the castle and rescue her (intervention), but they were surrounded by the Witch’s soldiers (stressor). With quick thinking, she took a bucket of water (intervention) and doused the Witch’s broom as she was trying to burn the Scarecrow, and the water made the Witch melt. Thus, Dorothy could get the broomstick (achievement of goal).

When returning to Oz, Dorothy asked to go back to Kansas (assertion skill), only to find the “Wizard” was not who he claimed to be. But he offered her a balloon ride home (intervention) which didn’t pan out. Finally, Glenda (support) told her that the ruby red slippers would take her back if she clicked her heels and said, “There’s no place like home (intervention).” When Dorothy awoke, she was back in her bed, surrounded by her family and farmhands (formal and informal supports), happy to be back in Kansas (achievement of goal).

Praxes provides training and consulting services to agencies that want to improve their treatment planning. For more information, please contact us.

Is Treatment Becoming More Important than Documentation?

dan.thorne@praxesmodel.com (Dan Thorne) — Wed, 18 Aug 2021 20:44:32 GMT

For years, Medi-Cal (or Medicaid) mental health services emphasize the value of reimbursement over treatment. What a practitioner did with a client didn’t matter as much as what they wrote down on paper or in an electronic health record. This strategy could be seen in the stress auditors and governmental agencies put on the documentation. Agencies would have revenue recouped, sometimes in the hundreds of thousands of dollars, because notes weren’t written properly. Subsequently, agencies focused more on the note than the care. As a result, clients weren’t seen, access was stifled, and outcomes didn’t improve.

Now, in California, the Department of Health Care Services (DHCS) is involved in the California Advancing and Innovating Medi-Cal (CalAIM) project. CalAIM has three primary goals:

Identify and manage member risk and need through whole person care approaches and addressing Social Determinants of Health;
Move Medi-Cal to a more consistent and seamless system by reducing complexity and increasing flexibility; and
Improve quality outcomes, reduce health disparities, and drive delivery system transformation and innovation through value-based initiatives, modernization of systems, and payment reform.

Recently at a meeting of provider agencies in Los Angeles County, further information was discussed about proposed changes to Medi-Cal mental health services. These changes include the following:

Allowing reimbursement of treatment services before the diagnosis is made. Previously, treatment could only begin after the practitioner made a diagnosis. Because diagnoses sometimes took weeks to determine, the treatment process was delayed; this change would expedite care.

Creating criteria for children to access services based on the experience of trauma and risk of future health conditions. Now clients would qualify for services not only if their conditions posed a functional impairment, but if they were at high risk of these impairments.

Change documentation so that:

Treatment plans would be replaced with problem lists. With a problem list, the verbiage to discuss goals, objectives, and interventions would be substituted with a checklist of symptoms or behaviors to address in care. This would reduce documentation time significantly.

Progress notes would no longer tie to the treatment plan but reflect the care and the billing codes. The practitioner could focus more on the client’s care at the moment than documentation.

Auditing would focus more on fraud, waste, and abuse, instead of documentation. The wrong note would be considered a “teachable moment” instead of recoupment.

All these ideas take documentation and give it a back seat to the real reason most providers got into the business; to help heal the clients that are served. If DHCS goes through with these ideas, it will be the biggest and most advanced change in over 30 years, leading to more clients being served and improved treatment outcomes.

For more information about Praxes' services in consulting, training, and treatment software, please contact us.

Adolescent Hindsight

dan.thorne@praxesmodel.com (Dan Thorne) — Thu, 12 Aug 2021 19:15:21 GMT

If adolescents could have hindsight about their actions, what would they change? Being an adolescent brings with it many exciting adventures. New opportunities to become independent, think about careers. And along with these bright spots come many dark clouds.

Risky behavior. Looking past the consequences and more at the thrill. This is why adolescents have higher rates of car accidents and suicides than other age groups. And also why they are more inclined to abuse drugs and alcohol. For the adolescent brain, impulses rule. So do emotions, thanks to the increased development of the amygdala. This is the brain’s center that controls emotions. And in the adolescent brain, responses to the world’s events are ratcheted up to new heights.

Wouldn’t it be great if youths could go back and look at their behavior? Or that of friends or others. And say, if they had to do it all over again, what would they do? Learning why adolescents do risky things not only involves the actual behavior. It also concerns the driving force behind the behavior. Knowing what they want helps to change the behavior.

For instance, a young woman sneaks out of her house to meet up with her boyfriend. Let’s just say they’re going to “hang out”. And skip the personal details. What is her need? Is it to be with her boyfriend? Or is it to show her parents she’s independent? Or even to express her anger with them? There are other ways to help her show independence or her emotions than sneaking out. Helping her do these improve her coping skills. And may reduce risk-taking behavior.

Suppose a young man was thinking of going with his friends. Someone had crystal meth and the friends thought it would be fun to try it. What is the youth’s motivation? Peer acceptance? Getting high or in an altered state? Escaping pain? Other ways exist to do these things. Sports and meditation release endorphins. Talking, journaling or arts help express feelings. And social skill development brings into other groups.

The nice thing about discussing hindsight is that you don’t have to wait until the behavior happens. You can approach the youth. Talk different scenarios. Roleplay what-ifs. Before they happen. Help the youth achieve their need in healthy ways.

One approach is to ask the youth about a specific event. One they did, are thinking about or heard about from someone else. Then ask them what the thrill or gain would be. Then what is the possible consequence and what could be done “in hindsight”. In the case of crystal meth, the youth might say peer acceptance, but the consequence is addiction, possible stealing, or worse. The youth can then talk and work on other ways to achieve acceptance, and look at the pros and cons of this peer group. Maybe better social skills, a hobby, or an activity can lead him to a different peer group.

PRAXES offers training on its Intensive Youth Practice to reduce their stress and improve behavior. It includes activities like the Hindsight one. For more information on the practice, please contact us .

Action-Based Outcomes: Quality over Quantity

Thu, 12 Aug 2021 19:12:53 GMT

Everyone wants outcomes. Employers and payors want them to see if the money they’re paying for behavioral health treatment results in client improvement. Organizations want them to look at the quality of the work they do and to satisfy those payors. And the professional, the clinician wants to ensure they do good work, not only because it is personally satisfying because it brings job security.

But how does an agency measure outcomes? An outcome is merely one measure of quality for an agency and a client. Choosing the right outcome measure makes a difference, yet different sources have different types of outcomes, which makes it difficult to please them. What is the best way to do so?

Here two examples of outcomes used by behavioral health organizations:

1. Quantity-based outcomes tell an agency how their client is doing compared to a standardized testing instrument. Because these measurements are validated and found reliable over years of testing, they have a high degree of confidence in predicting results. The CANS, PTSD-RI, Pediatric Symptom Checklist, and others offer this way of showing how a client does in improving their functioning. However, it still only looks at the behaviors based on how someone else measures them. Most measurement tests are conducted by a professional, a parent, or another third party who gives their subjective (and hopefully accurate) view of how a client does over some time. Yet it has its limitations due to the possibly slanted perspective.

2. Action-based outcomes. If a youth is told to clean their room, how they respond to the situation shows the behavior exhibited. If they don’t talk about their feelings when they argue with others, the youth demonstrates their problems with communication. These behaviors and functioning are outcome measures that test real behaviors. Unlike the other measurements above, which can be qualitative (or based on opinion), action-based outcomes are quantitative. A youth who hits the wall five times per day tells the clinician the frequency of the behavior, but not the trigger or cause of the behavior. When asking the youth about vignettes or situations that require action, the youth provides data about the situations and how they respond.

Reducing behavior is more about helping the youth manage their stress, their communication skills, and their self-regulation. Learning more about how they handle themselves in real-life situations, which provide quality information, leads to improved outcomes.

Apogee , Praxes’ treatment intervention platform, generates interventions that lead to positive behaviors and quantifiable outcomes.

For more information on a free trial for Apogee, please contact us.

Procedures: It’s How You Say It

dan.thorne@praxesmodel.com (Dan Thorne) — Wed, 04 Aug 2021 17:36:27 GMT

Policies are what you say; procedures are how you say it. As was discussed last week, a policy’s purpose is to tell everyone what you want to do. And now, the procedure tells how you’re going to do it.

Procedures are about the process. The steps your organization takes to follow a guideline. Comply. Teach new employees what to do. Explain to regulatory agencies how you plan on executing your policy.

So how do you accurately reflect what you’re going to do? The best way is to start with an outline. Figure out the steps which an employee, the organization takes to carry out the plan. For some writers, they have it in their heads. Steps A, B, C, etc. For others, it’s more difficult. And you can start at the end and work your way backward. What is your result and how do you get there?

Suppose your organization needs a process to detect high-risk children. The result is that you want them to have safety and/or crisis plans. This way, staff can assure the child and their family that, if they are possibly thinking of harming themselves or others or running away, there is a plan in place.

Here’s an example of doing this backward.

The family has a safety plan.
It was explained to them, and they understood it and completed it.
The family set up an appointment with the therapist.
The therapist’s supervisor reviewed the therapist’s evaluation and determined the child is at risk.
The therapist took their evaluation to the supervisor.
The therapist contacted the child’s family and significant others to get information about the child.
The therapist asked about the child’s suicide and/or homicidal thoughts, plans, and intent to rule out immediate or imminent danger.
The therapist asked the child questions about their behaviors, how frequently they occur, the severity and intensity.
The therapist evaluated the youth.

This may not cover everything. But it shows how the manager or the person making the procedure got to the beginning. By starting at the end. It may be easier to go the other way, but it doesn’t matter. The important thing is that the procedure should be as self-explanatory as possible. So that if it’s picked up at any time by a staff member, a regulatory agency, an accreditation organization, they can understand it in plain English. Once all the pieces are in place, they can then be written in outline form or the narrative. There is no right or wrong way. Just so it’s understood.

Providing clear procedures helps staff know their job and gives the agency structured protocols for their operation.

Praxes provides consulting services on policies and procedures. Here is a list of our services.

For more information, please contact us.

3 Strength-Based Approaches to High-risk Behavior

dan.thorne@praxesmodel.com (Dan Thorne) — Wed, 04 Aug 2021 17:27:06 GMT

To help youths with high-risk behavior, it takes strengths-based approaches. Foster family agencies and residential facilities now progress towards treatment and care for foster youth. But some of these youth fall into the high-risk categories. Such as the following:

· Commercially sexually exploited youth

· Substance abuse

· Fire setting or arson

· Gang involvement

· Sexual offenders

· Runaways

These are the high-risk behaviors that create the most trouble for placement. Most organizations in the past would look at an intake packet with these youths and say, “No way.” But in the new environment of the Family First Prevention Services Act , this is not possible. Because these youths need somewhere to go, and someone to help them.

They didn’t start with these issues. Through genetics, trauma, difficult home lives, something happened along the way. They are involved in these activities, but they can receive help.

To help these youths, it is best to understand what they have in common and know how to help. This is why three approaches utilize the youth’s strengths to try and help them improve.

1. Motivational Interviewing – these youths are very resistant to change. They got to the place where they’re at because of rejection, abuse, trauma, or neglect. They chose their behaviors, such as running away or gangs, and they rationalize why it works for them. To try and tell them differently doesn’t work. They don’t want to hear it. So meeting them where they’re at the help. Motivational Interviewing as a skill can help the practitioner be empathetic, listen and reflect, go with the youth’s resistance and be a sounding board. So the youth then is the change agent, not the practitioner.

2. Functional Behavior Analysis – each youth seeks out high-risk behavior for a reason. It gets their needs met. The runaway wants more freedom. The sexual offender wants control of their environment because they were maybe abused themselves. The gang member wants to feel part of a group, because their parents may have been absent or detached. Youths don’t seek high-risk behavior without a reason. And by finding the function of that behavior, the practitioner can teach them different skills, techniques, and strategies to help them change.

3. Harm Reduction – this approach started with Alan Marlatt in the 1990s when he looked at substance abuse treatment. Up until then, this type of treatment under the 12 step approach was either sobriety or using. All or nothing. Black or white. Dr. Marlatt felt that to help substance users, there had to be a more gray area, knowing that addictions will have relapses. That the behavior will always have a chance of occurring again. And so he developed this approach, which made a great impact on the field. Now it is being used in California for commercially sexually exploited youth. Because they can’t be expected to just leave their trafficking contact permanently. This also applies to runaways, gang offenders, and other high-risk behavior. Developing strategies to keep youths safe, and to give them options, helps them decrease the harm first. And as with Motivational Interviewing, the youth directs their care.

For more information about our training, please contact us.

Policy Writing: It’s What You Say

dan.thorne@praxesmodel.com (Dan Thorne) — Mon, 02 Aug 2021 21:53:49 GMT

Writing policies can be confusing; focus on what you say.

When writing your company’s policies and procedures, it is helpful to understand what to do. Most organizations create documents such as these for manuals. Proposals. Program statements. Accreditation. They serve a purpose. They tell your organization’s staff, the community, your stakeholders, and others what you do.

But policies are not the same as procedures. And it’s easy to get them mixed up. A policy tells people what you do. A procedure tells people how you do it. More on this next week.

Back to policies. Many organizations, when asked to write a policy, don’t know what to put into them. The first step is simple. Write the word, “Policy” at the top of the page. Then everything under that title follows. Sounds easy, but many organizations don’t do this.

Then what is a policy? It tells your audience what you do. What you want to do. And many different types of ideas can come into play.

It can be like a memo. Where you want employees to follow a guideline. Except a policy is more permanent. It can be a purpose. A philosophy. A vision. As long as it tells your readers what you do, now or in the future.

Let’s take an example.

Suppose you’re a behavioral health organization. And you as a leader notice a lot of youths are on psychotropic medications. It makes you wonder why this might be happening. You’re concerned because you know that youths suffering from trauma may appear to need meds. But they need trauma-based treatment by themselves or in conjunction with meds. And their trauma symptoms may be overlooked. You talk to your staff and the psychiatrist. The psychiatrist now does a cursory discussion about trauma with clients but is not sufficient enough.

Your clinical team recommends that the organization start using more detailed evaluations for trauma with youths. Such as standardized measures and a trauma-based evaluation process which gathers information from youths about their experiences and how it’s impacted them. They have all the steps they want the staff to use when youths are first in the program or need evaluations for psychiatry.

That’s good for the procedures. But you want everyone to know why this is so important. You want to put a statement and a rationale for evaluating youths for trauma before meds. This is your policy.

Here’s a suggestion:

Policy:

The ABC Organization recognizes that our youths and their families at times have experienced trauma. This can be in form of abuse, neglect, witnessing violence, traumatic events, etc. These youths have difficulties with their emotions, physical symptoms, and/or behaviors. As a result, their conditions may be more complex. It is the policy of ABC Organization that, before any youth being prescribed psychotropic medications, they receive a thorough trauma evaluation. This will consist of the XYZ Scale for PTSD and our own Trauma Evaluation form.

Just like that. Nothing too complicated. Although it can be as long as an agency wants. But this removes the “how” from the equation and leaves that for the Procedures.

Praxes helps agencies develop policies and procedures for regulatory compliance and policy manuals.

Here is a list of our services.

For more information, please contact us.

Assessing Youths: 4 Factors in the Biopsychosocial Model

dan.thorne@praxesmodel.com (Dan Thorne) — Mon, 02 Aug 2021 21:43:03 GMT

Before treatment starts with any youth, the assessment phase must occur. Assessments take on two different phases in treatment. The initial evaluation occurs once the youth admits to treatment. It can happen in one session to develop preliminary concepts about the youth’s condition and determine a diagnosis. While ongoing assessments continue as the youth is in treatment to gather more data and reevaluate periodically while the youth is in care.

The most comprehensive approach to evaluating a youth is the biopsychosocial assessment. Youths are not one-dimensional; focusing only on behavior problems leaves out their complex experiences. Four factors of the biopsychosocial assessment exist:

1. Biological- the youth’s medical condition, their health, and other features impair their functioning. A child on antihistamines may have trouble sleeping, resulting in concentration problems in school. Their nutrition, sleep, health, and development offer vital clues about their actions.

2. Psychological-how a youth, thinks, feels, and acts impacts their psychological way of life. Think of it as the CBT of assessments and how they interact with each other. A female’s beliefs of low self-worth can lead to depression and the use of Adderall to feel better.

3. Social- a youth is not an island; they interact with others. The assessor learns about their social network, their interactions with family, the socioeconomic status, and how it relates to the youth. A male living in poverty may steal from others to help the family pay their bills.

4. Cultural- not thought of in the traditional context of biopsychosocial evaluations, information about the youth’s religion and culture give a sense of how the youth perceives the world. Their values and beliefs come from their heritage and can benefit their resiliency. A transgender youth’s functioning suffers when their family rejects them, or they have no connection to other trans individuals.

The whole picture gives the clinician the ability to better plan treatment. Praxes’ clinical decision support system, Apogee, integrates with the biopsychosocial assessment to provide treatment skills and interventions.

And Praxes is also offering a live streaming training course on Assessment of Children. For more information, please contact us.

7 Guiding Principles of Assessing Youths

dan.thorne@praxesmodel.com (Dan Thorne) — Tue, 20 Jul 2021 22:16:15 GMT

Assessment is both an art and science in clinical work. Without a proper assessment, the rest of the clinical process suffers due to a lack of understanding of the client’s needs. And with today’s demands for shorter times to conduct an evaluation, the clinician has more challenges to create an assessment. Here are 7 guiding principles that provide a foundation for the assessment process.

1. Joining is Critical to the Assessment. The clinician needs to engage the client in a manner that helps them feel comfortable, at ease, not being judged. Rapport, relationships, or connection with a client mean more than the words received in an evaluation. Being with the client in the process, not against them (no matter what their history tells you) gives both of you a chance to move forward.

2. Be Curious. A client presents you with problems that they don’t have the perspective to see themselves. Being nosy, interested in their life and history shows you care about them and that opening up to new possibilities can lead to change.

3. Think Assessment All the Time. Most clinicians see assessment only as the beginning phase of treatment. Yet at each session, more opportunities exist to learn more about the client. In the first few sessions, they may not want to divulge everything; asking them more evaluation questions after a few weeks or a month may lead to more information to use in treatment.

4. Assessment = Intervention. When a clinician talks about patterns or problems in the session, the client may see the world differently. Talking about how problems have been handled in the past or suggesting future strategies helps the clinician see how the client responds to these ideas. Their acceptance or rejection of these approaches provides knowledge to the assessment process.

5. Assess for Strengths. Assessments tend to be about what’s wrong with a client. For example, a client may leave their seat 50% of their class, which is a problem. But the other 50% don’t, which means they engage in some behavior or like a subject that keeps their attention. These strengths can be built on for treatment goals.

6. Assessment Includes the Therapist. When meeting with a client, the clinician has to check themselves, too. Does the client bring up transference issues, feelings, and other “vibes?” Does the clinician feel restless or irritable in the client’s presence, and do others feel the same way?

7. Assess Using Multiple Perspectives. Not only should you be using your information, but that from family, other professionals such as teachers, or social workers. Observation, questionnaires, and other evaluation tools give you a total picture of the problem.

The assessment is to be a comprehensive process, but only a process that continues throughout the treatment of the client.

Praxes offers a course in the Assessment of Children and Adolescents. For more information about our training courses, please contact us.

Breathing and Its Benefits on Trauma Survivors

dan.thorne@praxesmodel.com (Dan Thorne) — Tue, 20 Jul 2021 22:12:06 GMT

Trauma needs reintegration work to be truly resolved, but breathing techniques have tremendous benefits.

When a youth or adult experiences trauma, they are stuck in the stress response. They feel continuous pressure, muscle constriction, high heart rate, and breathing. Experience hyperarousal and hypervigilance as a result. Every event, every stimulus may remind them of an earlier traumatic event. One they can’t escape. Although a child yelling or a loud noise may not be a stressful event, the trauma survivor’s mind thinks of it as a life or death event and the body responds accordingly.

The treatment techniques which help trauma involve reintegrating the mind and body. Approaches such as EMDR, psychomotor therapy, internal family systems, and other approaches succeed in reducing the youth’s trauma.

But what can be done on an everyday basis with youth or child who experiences a trauma cue? What’s to be to help them calm down?

Breathing is one of the best approaches. Because it provides quick results and reaches the youth’s autonomic nervous system to calm it down. When a person perceives they are in a stressful situation, their sympathetic nervous system (or fight or flight response) activates which increases their breathing. Think of someone in a panic attack or responding to a life and death crisis. Their breathing accelerates to enrich the body of oxygen so their muscles and body are at full alert.

But think about the youth your agency services. If they’ve experienced complex trauma or multiple instances of it, they’re constantly activating the fight or flight response. Unconsciously. And it can happen anywhere. Standing in a line. Smelling flowers. Hearing their father on the phone. Their sensory perceptions are magnified and everything can re-traumatize them.

Breathing is a major aspect of mind and body approaches. Yoga, mindfulness, meditation, imagery, Qi-Gong. All require that the participant learn to focus on their breathing. The inhalation and the exhalation of air. And not only that focus, but also the speed at which the breathing is occurring.

Why breathing? Because it is one thing a youth or anyone can do to stop the stress response. When breathing slows down, the body follows. The sympathetic nervous system goes on vacation, leaving the parasympathetic nervous system to help the body recover and calm down.

In Dr. Bessel van der Kolk’s book The Body Keeps the Score , he discusses how emotional regulation is a key element in working with trauma. Because the more youth can control their emotions, the more successful they will be in managing their behavior. This means if you have a youth you’re working with who has a history of trauma, teaching them breathing exercises helps.

The sweet spot for breathing is 6 breaths per minute. Which means one breath per 10 seconds. 5 seconds for slow inhaling and 5 seconds for slow exhaling. Breathing in through the nose and out through the mouth.

Your client is having a bad day. Another kid looks at him with a mean face and it triggers a memory. He takes slow deep breaths and removes himself from the other kid or turns away or just stands there. The muscles calm down, the body goes back to a neutral state. The feeling of wanting to hit the other kid is less likely to happen, because when the stress response goes away, so does the cycle of aggression.

Maybe it will help you as well. For all the secondary or vicarious trauma, you experience in your everyday social service work.

PRAXES provides training on behavioral health subjects, including Trauma-Informed Care and Interventions for Youth.

For more information or to customize a training for your organization, please contact us.

6 Reasons Why Bullies Bully

dan.thorne@praxesmodel.com (Dan Thorne) — Tue, 13 Jul 2021 23:55:20 GMT

There is more than one reason why bullies bully.

Youths who act aggressively towards others do so for a multitude of reasons. But to prevent bullying behavior, it pays to learn what sets bullying in motion. There’s a need, a desire for one youth to show dominance over another.

And there are different types of bullying. Among them are verbal, sexual, prejudicial, physical. Not to mention cyberbullying. Yet what leads one youth to try to show superiority over others comes from different motivations.

At least from the youth’s perspective, these different motivations appear to be true. And their perspective helps us to better understand how to develop prevention programs for youths.

Robert Thornberg published an article, Social Representations of Bullying Causes , in 2010 in Psychology in the Schools. In it, he discussed his research on school-age youths’ social representations of the causes of bullying. He wanted to look not only at how much bullying occurred, but how youths perceived it. And discussed it in their own words. They came up with six overall causes why bullies bully.

In order of most to least frequent, they are:

Social Positioning-youths saw this as bullying to reach status in a school or group’s pecking order. They described three different types. In these cases, those acting aggressively picked youths who were seen as physically weak, shy, unpopular, younger, lonely, or new.

· Bullying for status was for kids who wanted to be the coolest, the toughest.

· Bullying for power occurred when youths were struggling for authority. About being the boss.

· Bullying for friendship meant acting aggressively to win or keep friends.

Work of a Disturbed Bully-youths perceived an aggressive youth as someone who has their problems. They had emotional or behavioral issues like attention problems, bipolar, poor impulse control. Or the aggressor was a representation of trouble at home. Alcoholism. Violence. Poverty.

Revengeful Activity-youths saw this as an excuse to blame the victim for some type of harm that occurred to the aggressor. They were snitched on. Their little brother got in trouble. They felt ridiculed. A youth told the teacher about them. An eye for an eye mentality.

Amusing Game-youths describe this happening when the aggressor decides they’re bored. They want to have fun at someone else’s expense. The youth at recess finds another youth and pushes them, ridicules them, or does some other activity purely to make themselves feel better. Without caring about the collateral damage.

Social Contamination-youths say this occurs in a group format. Youths talked about how a student would be nice and kind to them. But once they were in a group and wanted to be part of the group, the comments changed. This shows how youths “change their stripes” depending upon who they’re around.

Understanding this behavior, aggressive in nature, help teachers as well as behavioral health professionals, deal with youths acting like bullies. They’re not this way all the time. But in social or emotional conditions, they need to prove themselves at the demise of another. Developing assertive skills for youths helps them avoid bullying or being bullied.

PRAXES offers training on courses for BBS CEU’s, among them Bullying Prevention and Early Intervention. For more information on training for your organization, please contact us.

3 Ways to Improve Clinical Interventions

dan.thorne@praxesmodel.com (Dan Thorne) — Tue, 13 Jul 2021 23:33:50 GMT

Clinical interventions are difficult to target for each client, but there are some ways to improve them.

The challenges most clinicians have in improving treatment outcomes are twofold. First, as much experience as a clinician has, they still have a limited repertoire of strategies available. Usually, it’s what they’ve used in the past. Second, with the pressures of large caseloads and demands on productivity, even if the clinician wants to research treatment modalities they have little time. Subsequently, it is common that clinicians use the same methods for their clients regardless of the client’s diagnosis or chief complaints.

Yet clinicians can sharpen their skills by following these three steps:

1. Identify the chief problem. Although this seems obvious, often clinicians get bogged down in too many problems or crises. The clinician when working with the client needs to specify the main problem behavior upon which to work. This problem should be the one that creates the most symptom reduction and improves the client’s functioning. Problems such as suicidal thoughts, distraction, unprovoked anger, fear of certain environments. These are examples of the types of details the clinicians work on.

2. Reverse the problem into the solution. Once determining the problem, the clinician goes to the opposite end of the behavior continuum. For example, if the problem is that the client runs away from their foster home, then the goal is to reduce these events. The clinician can then think about what this change would look like and what would replace the events. Less frequency, amount of time, reducing running to risky places would also be solutions. Then the clinician identifies with the client what would replace these behaviors. If the client didn’t run away, what would they be doing instead? Talking their problems through, helping others, engaged in positive activities as examples.

3. Inner or Outer Change? The clinician finally reviews with the client whether they need to modify their internal thoughts and feelings, alter their outward behaviors, or both. In the example here, the client can identify their stressor and feelings, then verbalize when they are feeling stressed or learn better ways to talk to others. Maybe writing down their level of stress at certain times of the day to be more aware of their emotions. Or learning how to socialize with their family or peers may benefit them. Plus for outer change, they find ways to channel frustration in physical activities, hobbies, mindfulness, and learning to tolerate stressful situations.

From these interventions, the clinician can then elaborate on more specific strategies for the client. Games, role-playing, listing strengths, or relaxation techniques are modes of making these changes. The more the clinician uses these options, the more they develop their tool kit.

If you want to learn more about how our software Apogee offers these improved interventions, please contact us.

The Six Types of Bullying

dan.thorne@praxesmodel.com (Dan Thorne) — Wed, 07 Jul 2021 18:48:38 GMT

Are your clients going to school fearful of bullying? Or are you fearful they will be the ones doing the bullying?

There are different types of bullying that affect children and youth. What a bully uses to aggressively control, intimidate, or humiliate their target depends. Upon the target’s differences, perceived weaknesses, or other factors. But understanding that bullying is not only physical help professionals understands the ways bullies think. And learning their means of acting helps to treat them and those around them to reduce this behavior.

Sherri Gordon has written many articles and books about bullying prevention. She wrote an article about these types of bullying. A link to her article is at the end of this piece. She listed six primary types of bullying.

They are:

1.Physical Bullying

This is something youths in behavioral health care understand. Many of them are either the targets or the aggressors in this form of bullying. There is usually a physical size difference between the aggressor and target. The aggressor slaps, kicks, shoves the target or does other physical acts. This becomes the more obvious form and which others notice, leading to school suspensions or other forms of restriction.

2.Verbal Bullying

With this form, an aggressor doesn’t need to be larger in stature but feels superior to others. These statements belittle, demean, and/or humiliate others. This occurs for many youths with special needs, who appear different or “weaker”.

3.Relational Aggression

This type of bullying isn’t noticed like the others. Tweens and teens, many times girls, use this to manipulate peers and affect social standing. This happens with gossip, rumors, breaking confidences, insults, etc. It’s designed to put the target on the “outside” group and the aggressor on the “inside” group. Think of the movie Mean Girls and you have an idea.

4.Cyberbullying

Becoming more common, the use of social media or technology to harm and embarrass someone. A text, a phone call, a chat, an image are the vehicles to cause pain. Facebook, Twitter, Snapchat, and Instagram are common sites where this happens. When a bully doesn’t want to face their target, this becomes easier.

5.Sexual Bullying

When youths engage in name-calling, crude comments, vulgar gestures, this leads to sexual bullying. This occurs with boys to girls or even girls to girls. This also includes sexting as well. The goal is to shame another person about their body, appearance, etc. At times it leads to sexual assault.

6.Prejudicial bullying

This type of bullying occurs when the aggressor has negative feelings about the target’s sexual preference, religion, or ethnicity. Based upon judgments the aggressor has, verbal attacks occur. But it can also be non-verbal, such as looks, facial expressions, gestures, etc.

By the way, these don’t only happen in school or youth atmospheres. Workplace bullying occurs frequently, as well as on the freeway, in stores, etc.

Bullying prevention requires a comprehensive approach. Which involves the adults in their environment. Those doing the bullying as well as the targets. And those who are the witnesses. Because all willingly or unwillingly participate in the actions. Just as in family therapy, everyone plays a role in the problem and everyone must contribute to the solution.

Here’s the link to Sherri Gordon’s information:

PRAXES provides training to behavioral health organizations on subjects such as bullying prevention. For more information or a quote for training courses for your organization, please contact us.

5 Things Teen High-Risk Behavior Have in Common

dan.thorne@praxesmodel.com (Dan Thorne) — Wed, 07 Jul 2021 18:39:41 GMT

What do teens who are at high risk have in common?

Many things. And sometimes nothing.

An 11-year-old boy on the autism spectrum bites his sister. A 14-year-old young girl spends more time with an interested young man who is trying to lure her into sex trafficking. The 15-year-old girl starts to cut herself in the bathroom at middle school.

These behaviors seem to have little in common. And they might. But what led the youths to exhibit these behaviors have much in common. They are not independent of each other.

Several behaviors are included in high-risk behaviors among youths. Such as criminal activity. Unprotected sex. Commercial sexual exploitation of children (CSEC). Aggressive behavior towards others. Or oneself. Substance use. Runaways.

This is not an exhaustive list. But these comprise the major behaviors which plague youth in children and family agencies. They occur with youths of all cultures, ethnic backgrounds, socioeconomic backgrounds, and geographic areas.

Are there ways of predicting the behavior and therefore helping to prevent them?

Perhaps.

What do these behaviors have in common? Other than they utilize 80% of the resources in an agency although they may make up 20% or less of the youth?

5 possible causes may be involved. Based upon research and observation of youths over the years, these are some similar links:

1. Medications - youths who are psychotropic medications are at the highest risk. Because they have already had problems within their childhood or teen years, and these concerns haven’t stopped. Nor have they been alleviated by traditional therapy or counseling. Seeing a psychiatrist or taking medications means that a practitioner believed at some time the problems were biochemical. And that medications would help the situation.

2. Trauma - the nature of trauma in some form leads the youth to respond to stressors differently than others. Typical youths when trouble occurs are at a calm frame of mind. The youth with trauma sees the situation from a higher state of arousal, fright, fear, anxiety, or aggression. Their responses are different based upon their history of high stress.

3. Isolation - youths who tend to stay away from others lead a more withdrawn life. Not to say that being introverted is bad; 25% of the population is this way. But when a youth doesn’t have friends, is not involved in any social clubs or groups, they are the “outcasts”. And tend to either be labeled this way and/or treated as different. Studies show when youths are labeled as outcasts, they tend to be more involved in high-risk behavior.

4. No communication - along with being isolated, some youths have no communication skills. They don’t talk about their problems, their feelings, what’s building up inside of them. Even elementary school children, when prompted, can learn to talk about their problems. When a teen or youth doesn’t feel anyone will listen, it’s a sign that they look for other ways to manage their emotions.

5. Overage - not necessarily a common term, but an overage is behavior to excess. A youth not simply being upset and breaking their pencil in class. But turning over their desk and slamming it down on the ground. Because they can’t modulate how they feel. Everything is magnified. They yell more, act out more, generally cannot contain how they feel. And as a result, they have more difficulties with others.

Seeing these behaviors in school, at home, and in the community can be warning signs of problems. And behavior health professionals can develop plans to help the youth learn new coping skills. Or deal with problems in therapy.

If you want to learn more about how Praxes’ software, Apogee , can help you with these behaviors, please contact us.

The GIGO Effect

dan.thorne@praxesmodel.com (Dan Thorne) — Wed, 30 Jun 2021 19:08:25 GMT

The amount of behavioral health agencies turning to electronic health records (EHR's) increases each day. While some agencies are required to have EHR’s as part of their contractual obligation with a county or state, others find it an efficient way to handle their documentation. This is true even with small residential facilities (QTRP’s or STRTP’s) that want to move beyond paper charts and have centralized record keeping.

Some agencies think that having an EHR will improve their treatment outcomes, develop better documentation, or improve treatment efficiency. They are sadly mistaken.

No matter what the reason behind the EHR expansion, the GIGO effect can still exist within the agency. The GIGO effect is an abbreviation for the term “Garbage In, Garbage Out”. This is not in any way meant to denigrate the assessments, treatment plans, or progress notes that the staff writes. It is more of an observation I have from over 40 years reading thousands of notes, charts, and the chore of explaining improper documentation to a regulatory surveyor.

An EHR is only a repository of information. Once the information is put into a record, the EHR cannot clean it up nor change it. For instance, a staff member writes a progress note that does not reflect the service provided to a client. That note, once completed, is submitted for approval to their clinical supervisor or a Head of Service. Then the reviewer has to take the time to read the note, review the chart, and see if the note fits the service provided. If a client’s goal is to improve social skills, and the note talks about going to a Starbucks for a Frappuccino, the note does not meet the threshold of indicating the medical necessity or the reason for the service. The note increases staff time to correct, poses a threat for financial recoupment, and doesn’t advance the client’s functioning.

What causes the GIGO effect? Several reasons exist. One, staff are in such a hurry to finish a note they don’t think through the necessary ingredients to put into it. Second, they may lack the skills or training on how to write it. Third, writing a note on paper and pencil is a very different skill than writing it on a computer. Although more staff are computer efficient nowadays, writing a note takes a specific skill set that many clinicians don’t get through school or in supervision. Finally, our WFA (Work From Anywhere) environment impacts the note. The days of going down the hallway to talk to your supervisor about how to write a note are gone. The staff is on their own.

Ask clinical supervisors how much time they spend reviewing notes. Then ask how much time they spend either parsing words to figure out if the note is “good enough” to approve or needs to be sent back. Suppose you are a large agency, and your supervisor has 10 staff under them. Each staff writes five notes a day. That means the supervisor has to approve 50 notes a day and give them each a lot of time to discern the medical necessity. Because of the volume, it’s no wonder that GIGO’s go through the system and end up as audit red flags from counties.

How to solve the GIGO effect? Agencies need to find ways to help staff manage time, spend energy on educating staff in the art of documentation. They also need to examine their EHR system to see if it is intuitive enough to help the staff navigate through it so note writing is not a time-consuming exercise.

Praxes' t reatment software, Apogee , works as a complement to the EHR by generating customized skills and interventions. For more information, please contact us.

Motivational Interviewing and Affirmations

dan.thorne@praxesmodel.com (Dan Thorne) — Wed, 30 Jun 2021 18:48:17 GMT

Affirmations are just one part of Motivational Interviewing (MI). And an important component in helping youths and adults find their way to change.

When clients are resistant, they don’t want to leave their situation. They prefer to stay addicted, overweight, in emotional pain, cutting themselves, etc. Their behavior provides some comfort and emotional gain. They also are afraid of what happens if they leave their usual means of living and try something different. It means giving up something they’re comfortable with, like a warm blanket they throw over themselves. This is true for many to who don’t want to or like change.

In addition, the client may not like the treatment process. Therapists or social workers poking. Prodding. Begging and cajoling. Trying to get them to be something they don’t want to be. As a result, they are wary and suspicious of the therapeutic process.

To this end, MI tries to provide a process whereby the client can feel comfortable just being themselves. Being accepted for what they bring into the session. Not feeling judged, put down, or that they are lazy and don’t want help.

One of the techniques which can help is Affirmations. This is part of the OARS strategy. When interviewing a client, it helps to provide them with positive reinforcement and praise. Give them a sense that you, as the practitioner, are supportive of them. Are on their side. This collusion with the client helps them feel that you understand. That you have an idea what it’s like for them.

Affirmations are exactly what they appear to be. Statements which give the client positive feedback for talking about their problems. Obstacles. Pain. Excuses. And reasons for staying the way they are.

Here’s some examples between Client and Practitioner:

C: “I don’t know why I’m here. I don’t belong in treatment.”

P: “I appreciate you being so honest about your intentions.”

C: “There is no way I’m going to stop running away from my mother.”

P: “It’s helpful to hear how you feel about your relationship with your mother.”

C: “At the rate I’m going, I’m not sure I’m going to be alive by the end of the year.”

P: “You’re really making progress in stating your fears.”

C: “Why should I stop using drugs? No one cares about me.”

P: ”You’re really putting yourself out there and sharing your feelings.”

By giving affirmations, the practitioner is not trying to change how the client feels. They’re simply telling the client they appreciate the openness. The candor. And that it’s hard to be in their shoes. Without judgment or trying to get them to change. This is a step in getting the client to be more willing to open up. To trust the practitioner and the process. To see that they’re hurting and that the practitioner wants to help. But in a gentle nudging way, not with a sledgehammer.

Affirmations can be helpful if used with other treatments, to give the client praise for their feelings. And further positive actions.

Learn more about Motivational Interviewing training courses by contacting us.

The P Word and Technology

dan.thorne@praxesmodel.com (Dan Thorne) — Wed, 23 Jun 2021 23:30:38 GMT

Every agency faces the P word with angst. Managers need it to meet their budgets but have little control over it. Clinical staff dreads the subject because they feel management doesn’t think they’re doing their jobs. It’s not enough to be on time to document their notes or have favorable outcomes with their clients. The P word overshadows everything.

The P Word, if you didn’t already guess, stands for Productivity.

Agencies are measured by the amount of time they have their staff spend face-to-face with their clients—the hours spent in actual treatment. But to better understand how to help staff be more productive, agencies have to know what makes staff productive.

Productivity is a function of at least five different variables:

Billing, as the more staff spend with their clients, the higher their hours are.

Documentation, because staff must chart what they’ve done or they cannot bill their services.

Supervision, to learn from their clinical manager the best way to treat their patient.

Staff expertise- their ability to engage clients, find the right treatment for them, and use these treatment tools in their sessions. The more they know what to do, the higher their productivity.

The final factor in the P word is training. Staff in most agencies don’t get the skills to treat their clients in school, and they yearn for ways to deal with crises, high-risk clients, and what to tell parents.

Technology can be a friendly companion to productivity. It can’t see the client for the staff. But it can:

Develop the interventions and complement documenting.

Extend the supervisor’s knowledge to provide skills.

Improve staff expertise through exposing skills in engaging and treating.

Train the staff on new strategies.

What ends up happening is that staff don’t fear the P word. Because they have more tools in their tool kit to work with clients, even the tough ones. Better tools reduce cancelations and improve how the staff works with clients to get their billing hours up as a rule, not an exception.

For more information on how Praxes uses technology to improve productivity, please contact us.

The Right Brain and Healing Trauma

Wed, 23 Jun 2021 23:11:05 GMT

When a person suffers from trauma, working with their right brain improves their social interactions and relationships.

Why is it that talking doesn’t help trauma survivors heal from their experiences?

There are several explanations to this phenomena. The first is that, when a traumatic experience occurs, the left side of the brain shuts down and the right side processes.

First, an explanation of the brain’s functions.

Two sides of our brain work together most of the time. But they each have their own functions. The left side is designed for logical thinking. It is the side we use when we read, do math, figure out logic problems. When we wish to explain our past, spew out statistics. It has an orderly fashion of working.

The right side of the brain is for creative and non-logical thinking. It’s where stories come from, music, art, poetry, dance moves. It’s also where our memories of sound, touch, and smell are stored. When we react to non-verbal gestures, faces, voices, it’s because of the right brain functions.

Dr. Bessel van der Kolk discusses memory and trauma research in his book, The Body Keeps the Score. When scientists started doing Functional Magnetic Resonance Imaging or fMRI’s, they learned how the brain functions during activity. Researchers would ask a trauma survivor to sit inside an MRI machine. And then they would ask them to recall memories and see where the brain stimulated. They found that the right side, especially in recalling traumatic memories, activated. While the left side of the brain totally shut down.

As a result, trauma survivors cannot put into words or logic what happened to them. As Dr. van der Kolk indicated, “In technical terms they are experiencing the loss of executive functioning.”

The second explanation is that people with traumatic memories reduce their healthy interactions with others. The right side of the brain develops our relationships. According to David Hosier in his work on Childhood Trauma Recovery, the right brain involves our ability to empathize with others, trust others, identify with them. Read emotions, form healthy attachments, and know non-verbal communication.

If traumatic memories reach the right side of a person’s brain, they may hinder these relationships. Which is why children who experienced trauma have difficulty with social interactions.

Then what are some solutions?

Practitioners in settings with trauma survivors should focus on the activities which are right brained in nature. Less talk, more doing. Activities such as art, drama, poetry, journaling, psychodrama, dancing, movement.

Mindfulness activities such as imagery, meditation, visualization, hypnosis, yoga, qigong, tai chi.

Telling a youth that it’s not their fault they were abused only goes so far. Helping them feel like a whole person integrated with mind and body helps combine the left and right side. A little at a time.

Giving them ways to retell their trauma experience as an observer, with someone there to help them through the experience, reshapes the memory into one they live with. And can accept.

These activities along with hundreds of others help the trauma survivor access their trauma memories in a safe environment, healing one step at a time.

For more information about our trainings, please contact us.

Root Cause Analysis in Behavioral Health Organizations

Mon, 03 Feb 2020 19:37:44 GMT

Root cause analysis can benefit organizations wanting to remove obstacles and avoid making the same mistakes repeatedly.

Root cause analysis is an invaluable tool widely utilized in scientific and engineering realms , specifically designed to identify the underlying causes of faults or issues that may arise. By adopting a proactive approach, you, as a professional in a Behavioral Health Organization, play a crucial role in effectively investigating the reasons behind specific incidents or challenges through a structured series of steps. This process helps you understand the factors that led to the issue and enables you to take actionable steps to prevent similar occurrences in the future. Behavioral health organizations can apply this methodology to enhance quality improvement efforts, refine clinical operations—such as crucial suicide prevention strategies—and strengthen their leadership functions.

One effective root cause analysis method is the " Six Ps " framework, introduced by Dr. Anthony Weiss in an article focusing on quality improvement. This approach encompasses six key dimensions: 1) **Patient-related factors,** which explore individual circumstances influencing patient care; 2) **Personnel or staff-related factors,** which assess the impact of staff dynamics and capabilities; 3) **Policies,** the formal guidelines that shape organizational processes; 4) **Procedures,** the specific clinical practices that influence outcomes; 5) **Place or environmental factors,** examining the physical or situational context; and 6) **Political or outside/institutional factors,** considering the broader setting in which the organization operates. By thoroughly evaluating these components, behavioral health organizations can enhance clinical processes and improve patient outcomes.

Another constructive approach involves a systematic five-step process for root cause analysis: 1) Define the problem, articulating the specific issue clearly; 2) Collect data, gathering relevant information for insight; 3) Identify possible causal factors, exploring all potential contributors to the problem; 4) Identify the root cause(s), narrowing down to the most crucial underlying issues; and 5) Recommend solutions, proposing actionable strategies for resolution. For example, if a behavioral health organization notices a trend of increased psychiatric hospitalizations among clients, it would first define the problem as hospitalizations. The data collection phase would involve analyzing various factors, including duration of stays, demographics of clients, treatment histories, types of medications, precipitating events, and management approaches. By investigating causal factors—medication non-compliance, insufficient crisis intervention, lack of family support, and inadequate crisis management systems—the organization would identify specific root causes that directly link to the hospitalizations, leading to tailored recommendations to improve outcomes.

Additionally, asking "Why?" multiple times—often five —is another powerful tool in root cause analysis. This iterative questioning approach encourages organizations to dig deeper and promotes accountability. For instance, if a behavioral health organization aims to enhance productivity due to lower-than-expected client engagement and revenue, the first "Why?" might reveal that staff are not billing efficiently. The second question could uncover a lack of knowledge regarding strategies to reduce cancellations or effectively engage clients. Following this line of inquiry, the third "Why?" might point to issues related to staff burnout, while the fourth could indicate challenges such as overstaffing or ineffective time management. Finally, the fifth "Why?" might reveal gaps in training. This process generates more profound insights and fosters a culture of reflection and continuous improvement.

However, it's important to note that root cause analysis is not without its challenges. It can be time-consuming, especially when dealing with complex issues. It also requires a high level of data collection and analysis, which may not always be feasible in resource-constrained environments. Despite these challenges, root cause analysis remains a constructive approach for organizations striving to eliminate obstacles and prevent the recurrence of mistakes. It ultimately leads to enhanced service delivery and a commitment to continuous improvement. By embracing these methodologies, Behavioral Health Organizations can effectively drive progress and make meaningful contributions to the welfare of their clients.