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The Village Network's Implementation Journey

David Paxton, LISW-S/Chief Clinical Officer of The Village Network, shared how they came to use Collaborative Problem Solving, its benefits, and advice for other residential programs seeking to implement the approach. The Village Network is an experienced, multi-discipline behavioral health nonprofit organization helping youth and families become resilient, healthy and have brighter futures.


Tell us about The Village Network and your role at the organization.

The Village Network. We just recently celebrated our 75th anniversary. We started in 1946 and now 75 years later, we're serving close to 400 kids a day in our residential and foster care programs. We're in 70 different schools across the state. We have six treatment foster care networks, and we specialize in working with children who've been traumatized, who are, majority of which are in the custody of local children's services in juvenile courts. Like a lot of states, Ohio's struggling with the number of children in care and the severity of the trauma children are experiencing. Like a lot of states, there are some local children's services where children are spending the night in the offices because there just isn't enough placements. So we're trying to meet that demand. But we now have a crisis center where children who are in crisis can be placed for short-term placement. And then we're actually going to be opening another one of those. And then Ohio's moving toward the PRTF, the Psychiatric Residential Treatment Facilities as well. I'm the Chief Clinical Officer, so my department is responsible for all the clinical trainings from orientation through the NMT and CPS. My department also makes sure that we are implementing our clinical models through fidelity. So we conduct annual fidelity reviews and program evaluations and ongoing training and consultation for our programs.

Several years ago, we joined with the state of Ohio to try to figure out how to decrease the use of restraints, physical restraints. We were a typical residential program with the typical number of restraints and chaos and going on in the residential programs. And one day, some of us were sitting around saying, we've got to do better than what we're doing. The kids are getting better somewhat, but not to the degree to which we thought they should be. So we joined with the state of Ohio. They had an initiative to reduce the use of seclusion and restraints. The big craze back then was TF CBT, and everybody had to use TF CBT. We would even take one of our residents in the residential program, take her, we took her to the doctor like we do. And even the pediatrician said, why aren't you guys using TFCBT with her?

So we hired a consultant, had all kinds of training and TFCBT, and you know what happened? Some of the kids got worse, the number of restraints increased. And about that time, I saw a flyer for an advertisement for a Dr. Bruce Perry training in NMT down in Athens, Ohio University. So we went down there and saw Dr. Perry give this lecture, and within the first 20 minutes of his presentation, he explained why TFCBT may not always be appropriate for children who are experiencing this new terminology he was using complex developmental trauma. How they don't have access to the cortex to be able to, they don't have the cortical strength to benefit from TFCBT. So I remember one night I was called into the residential program, and I saw a staff member escort a child from his bedroom into the timeout room. We actually were using a timeout room back then.

And I came back to see how they were doing, and she was physically restraining him in the timeout room. And then I saw her escort him back to his bedroom, and he continued doing the same behaviors. And with that presentation by Dr. Perry and that experience, we said, this is enough. We need to figure out something else. This isn't working. We dropped the TFCBT and we contact the Child Trauma Academy and started getting trained by Dr. Perry. And soon the restraints started to decrease, and the critical incidents started to decrease. So as we went through the training with Dr. Perry, we got certified in NMT. We had several staff train the trainer, and Dr. Perry began talking about Collaborative Problem Solving and just Dr. Stuart Ablon and how it matches up with NMT. And we were fortunate enough to have a foundation fund bring in Dr. Avalon and Perry in to train. And we haven't looked back since. We continue to decrease the number of restraints, and in fact, right now, on our strategy plan, we have an initiative to eliminate the use of physical restraints in all of our residential programs. So we'll see. But it's been very, very challenging, but it's been very satisfying, very rewarding to see the impact of NMT and CPS.

How do Collaborative Problem Solving (CPS) and the Neurosequential Model of Therapeutics (NMT) work together?

We see NMT as the theoretical underpinning of our work. The neurosciences obviously, and obviously the neurosciences informs Collaborative Problem Solving, but Collaborative Problem Solving, as the neurosciences, NMT in action and the Collaborative Problem Solving along with NMT. But Collaborative Problem Solving certainly speaks to the idea that it's all about relationships and actually sitting down in a respectful way and actually asking the child their opinion of what they think is going on and how can we help them solve with them the struggles that they're having. It has led to a much level, a much deeper level of engagement with the youth.

What has been the impact of Collaborative Problem Solving on the youth in your program?

I think what's really interesting, I think Collaborative Problem Solving it helps right away for one to establish that relationship. But it gives you a good gauge, a good read of where that child's relational skills are at and to what level do they trust the staff. And I know myself working with youth and doing Plan B conversations the same Plan B conversation can go on for several sessions, but you stick with it, and you start talking about what's the struggle about the trust and relationships.

I think that Collaborative Problem Solving really engages the youth at a deeper level, and it really helps the staff understand the importance of establishing that relationship. In some of our programs, our residential programs who've done particularly well with NMT and CPS, they all have done, but as we've implemented this, they've learned different processes to how to implement it. But one program, in particular, led away in training, actually training the kids in Collaborative Problem Solving. So the kids understood what's going on. Soon as the staff starts talking the Plan B way and they know what's happening and they engage in that. We had one situation where a youth wanted to change roommates, and he went to the staff and said, Hey, this idea about changing roommates, he says, "oh, it's going to work because I Plan B'd him."

And he actually used Plan B to talk to his current roommate to see how he would feel about switching roommates. So it's gotten to that level of engagement in some of the programs. The staff use it as a psychoeducation. And we've formatted some of our groups around the NMT, the sequence of engagement, regulate relate reason. And that reasoning piece is when they do in group; they do the Collaborative Problem Solving where they have a problem they want to solve. And as a group, they do a group Plan B, have a group Plan B conversation. Exactly. I remember one staff talking about how we tell the kids what this is, this is what we do. And he said, just that this isn't some big secret. This is what we do. It's not a secret, and it works.

What was it like to move away from a point-and-level system to Collaborative Problem Solving?

I've been in residential, doing residential work for a long time, and I was actually in Chicago as a childcare worker at a large residential program, and I was trained in a point-and-level system, a very popular point-and-level system. And then I moved to Ohio and started working for The Village Network. At some of our programs, I tried to implement this point-and-level system, and then I already had some point-and-level systems in their programs, but it got to the point where we just weren't getting the impact we wanted as much effort we put into this and as much just the time and energy and the training and the resources, we thought we should have been getting better results than we were. And about that time too, we have a new CEO arrived at the village network, and just coincidentally, he said to me, I think we need to get rid of the point-and-level systems.

And he and his previous job, he had done some research about point-and-level systems. He was on the educational side. So we explored the idea, and then we started introducing it to the staff. And we haven't looked back since. It was rough at first, it was difficult at first, and frankly, we even had some staff quit over it. They didn't quite understand what we were trying to accomplish. And frankly, we were young or new at this too. And in hindsight, we would've done it a little bit differently. But it's been some very hard or very rewarding work. Like any culture change or any implementation. Implementational science will tell you, as we removed the point-and-level systems, we had to make sure that everybody understood that this is what's replacing it, Collaborative Problem Solving.

And we had to be prepared that Collaborative Problem Solving takes practice. You have to practice a Plan B conversation. You have to practice the Plan B or the CPS APT and the TSI, and not everybody's at the same skill level. So I think we would've been a little bit more prepared to implement CPS before moving forward and removing the point-and-level systems.

And frankly, we learned just that idea of point-and-level systems and behavior modification and all about taking responsibility for yourself, pull yourself up by the bootstraps that is so ingrained in everything we do. So when staff heard that we're removing these from our programs, they kind of panicked, and they didn't quite understand what we were trying to accomplish, and it made people really nervous and some got really anxious. But we've changed our focus with NMT and CPS. It isn't about holding kids accountable. It's about helping them build that capacity to self-regulate, helping them build the capacity, create the capacity, build the capacity to self-regulate and to problem solve together.

And we explained to the staff, the child can't take responsibility for themselves until they have the neurological capability to do that. Taking responsibility for yourself, that's a very intangible idea. And that's something that happens up in the cortex. And these dysregulated children, they don't have that ability to always be as regulated to be able to do that. So that explanation really helped the staff understand. And we've taken everything instead of point-and-level systems, everything's on the basis of for what degree can the child keep themselves safe? So if a child, as an example, I always use this as example, the child. One Sunday, the group home goes to the YMCA and goes swimming, and you have a child in your program who has a history of running away, and he's doing okay, and you take him to the YMCA, and guess what he does? He runs away.

So then the next time you're working with them and the group's going to go to the pool, to the YMCA, our staff might have a Plan A conversation and says, you're not going to be able to go, because until you have those skills to be able to not run away, to become less impulsive than can regulate yourself, you're not going to go to the YMCA with us today. Now we'll help you develop those skills, and we'll help you work on that. And so that kind of framework, that explanation to the staff, they had a better understanding of what we were trying to accomplish. Everything's based upon safety, the degree to which a child will keep themselves safe, not a total of points that they've earned for the 24-hour period.

There are options with Collateral Problem Solving. So as the example of going to their YMCA, if they're going to their YMCA, the skills involved in that, if it surpasses the skill level of the youth, we're just setting them up in allowing them to go if they don't have that skill level. So that explanation helps the staff understand that, and it helps the youth as well, that we're just not saying no because we're saying no, we're saying no for a reason. We explain we want you to be successful. So, until you can develop that skill, we're not going to let you go to the why. We always though say, we will help you; we will help you build those skills. So it gives them some hope that it isn't just us saying no and see you later.

How has discharge from The Village Network changed with Collaborative Problem Solving?

It's interesting when we first started when we removed the point-and-level systems, it was really interesting. I didn't anticipate this, the biggest, the loudest protestors, I guess, among my staff. Among the staff, I thought it would be the childcare workers, but it was the licensed clinicians that were complaining the most. And I dug into, what is this about? And really, what it was is they were getting pressure from the referral sources, particularly juvenile courts. “Well, how am I going to know when my client’s ready for discharge? Now I don't know when they're going to get at level three because level three means they're ready for discharge.” So they were really feeling pressure and needed an explanation to talk to the referral sources. So it was a matter of training, training the staff on what would be a good response to that. And I understood it.

I mean, a probation officer needed an answer. So he or she could tell their judge about when this youth is ready for discharge. And once we explained that it's all about skill building and the child's ability to keep themselves safe, then they're ready for discharge. And something else that had happened along with that is the treatment plan became more relevant. So when is a child ready for discharge? When they obtain their goals actually under a mental health treatment plan. In so many residential programs, that gets lost, that the therapist over here doing this work, and then the childcare workers are doing over here doing this. And Collaborative Problem Solving brings the two together because they're both doing the same approach. So they're both working toward the same ends. And the Collaborative Problem Solving is incorporated into our treatment plans.

What has been the biggest challenge of implementing Collaborative Problem Solving?

I will say I think the biggest challenge of implementing CPS has been just that is a skill, is sitting down doing a Plan B conversation is a skill, and it takes practice. So finding the time within a residential program for the staff to be able to practice that, that has been the most challenging, challenging part of implementing Collaborative Problem Solving. When there's times when there's not chaos in a residential program, the staff can actually do a Plan B conversation. Although I think as we implement NMT and CPS, those times of chaos are decreasing, allowing staff more time to practice Collaborative Problem Solving.

What has been the change you have seen at The Village Network?

The biggest thing I think is staff understanding that it's skill, not will. That they're not choosing to behave this way. They could. He would if he could, as Dr. Alon would say. So the idea of the staff are less blaming, I guess. They have more empathy for the children. They understand that the children don't have the skills to always self-regulate and don't always have the skills to make the right choices. That has switched just the language. You hear the staff, instead of staff talking about he has his privileges, or he doesn't have his privileges, they're talking about to what degree can they self-regulate, or he's struggling with really regulating today. And just that enables them to step back and have more empathy and patience with the kids. They're much more engaged with the children in their relationships, and they get to know the kids really, really well.

And I think vice versa, the children really start to trust the staff. They really start to trust the staff. And for these children who've been traumatized and they're in out-of-home care, to begin that process of trusting somebody, we're essentially trying to create new templates in their brains of what safe relationships are. And Collaborative Problem Solving really helps us to do that. The youth, they have just deeper relationships with the staff. And I see this, the kids referring to their staff and their residential program with affection and with trust; they see the staff as a source of support and problem-solving, rather than rule enforcers and somebody who's going to take away my privileges. And there's just a deeper level of engagement with the kids.

How have you shared the Collaborative Problem Solving approach with families?

So, as we're discharge planning too, we engage the family, and some of our therapists talk to our parents about Collaborative Problem Solving and try to do some psychoeducation around Collaborative Problem Solving and how to do a Plan B conversation. And more importantly, what's behind Collaborative Problem Solving and the hopes that they seek out more help after they leave The Village. One of the appealing things to Collaborative Problem Solving is they're actually working on real problems. They're not artificial scenarios set up like you might have in an anger management group, but they're real problems that the children are struggling with. And the same ideas communicated to the parents that sure, out in the real world, you have to meet certain expectations or there's going to be consequences. You're late to work, you're going to get trouble with your boss. So we explain it to the parents that, how can we work with your child or how can you work with your child to see what's behind with them always being late for work and problem solve around that. And that seems to help them understand what we're trying to accomplish.

How has The Village Network and youth care been affected by Collaborative Problem Solving?

Now, Collaborative Problem Solving and the Neurosequential Model are similar frameworks. I think it is taking the mental health field in a different direction. I think up to this point, relatively speaking, I think the mental health field has, by focusing on point-and-level systems and behavior modification, we've, we got a lot wrong. And I think Collaborative Problem Solving is pointing us in the right direction. That it's all about skill building and working collaboratively with our youth and our clients and not working, not working against them, dragging them along, kicking and screaming to the treatment plan. Right? The Collaborative Problem Solving and NMT has changed. It's changed the agency so much. It's just been incredible. We've seen results that we've never thought we'd ever, ever see.


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