Question
How effective is the Attachment, Regulation and Competency (ARC) model for Residential Treatment Centers?
Quantity and Quality of the Research Literature
Ever since the Individual’s with Disability Education Act (IDEA), education systems have implemented the principle of Least Restrictive Environment (LRE), which holds that a student should have the opportunity to be educated in the general education classroom with peers to the greatest extent possible. This same logic has been applied to the psychosocial services field. Placing a juvenile in a Residential Treatment Center (RTC) has been criticized as being the most restrictive and expensive option for youth removed from their homes (Bates, English, & Kouidou-Giles, 1997). Therefore, a majority of the juveniles placed in RTC possess severe psychological and behavioral problems in order to qualify for this higher level of care (Briggs et al 2012).
According to a cross-site, 5 year study from Strickler et al. (2016), length of stay works on a bell curve, with the most drastic change happening between months 1 and 6, a plateau between months 6 and 10, and then negative effects after month 10. Shortened lengths of stay would be valuable not only for the residents, but also for the overburdened system.
Considering the level of restriction and expense associated with RTC, it is important to evaluate the kinds of youth that improve in RTC. Boyer et al. (2009) found certain “deteriorators”, youth whose symptoms became more intense in RTC, were more likely to have histories of repeated trauma exposure across developmental periods. Given that youth with a history of trauma make up a large portion of the youth in RTC, up to 92% according to Briggs et al.(2012), it is extremely important to learn how to work with these youth in RTC, especially considering their propensity to deteriorate with traditional RTC treatment.
A few guidelines have been set out for developing trauma informed treatment among juveniles. According to Amaya-Jackson et al. (2007), several components emerge as evidence based practice in the treatment of childhood complex traumas, including psycho-education, management of anxiety and trauma reminders, trauma narration and organization, cognitive and affective processing, problem solving, parenting skills, behavioral management, addressing grief and loss, emotional regulation, and supporting youth in the development of competencies that may have been delayed by the trauma. Despite this long list of intervention points for therapists working with children with complex trauma, there still existed a need for explicit strategies for RTC where there are multiple contexts the youth find themselves in.
These components include psychoe-
ducation, management of anxiety and trauma reminders,
trauma narration and organization, cognitive and affective
processing, problem solving regarding safety and relation-
ships, parenting skills, and behavioral management (im-
ported and adapted from a strong nontrauma empirical
base), addressing grief and loss, emotional regulation, and
supporting youth to resume developmental competencies
that may have been delayed or lost.
These components include psychoe-
ducation, management of anxiety and trauma reminders,
trauma narration and organization, cognitive and affective
processing, problem solving regarding safety and relation-
ships, parenting skills, and behavioral management (im-
ported and adapted from a strong nontrauma empirical
base), addressing grief and loss, emotional regulation, and
supporting youth to resume developmental competencies
that may have been delayed or lost.
As far as EBP is concerned for RTC, there does exist some evidence about what works best in establishing a trauma informed RCT. Importantly, TIC in RTC requires a systemic lens because the residents engage with many different professionals (counselors, SAVA workers, GALs, therapists, etc.) in multiple contexts (school, milieu, staffings, court). Therefore, staff education emerges as a crucial part of RTC TIC. Educating staff about the effect of trauma on an individual using a particular curriculum, Risking Connection, has been found to “shift attitudes about working in a trauma sensitive manner” (Brown, 2012, p. 513). This study supported the guideline put forth for Trauma Informed Care (TIC) to include staff training. Levin (2009) found that because of the frequency of misdiagnosis, many youth with trauma histories are being treated with psychopharmacological interventions, rather than treatment that specifically target their trauma history. Indeed there is some evidence that trauma focused interventions are also successful in addressing other causes of functional impairment (Layne, Ostrowski, et al., 2010). Another element of traditional RTC found to be an element that facilitates deterioration for traumatized youth was the use of restraints and seclusion. Restraints and seclusion can be re-traumatizing of course, but also limit the likelihood of the youth using adaptive coping skills (Conte et al. 2008).
Zelechoski et al. (2013) point out that merely living with other traumatized youth can be triggering for residents. Underscoring the importance of ongoing staff training, it is vital that the RTC program is able to manage triggering comments and events with flexibility. Zelechoski et al.(2013) suggest that this is accomplished with staff that demonstrates their commitment to maintaining the safety of residents. This is accomplished by empowering the staff through training to shift the view of themselves to “facilitators of change” from “agents of control” (Levin, 2009, p. 533). Zelechoski et al. (2013) acknowledges that control of maladaptive behavior has been traditionally a focus in RT, but recommends that the focus instead be on cultivating a resident with her own self-control and decision making abilities. In short, the recommendation is to steer away from compliance and toward empowerment.
Another important element for TIC within RTC is flexibility. The model needs to be flexible enough to apply in therapeutic environments, education environments, and the milieu. The model needs to be accessible to all staff at RTC, which is a real challenge. Considering that the most commonly used trauma therapy for youth Trauma Focused Cognitive Behavioral Therapy is only a therapeutic intervention, it is less practical for RTC since such a variety of staff members interact with youth within a RTC (Hodgden et al., 2013).
Often integrating all of these recommendations for Trauma Informed Care can be overwhelming to a system like an RTC that struggles to maintain daily function. Using a model of trauma informed care is a good idea for RTC that are already overburdened with work for their residents. The Attachment, Regulation, and Competency (ARC) model is a “components-based, contextual model of trauma-focused treatment that allows the clinical provider to integrate unique aspects of the client and caregiver into the intervention” (Zelechoski, 2013, p. 645). One of the benefits of ARC is its flexibility and accessibility. It can be taught to counselors, clinicians, and administrators across all the contexts necessary within a RTC, including school, therapy, and the milieu.
ARC is considered evidence based practice (EBP) because it was formulated with clinical expertise and the available evidence through research on trauma informed care within RTC. It also has a few studies that have evaluated its effectiveness. An independent cross-site evaluation found ARC to show significant reduction in PTSD symptomology as well as the Child Behavior Checklist for children ages 6-18 for a period of 6 months (ICF International, 2010). Arvidson et al. (2011) found Alaskan children in ARC to achieve placement permanency at a rate of 92% compared to a rate of 40% for the state of Alaska annually. Hodgdon et al. (2013) found significant decrease in overall PTSD symptoms among female residents in two RTC. Moreover, ARC was found to decrease use of restraints by 50% within 6 months of implementing the new model (Hodgdon et al., 2013).
ARC focuses on three core domains: Attachment, Regulation, and Competency. Within each domain are nine core targets of intervention along with a tenth target Trauma Experience Integration, which applies the skills learned throughout the domain to processing the traumatic experience.
In order to fully implement ARC, Fixsen et al. (2005) established a set of six stages. It includes assessing areas of need within the institution, establishing implementation teams, training the program staff, working with caregivers to develop more skills in line with the ARC framework, and regularly evaluating outcomes of the program. A systemic approach to implementation, from the top down ensures a full culture change.
ARC has also been considered effective by Arvidson et al. (2011) to work within diverse groups of clients. For young children, ARC increases attunement on the part of the caregiver to develop a firm attachment base for the child, while enhancing the caregiver’s ability to promote self-regulation and sense of self for the child. For culturally diverse populations, like the sample of Alaska Natives in the study above (Arvidson et al., 2011), conversations about caregiver affect management can help caregivers acknowledge when certain behavior is being misinterpreted through their own cultural lens. In short, ARC places an emphasis on self-reflection on the part of caregivers, therapists, and any other adults involved in the treatment of the juvenile. This self-reflection leads to more culturally sensitive treatment, making ARC applicable to different populations
My Answer
In light of the above research, TIC is not simply an optional treatment modality for RTC. In fact, it seems that TIC is a necessity for an effective RTC, considering the high proportion of residents struggling with trauma. Because of the vast array of professionals and contexts involved in a RTC program, it is also apparent that a systemic view of the program is necessary in order to have an integrated trauma-informed RTC. Staff training seems to be a salient feature in RTC, so that there can be continuity of care. ARC suggests ongoing staff training and conversations about self-reflection to encourage growth in caregiving abilities. Ongoing staff training also addresses the need for consistency amongst the system. Youth with trauma histories have long lived with inconsistency and not knowing what to expect, so they may become fearful when the adults around them contradict one another or show inconsistencies. Because of the amount of individuals involved in a RTC, it becomes vital for staff to regularly check in about their own reactions to youth and receive valuable training. This fear of inconsistency for youth is also addressed in ARC’s emphasis on routines and rituals (Arvidson et al., 2011). ARC is also culturally competent and certainly meets the qualification for trauma informed care.
Legal/Administrative/Clinical Implications
Administrators need to understand that in order to have a trauma informed RTC, it is important for clinicians to have time for reflection and evaluation of their both their own and their staff’s abilities, emotional reactions, and intervention points. This amount of time is rare in RTC because the treatment is already expensive enough without building in time to reflect for clinicians and other professionals. For example, a local RTC recently had to cut back on something in order to continue serving residents, so they cut back on trainings. This is problematic because of the systemic nature of RTC and the importance of staff cohesion for youth who are already accustomed to a world that is inconsistent and random.
Administrators also need to evaluate their program regularly in order to ensure that it is maximizing benefits.
Clinicians can help in making RTC more cost-effective by assessing the client’s regularly and shortening the length of stay to avoid plateau and eventual deterioration after 10 months. It also includes ensuring that RTC is the most appropriate option. Maintaining compliance with the principle of Least Restrictive Environment is paramount to helping juveniles improve their behavior and symptomology. Clinicians also need to be certain they are competent at the basic intervention points for trauma informed therapy as laid out by Amaya-Jackson et al. (2007).
Legislators need to understand the importance of the quality of staff on RTC. Low pay is consistently a barrier to RTC receiving staff and clinicians that are well suited to the work. The development of other options for youth removed from homes for justice related or human services related issues, like Therapeutic Foster homes, is something legislators need to look into because RTC is not a suitable or cost effective option for most juveniles.