A facility-wide consultation and training team as a catalyst in promoting institutional change

Analysis and Intervention in Developmental Disabilities Vol. 3, pp. 151-169, 1983 Printed in the USA. All fights reserved.

0270-4684/83 $3.00 + .00 Copyright © 1983 Pergamon Press Ltd

A Facility-Wide Consultation and Training Team as a Catalyst in Promoting Institutional Change Stephen G. Flanagan Camarillo State Hospital and UCLA School of Medicine

Mary E. Cray Doug Van Meter Camarillo State Hospital

Staff training in behavior modification and large scale program development at Camarillo State Hospital was facilitated by a mobile Consultation and Training Team. Working closely with top management, the team trained staff and developed services "on the job" in the residential Units. Staff acquisition of behavior modification skills was necessary but not sufficient for program delivery. Management practices promoting utilization of clinical skills and maintenance of programs were essential. Discussion focuses on the entry process at multiple levels in the organization, the use of active and directive training methods to achieve skill-oriented goals, multi-level evaluation of training, planning for maintenance, and social~political issues in "institutionalizing" positive changes.

A major challenge for applied behavior analysis in the 1980s is the establishment of effective technology for large scale implementation of behavior modification programs in rehabilitation, mental health, and developmental disabilities. Despite the rapid growth of behavioral technology and the burgeoning research and clinical literature documenting successful behavior analysis programs with many client populations, only gradually is behavior analysis and therapy becoming This report is based in part on work supported by a NIMH Hospital Improvement Project Grant to Camarillo State Hospital, No. MH-R20-C, from 1975 to 1978. The views expressed are the authors' and should not be construed as official policy of the NIMH or the California Department of Developmental Services. Reprint requests may be addressed to Dr. Stephen G. Flanagan, Camarillo State Hospital, Box A, Camarillo, CA 93011. 151

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available to a large population of consumers who may ultimately benefit. For the clinical researcher, the task is to come out of the "ivory tower" of the laboratory or highly-staffed and well-funded demonstration project and confront the practical issue of providing high-quality behavioral treatment services at a reasonable cost in settings where resources are limited, reliable data are often devalued, and control of many significant reinforcers and other variables is limited (Liberman, 1979). Clinicians and administrators working in "real-world" human service settings such as state health and welfare agencies, public mental health and developmental disabilities hospitals, schools, and vocational rehabilitation centers also face a choice of meeting often overwhelming immediate service needs using traditional methods versus investing some of the organization's scarce resources in support of innovative methods for service organization and delivery which hold the promise of greater long-term benefits for clients and staff. Behavioral technology is of value in teaching a wide range of skills to individuals with mental retardation, schizophrenia, chronic mental illness, autism, and other severe disabilities. Behavior modification procedures are also of value in the reduction or elimination of problematic behavior such as aggression and self-injurious behavior, as well as less serious but highly undesirable behaviors such as stripping, smearing, hallucinatory and delusional behavior, hyperactivity, stealing, and property destruction, which occur with some frequency among severely handicapped clients. The Clinical Training Team (CTT) at Camarillo State Hospital for the past 7 years has provided behavior modification training and program development services to managers and staff working with diverse client groups: chronic mental patients, hospitalized children and adolescents, and clients with autism and mental retardation. In this time, the training team's efforts have led to many successful behavioral programs as well as a number of failures. We will summarize the training team's methods of teaching clinical behavior therapy skills to staff and their evaluation. We believe that staff acquisition of skills is generally overemphasized as a factor facilitating innovation and planned change. While direct service staff members must acquire behavior management skills if proposed changes are to occur, skill acquisition is only one of a cluster of events and actions necessary for program implementation and maintenance. Drawing from experiences in the state hospital for illustration, the authors will discuss other key dimensions in institutional change and propose one model for getting there. A growing literature addresses necessary and sufficient conditions for institutional change toward adoption, successful application of behavioral methods, and factors which facilitate or retard change. This literature can be divided into studies involving empirical tests of the effects of behavioral interventions in the organizational setting, and studies or anecdotal reports assessing the role of factors external to applied behavior analysis. The former studies include research

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on such issues as staff training; effects of goal setting, contingencies of reinforcement, modeling, feedback, and other variables on service delivery; and identification, training and implementation of supervisory and managerial practices affecting service delivery. The latter reports address interpersonal, social, and political realities as they affect the change agent, the change process, and the institutional system. This literature will be cited very selectively in reviewing critical issues in the dissemination of behavior modification methods and their adoption by institutions. THE CONSULTATION AND TRAINING TEAM A mobile consultation and staff-training team provide relative advantages in comparison to other methods of organizing services to meet program development and staff training needs. Advantages include: 1.

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The trainers have convenient opportunities to analyze contingencies operating on client behavior and staff performance in the clinical setting. As a result, proposals for program change can be developed that are realistic and attainable. Trainers get the opportunity to demonstrate their skills in working with the trainee's clients, enhancing trainer credibility which is essential to acceptance and cooperation. Trainees learn clinical skills working with their own clients, reducing generalization problems after training. Trainers can more readily adapt behavioral procedures to special client characteristics in the latter's prosthetic settings; for example, clients with deafness or blindness, physical handicaps, cognitive or language deficits. Staff members who work together go through training at the same time, enabling cooperation and mutual support in implementing programs. Simultaneous interventions can be made by trainers aimed at improving staff clinical skills, supervisory and management skills, and environmental design. Training and program development can be accomplished in the workplace without removing staff or depriving clients of services as might be required in classroom or off-site workshop programs. For example, if a trainer needs to work with a staff member who is assigned to a group of clients, another trainer can sometimes "cover" for the trainee, maintaining continuity and assuring that cooperative staff are not punished by having to work to "catch up" when they return from training.

There are disadvantages also to consultation and training with a mobile team "in the trenches." Team members must catch the staff where they work--being flexible to schedule evening and night shift training as well as daytime work.

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Trainers must also work around nursing schedules which run 7 days per week with employees on varying cycles of days-off: on any given day, about two of every seven employees will be unavailable. Meetings and training sessions are threatened by telephone calls and client emergencies and by pressure on employees to do charting and paperwork; escort clients to clinics, courts, or offunit activities; and maintain the physical environment. Other disadvantages of the mobile team include the risk of elitist behavior on the part of trainers or, just as harmful, the perception of elitism by unit staff receiving the training. Staff are likely to act defensively on their own unit more so than in off-unit classes or training sessions. A question often asked by staff is "Why are you here? Does the administration think we're not doing our jobs?" To be successful, the team must be sensitive to potential problems and be prepared to use their social skills and shaping attitudes (Liberman, 1979)--acknowledging cooperation and progress and ignoring dysfunctional staff behavior. Team Composition

The first author, a clinical psychologist specializing in behavior therapy, is part-time director of the team. The second author is a full-time behavior analyst and supervises team members in their work. The third author is clinical director of Camarillo State Hospital who exercises supervisory responsibility over the assignments and performance of the team. Currently, two psychiatric technicians and two registered nurses with skill and experience as clinical behavior managers, and varying degrees of experience and skill in supervision and management, serve as the consultant/trainers. The role of the nursing personnel on the team is a central one: each has worked as a group leader or supervisor on Units, and knows first-hand the realities of the hospital setting. They are able to most effectively bridge the gap between being "outsiders" as agents for change, and maintaining the perception by unit nursing staff of being "one of us." The team members are also quite skilled at keeping the director in a practical and realistic mode of action, tempering overly ambitious and theoretically-based training goals. Mission

The Clinical Training Team was initiated in 1975 on a NIMH Hospital Improvement Grant to Camarillo State Hospital. The primary objective of the training team was, and is, to disseminate behavioral technology within the institution: to bring applied behavior analysis to bear on the skill training, resocialization, and behavior management needs of hospitalized clients; and to increase the effectiveness and morale of psychiatric technicians, nurses, and other direct service staff by making innovative, effective treatment methods available to them. This is accomplished by earning the confidence and trust of unit staff,

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working side-by-side with them, modeling and demonstrating the value of behavioral techniques by instituting data-based programming with their clients. After effecting improvements in client behavior that are reinforcing to staff as well as benefiting the client, the team teaches clinical skills. Brief active and directive workshops are followed by on-the-job rehearsal and feedback to staff while they work with their own clients. When these objectives are met, the team turns programs over to regular staff and then fades gradually out of the unit, leaving a well-run program behind. This paradigm continues to form the core of the clinical training strategy. Reflection on some disappointing results as well as dramatic successes point to critical issues in implementing and maintaining innovations in the institution. Aspects of the team's functioning to be reviewed here include the entry process, methods of staff training and its evaluation, the need for supervisory and managerial development in support of behavior modification programs, implementation problems, and structuring or "institutionalizing" change--making behavior modification a permanent part of the organization's way of doing business. ENTRY Entry for training purposes was facilitated by the full support for the CTT and its training mission by the executive director and clinical director of Camarillo State Hospital. Also helpful was the consultative and resource support provided by Dr. Robert Paul Liberman who had initially written and obtained the Hospital Improvement Grant from NIMH in 1972 and whose Clinical Research Unit at the Hospital had been in existence and providing behavioral assessment and therapy services to other units and staff of the Hospital since 1970. However, there are multiple levels of entry in the institution which present different problems and require divergent solutions. The levels addressed here are entry with upper management, middle management and the level of direct service--the ward or unit staff.

Entry with Upper Management Top management in the institution is an essential starting place for innovation. Formal responsibility for long-term planning and service development resides here, as well as the authority and control of resources necessary for any largescale efforts. Top management is also most sensitive to influences from outside the institution--legislators, parents, regulatory and licensing agencies, civic and advocacy groups, and other outsiders with impact on the institution's funding, operations, and sources of referral. This makes them aware of overall directions the institution needs to take, as well as needs for new services or redirected efforts. Gaining access to staff and clients depends on both the innovator's

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willingness to meet organizational needs as defined by upper management and on marketing innovations in terms of anticipated benefits to clients, staff, and the organization. For the academic researcher, accustomed to justifying efforts on the basis of contribution to theories o f behavior or advancing science, such a focus m a y seem secondary. For the applied behavior analyst, there is of course considerable congruence between research interests and service-oriented goals. The necessity of upper management support may foreclose efforts at innovation, however sorely needed, in some institutions when top management fails to support innovation (Fairweather, 1974). In other cases, upper management is a key to successful innovation. For example, the executive director of Camarillo State Hospital recently announced that those units developing and maintaining token economy programs which gained the approval of a facility-wide behavior management committee would be eligible for payments of $100 per month from a special fund to support back-up reinforcers for token exchanges. In a time of severely limited budgets, this opportunity not only supported behavioral programming directly, but also provided tangible and symbolic reinforcement to those staff who organized and delivered consistent programming.

Entry with Middle Management The entry and negotiation process with middle managers is summarized in checklist form in Table 1: This checklist is employed as a guide for trainers entering into clinical care settings and also in workshops on training and consultation. The key middle managers at Camarillo are program directors, who TABLE 1 Checklist for Negotiation of Entry in Continuing Education

A. Prearrangements and Setting 1. Choose appropriate time and place, away from telephones and interruptions. 2. Arrange for all key people to be present. 3. Determine relationships of participants and organizational structure. 4. If any participants or their functions are unknown, have introduction and brief background. 5. Avoid barriers between people, such as desks. 6. Dress similarly to consultees. B. Negotiation Skills 1. Facilitate all people participating actively. 2. Ask questions about problems, past solutions. 3. Listen; avoid making suggestions initially. 4. Use non-judgmental statements. 5. Establish credibility with brief review of past successes in training in the target area. C. Decision Making • I. Write goals which are specific, realistically attainable, measurable. 2. Write training plan, specifying who will do what, when, using what methods. Note any special arrangements needed. 3. Specify maintenance and generalization plan. 4. Specify evaluation plan considering levels of evaluation. 5. Contingencies of training, maintenance, and evaluation summarized in a written contract.

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have administrative responsibility for 3 to 5 residences or Units, and Unit Supervisors, who are senior nursing personnel with 24-hour responsibility for their units. Licensed nursing staff, psychiatric technicians, R.N.s, and L.V.N.s, and unlicensed hospital workers report to the unit supervisor through a shift lead or first line supervisor on each of the three shifts, while the physicians, social workers, rehabilitation therapists, teachers, psychologists, and other clinical staff, and the unit supervisors, report to the program director. Before entering a Unit or Program, a contingency contract is typically drawn up which specifies responsibilities of the training team and program management for a project• After getting "burned" several times on informal verbal agreements, which the trainers and middle managers recalled later as differing in important respects, the training team has since firmly adhered to written agreements in negotiating training and consultation goals• Written agreements, and tracking of progress, form the basis for top management holding the training team and middle management accountable for results• Table 2 illustrates a typical training contract. •

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Entry with Direct Service Staff As Repucci (1977) has pointed out, successful entry at top or middle management levels does not guarantee success in effecting changes at the level of client care. To minimize resistance by direct care staff, the team's initial entry step is to arrange to be formally introduced and "legitimized" by the program director and unit supervisor in a team meeting, usually scheduled at the 3:15 p.m. shift-change from day to evening staff. A brief presentation of the goals of the project is presented, along with the clear message that unit staff will participate in decision making on programs and that no changes will be made immediately. TABLE 2 Model Contract for Clinical Training and Program Development Camarillo State Hospital Clinical Training Program Development Contract Unit__, Program__

We agree that Unit___will initiate program development efforts to expand the Unit's delivery of behavior modification services to residents. Specifically, the goal of this effort is: Staff will carry out programsto increase residents' self-careskills and maintain residents' performanceof recreational and leisure time activities. We agree that the following specific objectives will be met with the following plans of action: Objective #1: Staff will follow schedules for client training. Plans: A. Shift leads will develop detailed schedules for client training and activities, and other staff activities such as health care, unit maintenance, charting, and medications, and staff meals and breaks. B. Schedules will include a minimum of 75 minutes per group per shift daily of training in grooming skills. (cont. next page)

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TABLE 2 (cont.)

C. Schedules will include a minimum of 30 minutes per group per meal daily of training in eating skills. D. Schedules will include a minimum of 60 minutes per group per shift daily of training in bathing skills. E. Shift leads will monitor staff schedule adherence, providing positive feedback and counseling as needed. Objective #2: Staff will provide toys and recreational materials for their groups and supervise their use. Plans: A. Staff will schedule supervised activity times for their groups for a minimum of one hour per shift daily (A.M. and P.M. shifts). B. Shift leads, rehabilitation therapist, and group leaders will develop and carry out a plan for obtaining, storing, maintaining, and replacing toys and recreational materials appropriate for each group in the group areas. C. Shift leads will monitor staff supervision of recreation, providing positive feedback and counseling as needed. Objective #3: All Staff will demonstrate clinical skills necessary to carry out programs in teaching skills and maintaining activities. Plans: A. Clinical Training Team will teach behavior modification skills in workshops and on-unit demonstration and rehearsal sessions. Curriculum will include: 1) Teaching self-care skills of toileting, dressing, eating, bathing and grooming, and 2) Group activity programming including prompts, reinforcement, and making "rounds" in group. B. Shift leads and designated nursing staff trainers will maintain staff skills by scheduling monitoring and feedback once weekly until criterion of 90% correct training procedures is met, and monthly monitoring and feedback thereafter. Contingencies of Training and Programming: 1. Unit Supervisor and all shift supervisors will complete organizational behavior management training, including practice exercises and shift schedules before self-care training workshops will begin. 2. Supervisory personnel will schedule staff for training in collaboration with Training Team, and assure attendance. Training Team will provide up to 20 hours per week of Unit Coverage as scheduled by supervisor. 3. Training Team will train, supervise in groups, and certify all nursing staff group leaders in each self-care area and in activity programming skills. 4. Training Team will collect, summarize, and evaluate data on effects of activity program on residents' behavior, and presnt results at 8 weeks planning session. 5. Program managers will conduct 10 weekly training audits at scheduled training times during the 4 weeks after all staff have been certified in all procedures, and present the data at maintenance planning session scheduled 8 weeks after all staff have been certified SIGNATURES: (Training Team Director, Program and Unit Managers, Clinical Director) D u r i n g the n e x t f e w w e e k s , the t e a m m e m b e r s s c h e d u l e t i m e to b e o n the u n i t , o b s e r v e a n d assist w i t h p r o g r a m m i n g , get to k n o w s t a f f a n d clients, e v a l u a t e the u n i t ' s f u n c t i o n i n g a n d p i n p o i n t (but a v o i d d i s c u s s i n g ) p r o b l e m s . F o l l o w i n g the i n t r o d u c t o r y p e r i o d , n e g o t i a t i o n s are started to specify p r o g r a m m a t i c c h a n g e s to b e t a r g e t e d , t r a i n i n g n e e d s , s c h e d u l i n g , a n d m a n a g e m e n t issues r e l a t e d to c h a n g e s . T h i s t y p i c a l l y i n v o l v e s m e e t i n g w i t h direct s e r v i c e staff, s u p e r v i s o r s ,

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and the unit manager, and checking back with the program director to concretize plans. Team members listen for evidence of low morale, such as a high rate of negative statements about co-workers and unit by more than one or two employees; or staff inactivity, or communication problems such as arguments or unsolved simple problems. When these baseline problems are identified, the training team often suggests team-building efforts prior to or parallel with clinical program development. By the time program implementation begins, staff on the unit may not be entirely sold on the changes that are planned, but they will admit that they had a chance to participate in the planning and decision making. Also, by this time the unit staff know the trainers, and a majority like the trainers. The importance of informal interaction and relationship-building with unit staff was highlighted for the training team when, after the team had been working for several weeks with the unit, a unit supervisor approached one of the trainers and said, "I was a little worried about you after our first meeting, but now I can see you're one of us." Many times, staff justified to each other trying new ways of working with clients on the grounds that the trainers were "good people" and deserved a chance to demonstrate their methods. The training team's efforts to build positive relationships with staff early in the intervention may seem to some like inefficient use of a trainer's time. One should consider, however,that the alternative may be to be "out-waited" and passively tolerated for weeks during training by hostile staff, who know that "this too shall pass away." Successful entry at all levels is the preliminary step to starting the change process. The selection of an appropriate curriculum and the conducting of effective training are the next steps. STAFF TRAINING AND EVALUATION Curriculum

Definition of the knowledge and skills needed by direct service staff will vary as a function of the client population served, the assumptions we make about the level of independence staff can demonstrate in programming, and developments and refinements in behavioral technology. The training team teaches a wide range of content areas, as illustrated in Table 3. Each curriculum developed includes a trainer's guide organized to include workshop content, time frames, audio-visual aids, modeling instructions, rehearsal guidelines, experiential exercises, handouts and forms used. On-the-job feedback regarding skills is facilitated by the development and use of skills checklists which guide the trainer in observing relevant features of performance. Checklists have the added advantage of making the observation and feedback less threatening for the trainee. By reviewing the checklist ahead of time, the

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TABLE 3 Clinical Training Team Curriculum: 1975-1982 Independent Grooming Clients: Chronic mental patients, mildly and moderately retarded adults in residential programs. Procedures: Task analysis and assessment of client grooming skills; modeling, shaping, prompting, graduated guidance; generalization and maintenance through fading staff control and teaching self-monitoring and self-reinforcement skills. Activity Programming Clients: Chronic mental patients, developmentally disabled clients. Procedures: Environmental design, materials availability, prompting and reinforcing play, behavior management strategies, mild time out for disruptive behavior. Social Skills Training Clients: Chronic mental patients, developmentally disabled clients, child and adolescent psychiatric patients. Procedures: Social skills assessment and goal setting; group organization; modeling, rehearsal, feedback, prompting, shaping, reinforcement; generalization and maintenance strategies. Self Care Skills Clients: Severely and profoundly retarded clients. Procedures: Task analysis of grooming, dressing, bathing; prompting, reinforcement, shaping; forward and backward chaining. Toilet Training Clients: Severely and profoundly retarded clients. Procedures: Habit training, Foxx-Azrin (1972) day and night procedures, differential reinforcement, simple restitution program. Mealtime Programming Clients: Developmentally disabled and autistic clients. Procedures: Assessment of mealtime behavior; grouping strategies; prompting, reinforcement, mild time-out. Group Management Clients: Severely and profoundly retarded clients. Procedures: Environmental design, seating plan, stimulus control, compliance training, differential reinforcement strategies, use of social and primary reinforcers, zone coverage with two trainers for 1:1 training. Managing Behavior Problems Clients: Chronic mental patients, developmentally disabled, autistic clients. Procedures: Individual behavior modification programming for aggression, self injury, destructive and other problem behaviors. Stimulus control, differential reinforcement, extinction, time out from positive reinforcement, mild aversives, ethical and legal issues and procedural safeguards. Organizational Behavior Management Trainees: Middle managers and first line supervisors. Procedures: Pinpointing and measuring staff performance, functional analysis, feedback, reinforcement, counseling process. Scheduling, monitoring and feedback systems for clinical services delivery.

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trainee knows exactly what behaviors will be noted, and feedback is perceived in terms of defined skills rather than in terms of arbitrary whims of the observer.

Staff Training Methods Active and directive training methods are supported in the literature as effective in teaching clinical skills (Goldstein, 1973; Nay, 1975; Ford, 1978; Matarazzo, 1978). Active and directive methods rely on trainees learning through active participation in the training effort: brief instructions are followed by the trainer modeling therapist behaviors. The trainer provides discriminative cueing, drawing the trainee's attention to relevant aspects of the modeled performance. Trainees rehearse skills while the trainer coaches and prompts correct performance. The trainer provides feedback on the performance and if necessary, trainees rehearse further until a skill criterion is achieved. Evidence suggests that active/directive methods are preferred by trainees over lecture/discussion and question and answer formats for training (Kuehnel, Marholin, Heinrich and Liberman, 1978). Trainers from the CTT use active/directive methods during workshops as well as in on-unit training sessions.

Evaluation of Training Kuehnel et al. (1978) identified multiple levels of evaluation in continuing education. Among these are need assessment, trainee satisfaction, knowledge acquisition, skills acquisition, utilization of treatment methods, and client outcomes. Each level refers to a type of outcome of training and each may be relevant to the overall assessment of training effectiveness. The Clinical Training Team uses the levels to plan evaluation strategies.

Need assessment. The Team's entry approach allows for detailed need assessment at multiple levels in the organization, and often the identification of needs will differ at different levels. For example, middle management in one program defined managing clients' inappropriate behavior as a goal for consultation and training. However, with firsthand, on-unit experience and discussion with staff, the Clinical Training Team identified low levels of client activity and engagement with their environment as a primary need. An unstimulating environment and limited access to recreational materials and activities set the occasion for high rates of aggression and other maladaptive behaviors. Further discussion with unit staff and middle managers led to a contract for staff training and program development focusing on increasing clients' engagement in activities. Trainee satisfaction. At the end of each training session, staff anonymously rate their satisfaction with aspects of the trainer's presentation, such as clarity, organization, response to questions, friendliness. These results provide immediate

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feedback to the trainer as well as suggesting what particular workshops or training packages may need revision. Trainers report that this evaluation helps keep them on-task. Knowing they will receive immediate feedback, they work to maintain good ratings. A working assumption of evaluation through satisfaction ratings is that staff are more likely to use new treatment methods when they enjoyed learning about them. Knowledge and skill acquisition. Workshop evaluations include assessment of knowledge acquisition through pretest/posttest or posttest-only formats. The focus of knowledge assessment is on practical facts and procedural matters, not on theoretical distinctions. Much stronger emphasis is given direct observational assessment of skill acquisition. This assessment is sometimes based on role-play of critical treatment skills, for example delivering positive social reinforcement or using a sequence of prompts to elicit behavior. More often, trainers monitor and give feedback to staff on actual application of behavioral procedures with residents. A skills checklist is devised which covers the critical clinical skills for a particular treatment method. For example, the trainer might watch an employee teaching a client to shave himself, and note whether the employee gave instructions in a loud and clear voice, followed a task analysis, prompted minimally using the proper sequence of prompts, and reinforced the client immediately and enthusiastically when the target behavior occurred. Utilization. Staff may be satisfied with training, and learn the knowledge and skills to provide behavioral treatment, but clients do not benefit unless the methods are used and prove to be effective. The training team conducted "training audits" on one unit after staff training was completed. With the cooperation of program management, an observer entered the unit when client training was scheduled and noted whether the activity was occurring as planned. Staff utilization of skills they had acquired in training varied over a one-month period by type of activity, by client groups, and by shifts. Self-care skills training ranged from 50% to 100% utilization; mealtime training ranged from 44% to 83%; and recreational activities training ranged from 17% to 33%. Utilization as low as 17% for explicitly scheduled client training, immediately after staff have learned and practiced the procedures, highlights the importance of planning for maintenance of programming and underscores the need for effective management strategies in service delivery. In the example cited here, the program director used the results of the audits to make management changes on the unit which resulted in improved service delivery. Client outcome. There are several levels at which the training team addressed

client outcome. First, by installing data acquisition and summarization systems as a part of consultation and training interventions, the training team increased the chances that staff would evaluate client progress and response to treatment

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objectively. Second, systematic data collection on client behavior was done in evaluation of C'IT program development and training efforts. For example, CTT trained a number of units in programs to increase clients' play and recreational activity. Direct observational data supported the efficacy of the procedures when applied by the CTT, and subsequently supported effectiveness with CTT-trained staff as trainers. Indirect measures of client outcomes have also been used, such as reductions in the use of emergency (prn) medications and restraint, or reduction in special incident reports on units when staff learn behavior modification strategies for handling aggression, self-injury and destructive behavior (Note 1). SUPERVISORY AND MANAGEMENT DEVELOPMENT Training is overemphasized as a factor in service delivery in the institution, and organizational facts of life are usually underemphasized. To exaggerate slightly, institutional management control often seems to consist of antecedent stimuli--directives, memos, instructions, and forms; and delayed aversive consequences for poor performance, while good performance is on an extinction schedule. For example, Quilitch observed that memos from the program director encouraging staff to engage clients in activity programs resulted in no change in the activity participation on four units serving mentally retarded clients. Inservice training in activity programming on two units had no impact on the delivery of activity programs. However, assigning staff to activity duty, and posting in a public place the name of the activity director and the number of clients involved in activities each day led to an immediate and substantial increase in client activity participation. This result was replicated on two additional units where staff received no activity training (Quilitch, 1975). Luke Watson (1978) provides a well-developed model of management practices in his writing on management systems in service delivery: supervisory personnel make sure that staff write their schedules and supervisors monitor performance and give feedback and reinforcement to staff for following training schedules and using behavior modification skills. Supervisory personnel resist efforts to institute organizational behavior management programs. They resist actively by arguing that structured management is not suitable for their personal style or that they are really already doing it, but they do it more efficiently and without unnecessary data. They resist passively by accepting homework assignments and returning without the work done. Trainer persistence, breaking the task into smaller steps, programming reinforcement through contingency contracts, and reinforcing the smallest steps toward compliance initially and shaping the desired performances can overcome these resistances, just as these procedures are effective in work with direct service staff and clients. The behavior analyst change agent views the consultant-supervisoremployee behavioral influence chain as being just as important for establishing improved employee behavior as the supervisor-employee-client chain is for im-

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proving client skills and behavior. An illustration of the importance of supervisory input in programming came in a study of mealtime skills training with staff and autistic clients. The trainers taught management of mealtime behaviors through pinpointing target behaviors for each client to increase (e.g. taking small bites of food, putting utensils down between bites, using napkin), and behavior targeted for decrease (for example, eating with fingers, snatching food from others). Staff use of prompting and reinforcement as well as the mealtime behaviors of clients were tracked during baseline, after staff training in the procedures, and after scheduling and prompting: each staff member was assigned to work with one group of residents and given a set of prompt cards describing each resident's pinpointed behavior to be kept in sight during meals. Data on staff prompting and reinforcement showed no change from baseline to post-inservice training, and client behaviors showed no changes. Following assignment of staff to groups and posting of prompts for staff, prompting and reinforcement of clients increased, and client behaviors improved (Note 2). PLANNING FOR MAINTENANCE Getting innovative programs implemented can be a major challenge. Maintaining programming after the "sparkle" has worn off is the real payoff. The consultant/trainer must keep the goal of permanently changing the institution at the f o r e - - a n d make every effort to institutionalize new ways of doing things. Fading

During staff training and implementation of an innovative program, much of the leadership in programming is assumed by the training team. The trainers write, conduct, and document progress in skills training and behavior management programs, develop schedules of activities, monitor staff performance and give feedback and reinforcement to employees on their work. When the goals of the intervention have been realized, the next step is to turn over all critical tasks to regular staff members. Supervisors assume responsibility for scheduling, monitoring and feedback; group leaders write, conduct, and document progress in skills training and behavior management programs with occasional assistance from supervisors or ancillary staff skilled in behavioral engineering. Only when the regular staff have identified these tasks, made them a part of the unit's procedures, and assumed responsibility for them can the consultation and training team make its exit with some assurance that the unit will continue its successes. For example, in comparing the success of one unit's maintenance of a self-care skills training program with two units' failure to maintain the same programming, we noted that the successful unit had assigned the role of training coordinator to one employee on each shift. The unit supervisor on the successful unit kept in regular contact with the training coordinators to maintain training and certi-

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fication of employees on their shift and to monitor delivery of training to clients. The training team, as in-house consultants, are available to units for follow-up assistance in maintaining programs.

Eliciting Cooperation and Follow-Through At the start of the program, the training team sets goals with middle management. Contingencies are agreed upon and scheduled evaluation points are determined when continuing the project or terminating is determined by completion of the actions agreed upon. All of these are antecedent events. Tracking progress and delivering consequences for compliance or noncompliance are also necessary. If critical terms of the agreement are not met, the consultant brings this to the program manager's attention and the manager takes action to see that the terms are met. If top management fails to track progress and deliver effective consequences, critical events or actions do not occur and failure is guaranteed. Unfortunately, failure is often attributed to behavior modification procedures being impractical or unworkable when in fact they are merely untriod. A case example may illustrate this concretely. Unit A was a ward serving 35 severely and profoundly retarded men. Activity programming was selected as the target for staff training and program development. Supervisory staff also entered into organizational behavior management training in which they learned and practiced setting goals for staff performance, communicating these goals through scheduling, monitoring performance and providing feedback and consequences to staff for running activities programs. Recreational materials were made available to clients. Staff were trained in the use of a simple prompting and reinforcement regimen combined with making rounds of the various residents in a group to encourage appropriate play with materials. Middle managers had agreed to schedule staff to participate in training sessions and in on-unit feedback by trainers in their groups, and assigned staff to work on activities programming at specified times each day. Supervisors praised staff members who completed their activity programs. When some staff members failed to attend training or work with their groups at scheduled times, middle manager's were aware of this and appropriate actions were taken to assure compliance. Data on staff prompting and reinforcement and client engagement with materials during training and follow-up on unit A showed significant increases on both measures. Unit B, a cocd unit serving clients ranging from mildly to profoundly retarded, contracted for the same activity program and supervisory training. However, the supervisory personnel did not follow through on monitoring and giving feedback for scheduled activity programming by staff. When noncompliance by some staff was brought to the attention of middle management, action was inadequate. Upper management requested that the training team "make the best of the situation" by completing training with cooperative staff members, but the damage was done: without management effort in support of the project, direct service

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staff were unable to maintain their efforts. Data on staff services and client activities indicated the project had little or no impact.

SURVIVAL AND POLITICAL REALITIES: FIGHTING FIRES For the first three years, the team was in a relatively secure position with stable extramural grant funding and projects rolling along. By the third year, with imminent termination of the grant, however, survival became a dominant theme for the training team despite its excellent record of delivering effective training and developing practical, workable programs. The team director met with top administrators and with directors of the hospital's various programs to seek commitments to support the team beyond the grant. Although many were appreciative of the team's services, none would make a commitment to continue the project on "hard money," funding positions from hospital allocations. For innovations to be adopted, they must hold the promise of alleviating organizational pain (Hammerlynck, 1980). For Camarillo, we discovered the pain in a program for clients with mental retardation and severe behavior problems. This program had been innovative in the early days of token economy development in the late sixties and early seventies, but these programs had been long abandoned and they had failed to keep up with rapid changes in developmental disabilities services in the seventies. When the team arrived there in 1978, the program was under close critical scrutiny from within and outside the hospital. An overemphasis on custodial care and failure to provide habilitation programming and treatment services to residents were primary deficiencies. Psychotropic drugs were being overused as a substitute for programming, and often as the only treatment modality for some residents. The physical condition of the unit was poor, and overworked staff who spent much of their time attending to "crises" in client behavior had little time to devote to clients' dressing, grooming, and toilet training needs. Staff morale was low, and they had little pride in their work. These problems had led to a consortium of regional centers forming a committee to work with hospital administration on reforms needed in the program. Regional centers are state funded private nonprofit agencies charged with overseeing services in California for all persons with developmental disabilities. Every state hospital client is also a client of a regional center. Two units in particular, one for men and one for women, were considered the worst in the facility; both housed clients ranging from mildly to profoundly retarded, with severe behavior problems including self-injurious behavior and aggression, as well as a wide range of socially undesirable behaviors: for example, stripping, yelling, smearing, hyperactivity, and property destruction. Many clients also had behavioral deficits in self-care and basic living skills: toileting, bathing, dressing, eating, grooming and hygienic behaviors, social interaction, leisure and recreational skills. The team could assume responsibility for reform of the male unit in exchange for continued survival as a team.

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The training team took the task and used all of the principles outlined above to implement programming. Staff learned to use operant skills to teach grooming and self help skills. Behavior intervention programs were developed for the most serious maladaptive behaviors, and staff were trained in implementation. A coordinator with experience in behavioral engineering assumed clinical leadership on the unit, working with the unit supervisor to establish schedules for training and activities, and helping group leaders to promote consistent efforts. The effort paid off. Clients' skill acquisition went up from an average of 1% improvement before the program to 25% during program development and 40% one year later. Behavior problems showing improvements increased from 4% before training to 38% during training and 80% one year later. (Skill deficits improved more modestly than behavior problems because there were many more identified skill deficits and training time was limited). Wet beds were reduced by 2/3. There was a 40% reduction in the use of emergency psychrotropic medications (prn's) in the one year after the start of the program, from an average of about 50 per month to an average near 30 per month. The other units in the program continued to average around 50 prn's monthly. One client frequently charged into the unit office to grab cigarettes, often pushing down employees in the process. He had injured employees on numerous occasions. After the client was placed on a differential reinforcement program, the behavior decreased and there were no subsequent employee injuries due to this client. Residents who had been receiving total physical care from staff did more for themselves in dressing, grooming, bathing, toileting. About 18 months after the end of the intensive training and program development efforts, the unit regressed. Staff turnover had taken its toll, and new staff did not receive behavioral skills training consistently. A few energetic group leaders who provided mutual support continued to work effectively with the selfcare and activity programming of residents in the absence of clinical leadership by supervisory personnel or any team-efforts. One efficient coordinator/evaluator left the area, another took a different position. Efforts to rekindle the project were unsuccessful. There were no crises or external pressure to motivate change, and too few of the key people involved in maintenance of the program remained to keep the program alive. The Regional Center Committee was pleased with the reforms, and had since reoriented its mission to liaison with the hospital. The training team's efforts with the women's unit in this program had a more favorable outcome. In this case, key individuals including a strong unit supervisor, a psychologist who had interned with the training team and later assumed clinical responsibility on the unit, and a core group of dedicated and hard working staff were committed to maintaining the unit's gains and saw that behavioral treatment was followed despite bureaucratic obstacles and budgetary cutbacks. Slama and Bannerman (1983) summarize this program's success story. Flexibility, and a willingness to meet current organizational needs are keys to political survival and future opportunities to implement needed improvements

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in services for clients. Past examples of the training team's flexibility include providing assistance in the 24-hour monitoring of a community care facility employing publicly controversial punishment procedures, until the Regional Center and Department of Developmental Services could set up a hearing on the controversy; and voluntarily providing direct service coverage on a unit for deaf and heating handicapped residents during a critical staffing shortage. A second principle for political survival is to keep a high level of visibility. Publicizing projects and activities, making professional presentations at regional and national conferences, publishing articles and research papers, speaking to community and civic organizations, and consulting with community agencies reflect positively on the hospital or organization and bolster the team's image. The Clinical Training Team initiated the Camarillo Conference on Behavior Analysis and Therapy in 1978, and CCBAT-4 was held in October of 1981. In addition to providing training and information on new directions and successful programs for behavior modifiers in state hospitals and community settings, the conference provides positive publicity for the hospital in the local community, promotes staff acceptance and interest in behavioral techniques, provides recognition and reinforcement for behavioral innovators, and enhances Camarillo's image as a center for behavioral technology. SUMMARY

The Clinical Training Teaan served as an integral part of Camarillo State Hospital from 1975 to 1982. In those 7 years, significant progress was made toward "institutionalizing" behavior modification technology. Administrators and direct service staff are generally cognizant of and oriented toward behavioral treatment approaches. On-line staff are better skilled in conducting behavioral treatments. On a large scale assessment of basic behavior modification skills, CTT-trained staff performed significantly better than the facility-wide average. The hospital has attracted and kept a number of behaviorally skilled professionals, including several psychologists who interned with the training team and have incorporated the training model in their work with staff and clients. Maintenance of gains in providing high quality services is a continuing struggle. As federal and state governments continue to experience diminishing revenues, legislators and administrators are finding resources scarce in meeting the right of people who are mentally ill, handicapped, or developmentally disabled to appropriate education, training and treatment. Although behavioral approaches offer advantages such as data-based accountability, and cost effectiveness relative to traditional institutional practices, behavioral clinicians will need to be assertive in advocating for clients needs and willing to take on the political challenges of large-scale program development if they hope to use the technology to improve the lives of disadvantaged people.

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Acknowledgements--The authors are indebted to Clint Rust, Executive Director of Camarillo State Hospital for his support of the program, and to Robert Liberman, M.D., for his encouragement and counsel on this project as well as for his leadership at Camarillo and nationally in disseminating proven behavioral technology. Requests for reprints should be addressed to the first author, Camarillo State Hospital, Box A, Camarillo, CA 93010.

REFERENCE NOTES 1. Flanagan, S. & Cray, M. Annual Report of the Clinical Training Team, 1978-79. Camarillo State Hospital, Camarillo, California, July, 1979. 2. Clinical Training Team. Mealtime Programming for developmentally disabled clients. Workshop presented at the fifth annual California Behavior Analysis Conference, Stockton California, April, 1981.

REFERENCES Fairweatber, G. W., Sanders, D. H. and Tomatzky, L. G.. Creating Change in Mental Health Organizations. Elmsford, N.Y.: Pergamon Press, 1974. Ford, J. Training in Environmental Design. In L. Krasner (Ed.) Handbook of Environmental Design. New York: Pergamon Press, 1978. Foxx, R. M. and Azrin, N. H. Toilet Training the Retarded. Champaign, Illinois: Research Press, 1972. Goldstein, A. P. Structured Learning Therapy. New York, Academic Press, 1973. Hamedynck, L. A. When you pass the behavioral buck--make it contingent. The Behavior Therapist, 1980, 3, No. 5, 5-9. Kuehnel, T. G., Marholin, D., Heinrich, R. & Liberman, R. P. Evaluating behavior therapists' continuing education activities: The AABT 1977 Institutes. The Behavior Therapist, 1978, 1, 5-8. Liberman, R. P. Social and Political challenges to the development of behavioral programs in organizations, in Trends in Behavior Therapy. New York: Academic Press, 1979. Matarazzo, R. G. Research on the teaching and learning of psychotherapeutic skills. In Garfield, S. and Bergin, A. (Eds.). Handbook of Psychotherapy and Behavior Change, 2nd Edition. New York: John Wiley, 1978. Nay, W. R. A systematic comparison of instructional techniques for parents. Behavior Therapy, 1975, 6, 14-21. Quilitch, H. R. A comparison of three staff management procedures. Journal of Applied Behavior Analysis, 1975, 8, 59-66. Repucci, N. D., Implementation issues for the behavior modifier as institutional change agent. Behavior Therapy, 1977, 8, 594-605. Repucci, N. D., and Saunders, J. T. Social psychology of behavior modification: Problems of implementation in natural settings. American Psychologist, 1974, 29. Slama, K. M., & Bannerman, D. Implementing and maintaining behavioral programming in an institutional setting. Analysis and Intervention in Developmental Disabilities, 1983, 3, 171-190.