Riverview Hospital for Children and Youth: A Culture of Promise [1 ed.] 9780819575906, 9780819575890

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RiveRview Hospital foR CHildRen and YoutH

a dRiftless ConneCtiCut seRies Book This book is a 2015 selection in the Driftless Connecticut Series, for an outstanding book in any field on a Connecticut topic or written by a Connecticut author.

RiveRview Hospital foR CHildRen and YoutH A Culture of Promise ...

RiCHaRd J. wiseman

wesleYan univeRsitY pRess Middletown, Connecticut

Wesleyan University Press Middletown CT 06459 www.wesleyan.edu/wespress © 2015 Richard J. Wiseman All rights reserved Manufactured in the United States of America Typeset in Arnhem by Tseng Information Systems, Inc. The Driftless Connecticut Series is funded by the BeatRiCe fox aueRBaCH foundation fund at the Hartford Foundation for Public Giving. Wesleyan University Press is a member of the Green Press Initiative. The paper used in this book meets their minimum requirement for recycled paper. The manual excerpts in this book are provided for historical reference and are not recommended or endorsed by Connecticut’s Department for Children and Families. Library of Congress Cataloging-in-Publication Data Wiseman, Richard Riverview Hospital for Children and Youth : a culture of promise / Richard J. Wiseman. pages cm.—(A driftless Connecticut series book) Includes bibliographical references. isBn 978-0-8195-7589-0 (cloth: alk. paper) — isBn 978-0-8195-7590-6 (ebook) 1. Riverview Hospital for Children and Youth (Middletown, Conn.) 2. Mentally ill children—Care—Connecticut—Middletown. 3. Child psychotherapy— Residential treatment—Connecticut—Middletown. I. Title. RJ504.5.w56 2015 618.92′89140097466—dc23  2015011319 5 4 3 2 1

Cover illustration: Aerial Photograph of Riverview Hospital, circa 1995. Courtesy of Richard Ribisl

To my wife, Eunice G. Wiseman, our son, Kenneth R. Wiseman, and our daughter, Lauren W. Sullivan, who sat through many family meals while I monopolized the conversation talking about the latest growing pains of the new Children’s Unit

RiverView—The Years Jacqueline Reardon, 1984 A time for us, for them Those countless faces The hurt they feel, we feel Their tears awash with our own The joys of discovery They awaken To light To life To self And we rejoice with them For we, too, are awakened To all that is theirs . . . And ours

Contents ... Foreword by Louis Ando xiii Author’s Note and Acknowledgments xvii 1. On the Way Up the Hill 1 2. A Place to Start 8 3. A New Home 22 4. A New Direction 34 5. Children Do Not Belong in Psychiatric Hospitals! 45 6. A New Name 59 7. The Evolution of a Milieu 64 8. Children’s School 82 9. Recreation in the Children’s Unit 92 10. Adolescence 98 11. Teamwork 106 12. Identity 117 13. Post-Merger 135 14. A Broader View of Change 186 15. Addressing the Mood in the Milieu 194 16. The Next Generation 205 appendixes 1. Excerpts from The Behavioral Learning Environment Unit: BLEU—A Handbook and Training Manual Prepared for the Staff at Connecticut Valley Hospital Children’s Unit 211 2. Excerpts from ABCD Program—Staff Manual 219 3. Excerpts from Sunburst Program Manual 235 Notes 245 Bibliography 253 Index 259 Illustrations follow pages 58 and 134

foRewoRd ... Historically, state- operated mental health systems are not noted for innovation. Funding limitations, staffing issues, political realities, and the slow speed at which public systems often operate mitigate against cutting- edge treatment approaches no matter the good intentions of those in charge. Images of public mental hospitals pervade the movies and literature, promoting visions of large brick and stone buildings with barred windows and locked doors. Patients are imagined to shuffle about wearing faded, institutional pajamas. Rooms look bleak, beds uncomfortable, and personal items absent. Sadly, this portrayal isn’t far from the mark. And our children were once a part of this system. Even after mental health reform began, children were treated like adults. Eventually, however, came the recognition that children are not small grown-ups. Children need to be treated differently. For numerous reasons, Connecticut lagged behind much of the nation in this movement. This book tells the story of Connecticut’s initiative to develop a state- operated children’s hospital that treats children as children, adjusting to developmental, learning, and experiential differences. It’s a story told from the perspective of those who were intimately involved by the individual who was at the center of our work. It’s a story of how this vision drew in others of like mind and put together a work family that revolutionized children’s mental health care in the public sector. Richard “Doc” Wiseman imbued his work with the notion that the children who needed mental health services should be treated most basically as children. Along with individual, group, and family therapy, the program at Riverview Hospital encouraged play and recreation. Children wore their own clothes, and it was not uncommon for staff members to purchase clothes that were a little more trendy so that a child could better “fit in.” Kids were encouraged to decorate their rooms and participate in community activities. This is not such a big deal now, but it was quite remarkable in 1974. xiii

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Foreword

Certainly Doc was supported by the academic environment at Yale, the state legislature, and numerous mental health and children advocates. Even with this support, however, children’s mental health reform in Connecticut occurred only because people with courage and determination pushed hard. Doc Wiseman had the ability to identify people with commitment and to nurture that quality. He always fostered new ideas and gave people the latitude to work on areas of interest or concern. In times of fiscal deficiency, political strife, and organizational inertia, he held their dream together with charisma, determination, force of personality, and hard work. He and others named in this book have improved the lives of thousands of children. I’m privileged to have known and worked with many of them. At the time of this writing, a spotlight has been turned on the issue of mental health. With the horrific events of December 2012 that claimed twenty- eight lives at Sandy Hook Elementary School in Newtown, Connecticut (including those of the disturbed perpetrator and his mother), attention has turned to mental health services and needs. A task force was established, co- chaired by a psychiatrist and a physician, to examine and make recommendations regarding access to mental health services for youth. In addition, legislation has been passed requiring that the Department of Children and Families develop a plan to create an integrated mental health service delivery system involving six state agencies. As a start, these efforts are laudable. However, caution is necessary. To not repeat the mistakes of the past, it is important to be reminded that children are not small adults. As this book documents, children’s services must be developed and provided in a different way than adult services. Since adult mental health issues tend to be discussed more frequently in the media, any crisis and/or threat to public safety could result in children’s services losing resources. Finally, there is a natural tendency for policy makers to move on to the next problem of the day. It is up to us to hold the focus. By writing this book, Doc Wiseman helps us keep one eye on the successes and failures of children’s services in Connecticut’s mental health sys-

Foreword

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tem as we move forward. It is incumbent on those of us in the mental health field now and those who choose to serve in the future to keep the needs and concerns of children always in the forefront. Louis Ando Middletown, Connecticut, 2014

autHoR’s note and aCknowledgments ... Children’s mental health is an intrinsic part of their overall health and well-being. At least one in ten children—as many as 6 million youth—experiences a mental illness that severely disrupts his or her daily functioning at home, in school, or in the community. Numerous barriers prevent children and their families from obtaining needed services, including stigma, shortages of mental health professionals, insufficient coverage of mental health services in public and private health insurance programs, inadequately trained clinicians, and complex and fragmented service delivery systems. This book is an institutional history of a progressive psychiatric hospital for children and youth, one of the first of its kind. My own experiences as superintendent and clinician at the hospital form the spine of the story, and the voices and experiences of many staff members and administrators round out the picture. You will note that very few former patients appear in the book. This is because the stigma of hospitalization is still very real. I hope you will find within these pages a story of hope and courage. The institutional history of Riverview is a personal history. It is about the people who made it happen. Over the years, hundreds of individuals—psychiatrists, psychologists, social workers, nurses, childcare workers, groundskeepers, administrators, teachers, recreation/rehabilitation workers, housekeepers, nutritionists, business managers, personnel workers, clerical staff, medical records technicians—played special roles in making Riverview what it was and is today. Throughout this book, I mention many names as a way to preserve some of this history. In addition, I enjoyed spending time with and learning so much from each of the many people I interviewed and who contributed to the writing of this book. Weaving our stories together, I hope to present an account that is not only interesting, but also a useful record of what was and, for good or for bad, what could be. I have also included samples of key documents and tools, so that those interested in helping children with mental health issues can easily access and xvii

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Author’s Note

adapt these materials. Throughout the text, you’ll see many endnotes. Some document interview data, but many expand and add anecdotes to the narrative. My most heartfelt thank you goes to the staff and volunteers who worked so selflessly to make Riverview the model of effective mental health services for children that it was for so many years. While the cover of this book designates me as the author, the fact is that I have relied extensively on the words and experiences of many others. This is particularly true of Louis Ando, my friend and colleague who assisted me in many ways throughout the writing of this history. During the past year, as I began to lose steam, it was Lou’s enthusiasm and encouragement that motivated me to finish the task. He started out simply by editing some of the earlier chapters, but as he became more and more involved in the project he contributed his segment of Riverview’s history, significantly broadening the story. He restructured the format, fact- checked, and added some of the finishing touches. I’d like to express my appreciation to the following individuals from Riverview who contributed information or were interviewed for this project. Most interviews took place in my colleagues’ offices at Riverview between the years 2000 and 2010. All those quoted in this book responded voluntarily and acknowledged that they would likely be quoted (some of the interviews have been very lightly edited for readability). The job titles listed after their names are those reported by the Human Resources Department of the Department of Children and Families (dCf) at the time this book was written. As is always the case when individual contributions are listed, I fear that some persons may have been inadvertently left out. To those I missed, I offer my sincere apologies, and gratitude. Linda Adams, teacher Randy Adams, school principal Craig Allen, psychiatrist Henry Alton Allen, Jr., psychiatrist Thomas Allen, pupil services specialist Debra Anderson, assistant superintendent Louis Ando, child and family bureau chief

Author’s Note

Mehaden Arafeh, Connecticut Valley Hospital superintendent Robin Arnsten, psychiatric social worker associate Muhammad Waqar Azeem, medical director Bernard Barile, clinical psychologist Anthony Bartell, children’s services worker Michael Bartolotta, plant facility engineer Nachi Bhatt, teacher and pupil services specialist Peter Briggs, supervising clinician Peter Brown, superintendent of the State Receiving Home Randolph Burnham, psychologist, Behavioral Learning Environment Unit (Bleu) Linda Cahill, head nurse Linda Carabetta, director of nursing Andrew Cass, assistant superintendent Joseph Cautella, behavioral specialist consultant Oliver Clark, director of nursing Daniel Clifford, children’s services worker Pat Colanghi, nurse manager Robert Delvecchio, teacher Elizabeth Donlon, teacher Kevin Dowling, nurse supervisor Kathy Duffendack, supervising dietitian Marvin Farbman, children’s services worker Bette Flynn, teacher David Frieze, director of institutional services Willie Fuqua, teacher Herbert Gewirtz, director of Children’s Unit (1963–1965) Lewis Goldberg, supervising psychologist Elizabeth Grady, rehabilitation therapy supervisor Mark Harrington, fiscal administrative assistant Robert Haxton, administrative services officer Jeffrey Hewett, assistant superintendent Steven Hodge, pupil services specialist Irving Jennings, psychiatrist Lynn Johnson, lead children’s services worker Joyce Jones, Children Services Unit supervisor

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Author’s Note

Krista Judson, lead children’s services worker Adam Kaczmarek, lead children’s services worker Mark Kaplan, supervising psychologist Janice Karpinski, purchasing services officer Jane Klemba, head nurse Karen Kovall, teacher Jeffrey Landau, psychiatrist Charles Leonard, superintendent of High Meadows Michael Lustick, psychiatrist, medical director of Altobello Adolescent Hospital John Lynch, clinical social worker supervisor Chris Malinowski, advanced nurse practitioner Judith Raczkowski McCain, director of residential care Peter Marshall, co- director of Children’s Unit (1969–1971) Frederick Miller, Children Services Unit supervisor Anthony Nalewajek, Children Services Unit specialist Joan Narad, psychiatrist Sarah Newkirk, assistant principal Laurie Nichols, volunteer Donna Nolan, teacher Gary Nolan, teacher Judith Normandin, superintendent of Altobello Adolescent Hospital Jacqueline O’Brien, clinical education specialist Keith O’Leary, supervising nurse Geraldine Pearson, nurse specialist Marcia Pease- Grant, psychiatric social worker supervisor Melodie Peet, superintendent of Riverview Sangeeta Peschuri, psychiatrist Sandra Pizzo, children’s services worker Robert Plant, division director of Community Mental Health Services Thomas Prue, rehabilitation therapy supervisor Richard Pugliesi, psychiatrist Susan Reale, psychiatric social worker Jacqueline Reardon, executive secretary

Author’s Note

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Jay Resnick, teacher Charles Rich, psychiatrist Mark Root, director of nursing Thomas Royce, children’s services worker Francis Rusczek, psychiatric social worker associate Ellen Ryder, psychiatric social worker director Michelle Sarofin, superintendent Marianne Sculley, secretary Edward Shukis, teacher Lesley Siegel, medical director Robert Sinkewicz, psychiatric social worker Andrea Spaulding, lead children’s services worker Margery Stahl, superintendent of Altobello Adolescent Hospital and Riverview Margaret Stewart, assistant superintendent Leonard Suchotliff, superintendent of Housatonic Adolescent Hospital Carl Sundell, superintendent of Riverview Wilson Tirado, supervising nurse Anthony Ventrelli, teacher Joyce Welch, superintendent of Connecticut Children’s Place and Riverview David Wells, rehabilitation therapy assistant Frank Winiski, children’s services worker Eunice Wiseman, teacher Many thanks to Lisa Dierker, professor of psychology at Wesleyan University, who awarded tutorial credit for the work of three students: Leah Wiley, John Friedberg, and Michelle Wellington. They combed through annual reports, transcribed taped interviews, and gathered information. They also helped edit some early chapters. Also, special thanks to two amazing women who were with me during my twenty years at Riverview: Margery Stahl and Jacqueline Reardon. One organizational consultant described Marge as the “mom” of our mom and pop organization. With her nursing background Marge leaned heavily on a medical model, while I moved toward a residential

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treatment approach. Nevertheless, Marge was totally loyal and committed to the task of providing the best possible care for the children. She was responsible for and mentored the largest number of staff members. Jacqueline Reardon was our executive secretary. Jackie once replied, “I’m just a country girl,” when a Joint Commission on Accreditation of Hospitals surveyor asked her pointed questions. Truth be told, Jackie knew everything and everyone and generally kept me informed of the mood and atmosphere of the day. Smiling and pleasant, she also had a great sense of humor. When I embarked on walks around the facility I’d say, “I’m going to MBWA” (manage by walking around); Jackie added another A—“aimlessly.” Special thanks to Frank Winiski for taking most of the recent pictures (2004–2010) in this book. Others whose particular area of expertise was shared when needed include: Victoria Brothers, personnel specialist for dCf, who verified the spelling of all staff members listed earlier; Gloria Gdovin, for her many hours of speedily typing chapters of the manuscript, saving me triple the time; Kandace Yuen, medical librarian at Connecticut Valley Hospital, for searching the archives for dates and pictures of older buildings as well as giving me access to historical material at CvH. Thanks, too, to Matthew Kabel, who saved both me and my computer from an early demise. Last, but hardly least, I am indebted to my editor, Victoria Stahl, whose patience, persistence, and professionalism guided me through the highest standards. What started out as a simple memoir for my grandchildren and perhaps for some close friends and colleagues has transformed into a historical document. Thank you, Victoria. I’d like to add my very deep appreciation for the children who passed through Riverview. Their shining presence made me feel that I had the best job in Connecticut. Rocky Hill, Connecticut, 2014

RiveRview Hospital foR CHildRen and YoutH

[ CHapteR 1 ]

on tHe waY up tHe Hill ... I did not set out to write a whole book about Riverview. Originally, my intention was to write a history of the children’s mental health system in Connecticut based on my sixty years as part of that system. Having witnessed a very slow evolution that still is a long way from meeting the mental health needs of children and their families, I had titled it “On the Way Up the Hill.” The story of Riverview was contained in one chapter. As I thought about the chapter on Riverview and my twenty years as co- director and then superintendent there, I became acutely aware of how my previous experiences in the mental health system had forged a philosophy regarding the treatment of seriously emotionally disturbed children and the function of a state hospital in the continuum of care that guided me in my vision of what Riverview should be. As I explored these paths, the chapter on Riverview turned into a book. Here you will find the story of how Riverview came to be and what it represented for children’s mental health treatment. Let me start with a brief account of the experiences that led me to Riverview, as well as a chronology of the hospital. When I graduated from high school in 1946, I attended Drew University, Madison, New Jersey. After my freshman year, I transferred to Springfield College, Springfield, Massachusetts, majoring in group work and community organization, and was invited to join the football team. By my senior year, I realized I was eligible for another year of football, so I returned and received a graduate assistantship in guidance and personnel. There I was involved in teaching an introductory psychology course called “A Student Structured Class,” which merged the work of three contemporary psychologists: Carl Rogers’s client- centered therapy approach, Abraham Maslow’s theory of motivation and selfactualization, and Milton Rokeach’s organization of belief systems. This formed the basis of my master’s research in 1952. 1

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In addition, I was asked to teach an orientation class for incoming freshmen. This happened to be the first year that women were admitted to the college. In my class there was a student named Eunice Ganung, and I stumbled over her name when calling the role. She came up to me to correct the pronunciation, and we became interested in each other. She became the first coed to graduate, finishing in three years, while I completed my air force commitment. When I returned we married, and within two weeks I took a job at Children’s Village, in Hartford Connecticut. I accepted a group work supervisor position, and my duties included supervising and directing a wide range of activities utilizing volunteers from the community. After a few years, my wife and I were asked to fill in as house parents in the cottage for older boys (twelve to fourteen years old). We became “parents” for a year, with twelve kids along with our own two-year- old—our boys. One of these boys, Jimmy, was always in trouble—except in our house. He adored my wife, Eunice, and would announce to the other boys at bedtime, “I don’t want anyone to be noisy and wake up Kenny,” our son. Ours was the quietest bedtime in the village. Nevertheless, because Jimmy was always getting into (playful) trouble and annoying other staff members, a meeting was called for the purpose of discharging him. I spoke up for Jimmy, saying that he always admitted to what he had done and never blamed anyone else. I liked him. We all agreed to give him another chance. He stayed as long as possible. When he aged out, he went to a facility in Litchfield. There, he contracted appendicitis. Since he had nowhere to go to recuperate, Eunice’s parents, who had a cottage at a nearby lake, took him in. He officially became a member of our family. Later, Jim became a successful businessman, owning his own contracting company. He married and has four children. On special occasions, Eunice and I are invited to sit at his family table. When we decided to move to a retirement facility, it was Jim, with his company van, who helped us move. My Children’s Village experience left me with a true sense of the importance of the other twenty-two or twenty-three hours in these kids’ lives and the feeling that the fostering of children around the clock is at least as important as their one- or two-hour therapy sessions. I

On the Way Up the Hill

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made the decision to invest in further training, and we left for Michigan State University, where I would pursue a doctorate in child psychology. There I had the fantastic experience of working for three years in play therapy with an autistic child and also learned the importance of individual work. But I still wanted to work with children in groups, and I was the first student in our campus psychology clinic to run a play therapy group, with four children. Also during this period our daughter, Lauren, was born, and we became foster parents to a fifteenyear- old girl who had run away from a treatment center in Texas. Sue lived with us for two years, and we thought of her as a “borrowed sister” for our son and daughter. Sue’s two children and their children continue to be part of our extended family. When I returned to Connecticut, Ph.D. in hand, my first job was with the Connecticut Valley Hospital (CvH) Department of Psychology. That was in 1962, the very year children from other hospitals were relocated at CvH. Three years later I was asked to be director of the Connecticut Service Corps, a takeoff of the newly formed Peace Corps. During each of the next five years we hired 150 students to fill ten-week sessions. Students came from all over the world to spend time “socializing” with patients from the back wards of our four state hospitals (including the new Children’s Unit). One group went with my family and me to the woods in Danielson, Connecticut, and with the help of patients from CvH, Norwich Hospital, and Fairfield Hospital we built Camp Quinebaug.1 Every two weeks a new group of sixty patients from the hospital (adults in early summer, children in late summer) would become campers before returning to their respective hospitals to become patients again. Witnessing this transformation from patient to camper to patient was an amazing and frightening experience, one that left an indelible imprint on my thinking about the nature of hospitalization, or what I coined “patientitis.” And I wasn’t the only one who felt this way. Around a campfire one night, students were bemoaning how the campers resumed their roles as sick people upon boarding the bus for their hospitals. The students concurred that something should be done. Matt Lamstein, a student at Wesleyan University, returned to school and organized a community advisory committee with me

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as clinical adviser. The university gave them a house, and the group recruited student volunteers as staff. They named the place Gilead House, after a favorite campfire song, the African American spiritual “There Is a Balm in Gilead.” The house is now a million-dollar operation, called Gilead Community Services, providing aftercare patients in Middletown, Connecticut, with a wide variety of clinical services.2 After five years as director of the Service Corps and director of Camp Quinebaug, I was appointed, along with Peter Marshall, co- director of the newly formed Children’s Unit at Connecticut Valley Hospital. Peter and I realized that while some children need a secure setting, with an intensive, highly structured treatment model, we wanted our program to be as unlike a hospital as possible. Fortunately, our boss, Deputy Commissioner Charles Launi, and Commissioner Wilfred Bloomberg agreed with us. What follows are the stories of how the Riverview Children’s Unit came to be and the amazing challenges that existed for those of us who built a mental health system to serve children.

RiveRview: A Timeline 1943–1955 Public awareness grows of plight of children with serious mental health issues, including autistic children, who at that time were considered mental health patients. 1947 House Bill 441 passes, recommending construction of a seventy-two-bed facility. 1957 High Meadows Residential Treatment Facility constructed with far fewer beds than required. Several children sixteen and under are still in Connecticut’s state adult psychiatric hospitals, referred to as “insane asylums.” 1960 Connecticut Department of Mental Health is formed. 1961–1962 Children sixteen and under are transferred to Connecticut Valley Hospital (CVH) from the three adult psychiatric hospitals. They sleep wherever beds can be found on the adult wards. 1962–1963 Children are brought together to form the Children’s Unit, boys located in Beers Hall, a section of Shew Hall, otherwise occupied by adult patients. The girls occupy an adjacent section of Weeks Hall, built in 1868. 1964 Blue ribbon committee recommends moving the Children’s Unit to a new site on the grounds of CVH. 1965 Children are moved to Merritt Hall, a newer building (built in 1960) primarily for adult women. Three wards on the top floor are allocated to children. 1966 Architect Val Carlson is hired to draw up plans for proposed Children’s Unit school on CVH grounds—on the hill overlooking the Connecticut River—with Silvermine as a central building housing a dining room, a kitchen, conference rooms, and medical records office. 1969 Letter goes to Governor John Dempsey from Children’s Unit staff pleading for recognition of inadequate staffing of Children’s Unit; co-directors Wiseman and Marshall are appointed to new Children’s Unit as an autonomous unit of CVH, with separate budget and control of programing, reporting directly to commissioner’s office; two child psychiatrists from Yale Child Study Center are assigned as consultants; development of milieu therapy concept begins as part of the change from the medical model to a residential treatment model. 1970 Children’s Unit redefines mission as a treatment service instead of a placement/referral service; adolescent program is developed in the state’s three

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RiveRview Hospital adult hospitals. New facility at Silvermine Complex is official; recreation becomes a department.

1971 Letter goes to Hartford Courant about failure to fund new facility; funds are received and new facility opens. Dedication ceremony for the RiverView School takes place on October 8. 1971 Governor Meskill, in downsizing government, eliminates co- coordinator positions. Wiseman is director; letter from entire staff goes to governor and results in funding of new staff position for Children’s Unit. 1972 BLEU, Behavioral Learning Environment Unit, begins and behavior modification is utilized with “autistic” kids; new facility is dedicated; children move to new campus. 1973 Governor Meskill appoints commission to study which department should have responsibility for autism—co- chaired by a representative from Department of Retardation and Department of Children and Youth Services (DCYS). Wiseman represents DCYS. 1975 Senate Bill 1446 transfers all mental health programs to DCYS, including facilities; Children’s Unit becomes Riverview Hospital. 1977 Public Act 77-43, An Act Changing the Name of the Children’s Unit at Connecticut Valley Hospital to Riverview Hospital for Children, determines age limits, allowing parents the right to sign child six and under for treatment, but any child fifteen or older can self- commit. The “v” in Riverview is now uppercase: RiverView; DCYS becomes an official special school district. 1980 Riverview program starts new management structure. 1981 Riverview cottages go coed; Autistic Unit moved to round cottage, renamed Alpha. 1982 Interim management team appointed to restructure Altobello Adolescent Hospital. 1983 Riverview staff develops community services program. 1984–1985 Major renovations completed in cottages. 1986–1987 A facility for adolescents is planned on grounds of Riverview. 1988–1989 Construction begins on adolescent facility. 1989 After twenty years as co-director, then superintendent, Wiseman retires. 1990–1991 Margery Stahl becomes acting superintendent of Riverview and Altobello and is eventually appointed superintendent of combined facilities; decision made to merge adolescent facility with RiverView to become a single facility with full hospital status.

On the Way Up the Hill

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1992 Stahl retires, and Carl Sundell is appointed superintendent; regional directors announce that RiverView will be renamed Riverview Child and Adolescent Psychiatric Hospital, dropping the uppercase “V.” 1993–1997 Children and adolescent facilities are merged; administration changes four times; residential treatment center philosophy becomes that of formal hospital model; Riverview becomes an official hospital upon accreditation under hospital standards; all adolescents are transferred or admitted to Riverview Hospital for Children and Youth. 1997 After successful completion of the merger, Carl Sundell retires and Louis Ando becomes acting superintendent. 1998 Ando becomes full superintendent but given temporary assignment as bureau chief in the central office of Department of Children and Families as an additional responsibility. 1999 Robert Plant, Ph.D., appointed as superintendent when Lou Ando promoted to bureau chief of medical services in central office. 2000–2004 Focus becomes designing ABCD, a new milieu program, and implementing it in all residential units; decreasing length of stay; reducing use of mechanical restraints. 2004 Melodie Peet becomes fifth superintendent as Plant transfers to central office in charge of community system of care development (community collaboratives); this becomes a period of internal strife, poor morale, staff and kids acting out. Central office orders external program review; newspapers reflect concern; and politicians suggest closing Riverview as too costly. 2008 Melodie Peet resigns. Joyce Welch, superintendent of Connecticut Children’s Place, becomes superintendent and begins recovery efforts. 2011 Joyce retires after bringing order back to Riverview; Michelle Sarofin becomes new superintendent. 2012 Riverview retires. A new entity named the Albert J. Solnit Children’s Center with mission to be the center of children’s mental health services opens. 2014  Full description of changing mission is in progress.

[ CHapteR 2 ]

a plaCe to staRt ... In 1962 children diagnosed with serious psychiatric or behavioral difficulties were admitted to Connecticut Valley Hospital in Middletown and eventually placed in the Children’s Unit. However, it was many years earlier, in the early 1940s, that legislators, parents, mental health professionals, and scholars from the Yale Child Study Center planted the seeds for reforming children’s mental health facilities in Connecticut. These innovators identified problems in the mental health system and began talking about the need for a residential setting for children and youth unable to be served in traditional child guidance clinics or residential child- caring facilities. A survey in 1943 by James M. Cunningham of the State Bureau of Mental Hygiene provided enough evidence to support the need for a psychiatric study home. In 1945 Governor Raymond Baldwin appointed a child home study committee that repeated the survey, focusing on the number of new cases referred to the juvenile court, State Child Welfare Division, or Council of Social Agencies in the calendar year 1945. These agencies were asked to identify children under the age of sixteen who met one of the following criteria: (a) Required more careful observation and diagnosis than could be provided in an existing outpatient clinic if one were available. Or (B) Required a more extended period of psychiatric treatment, excluding children diagnosed as psychotic and needing longterm care. There were 636 children so identified, 355 in category A and 281 in Category B. In their preliminary report to the governor dated 23 December 1946, the Subcommittee on Operations unanimously recommended that “a 8

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cottage type of institution [be] required for satisfactory work with the children,” and “the individual cottages should be small, housing no more than twelve children each.” It was agreed that the central treatment building would be planned with facilities for carrying out treatment with one hundred children in residence. The committee recommended the “immediate establishment of a seventy two bed cottage type of institution with an embracive children’s program under psychiatric direction.”1 In 1947 the first positive step in the implementation of this recommendation came in the form of House Bill 441, submitted to the Connecticut General Assembly. It was favorably received by the Committee on Welfare and Humane Institutions, but not by the Appropriations Committee, which had the responsibility of approving the $643,000 needed. In 1948 the new governor, James McConaughy, former president of Wesleyan University, Middletown, Connecticut, reactivated the Child Study Committee. The committee submitted its report in December 1948 to Governor Chester Bowles after McConaughy’s untimely death. Amending the original study—“inasmuch as the records of the State Hospitals indicate that approximately fifty psychotic children are admitted each year to the state hospitals, it is therefore recommended that two more twelve-bed cottages should be added to the Study Home”—seemed to be a fallback decision. The report further states, “It was hoped that the three mental hospitals might establish in one of their institutions a children’s ward with proper personnel and a program to service the approximately twenty-five psychotic children now scattered among the three institutions. Since this proposal has not proved capable of accomplishment, and since the need to provide adequately for these children remains as pressing as ever, the committee has concluded and accordingly recommends . . . the inclusion of these children in the Study Home.” The subcommittee also recommended that “a psychiatric study home should not be established on the grounds of any existing institution in the state” and voted unanimously in favor of the recommendation. The final recommendation was that “the home be planned in terms

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of eight twelve-bed cottages, or a total bed capacity of ninety-six,” and an additional twenty-four beds for psychotic children. The subcommittee estimated that the cost of funding this venture would be $308,198, of which $198,198 represented expenditures for personnel and the remaining $110,000 for costs of operation.2

tHe CHildRen of ConneCtiCut valleY Hospital On 1 October 1953, the Connecticut Department of Mental Health with John Blasko as commissioner replaced the Joint Committee of State Mental Hospitals. Elias J. Marsh, previously with the Department of Health, Division of Mental Hygiene, and an outspoken advocate for children, succeeded Blasko in July 1957. Marsh was instrumental in moving ahead with the development of appropriate services for children residing on adult wards. He therefore ordered a full assessment of all children sixteen and under in Connecticut psychiatric hospitals. This included Norwich Hospital, Norwich; Fairfield Hills Hospital, Newtown; and Connecticut Valley Hospital, Middletown (then known as Connecticut Hospital for the Insane). His assessment showed sixty children housed on the various adult wards—eating, sleeping, and mingling with adult psychiatric patients. This meant that, on any given day in 1957, you might run into a seven-year- old autistic girl sharing a room with a sixty-seven-year- old psychotic woman. Finally, after years of discussions, modifications, site searching, and various other delays, the State of Connecticut appropriated $250,000 to build Connecticut’s first Child Study and Treatment Home for emotionally disturbed youngsters. The result of these discussions was the building of High Meadows in Hamden, Connecticut. Unfortunately, funding was sufficient to house only a limited number of beds, many fewer than had been requested. After a lengthy search, the state appointed Charles Leonard as the first superintendent of the newly constructed High Meadows. In a personal interview conducted on 1 May 1990, Charles shares his account of what happened: The original plan was to have beds for sixty children, but even though the money had been approved on paper, the General

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Assembly only released enough for one building serving twenty children: fourteen boys and six girls. When it opened, everybody thought we would be able to take all the troublesome kids and of course that wasn’t true. . . . So the big questions came up about two years after High Meadows was built (about 1959 or ’60): one, how come High Meadows wasn’t taking these kids, and two, if High Meadows isn’t going to be the answer . . . then what about these kids in the adult wards?3 Dorothy Inglis, newly appointed chief social worker at High Meadows, interviewed each child, read every record, and performed clinical evaluations. In an article published in the Journal of Orthopsychiatry and presented at the 1957 annual meeting of the unit’s board, she and coauthor Elias J. Marsh reported the results of their study. In their summation they conclude: “Mental hospital use for children points to the need for the community to review its resources and its problems, to bring programs inherited from the past in line with the present knowledge of human behavior. We may have many worthwhile individual programs. However, they must be coordinated in a communitywide effort to meet the full range of children’s needs. Until this is done those who are not provided for may continue to be found in places never meant to serve them, such as the state mental hospital.”4 This remarkable study—as well as increased pressure from the professional community, hospital superintendents, the acting commissioner, and the legislators—led to the consideration of bringing all children under sixteen years of age to a single hospital as a demonstration project. Exactly why Connecticut Valley Hospital was chosen is not clear, but certainly its central location was a major factor. While superintendents from each of the three hospitals—Ronald Kettle of Norwich, William F. Green of Fairfield Hills, and Harry S. Whiting of CvH—were reluctant to admit children into their hospitals, Whiting apparently accepted the responsibility. Unfortunately, the children were not housed together; they were placed “wherever feasible throughout the hospital.”5 In September 1958, Wilfred Bloomberg was appointed commis-

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sioner of the Department of Mental Health, and the intention was to establish nineteen new positions at the proposed children’s services at CvH. When hospital administrators were unable to find a psychiatrist interested in overseeing the CvH program, Max Doverman, the former superintendent of the Children’s Welfare Center in New Haven, stepped up as coordinator. His job was tough. He had responsibility for CvH’s children, but very little authority. Children were still housed on the adult wards. The psychiatric residents on the individual wards provided the “treatment,” and Doverman was responsible for education and recreation. In 1960 a full-time psychologist, Herbert Gewirtz, was hired. Although new personnel placement continued, change occurred slowly. In his July 1960 report, Whiting wrote, “The Children’s program did not make the progress during the year that we have hoped it would. Efforts consisted largely of trying to provide better care for the children we have with a very limited staff until recently as it was predominantly a volunteer service.” He also disclosed that the children continued to be housed on the adult wards and the coordinator’s responsibility was pretty much limited to education and recreation.6 To compound matters, once the decision had been made to admit more children to CvH and word spread that a children’s program existed (albeit in its infancy), a floodgate opened. More and more children arrived at CvH. Whiting and Doverman hired eight college students to oversee evening and weekend recreation activities. This was a significant step forward because it constituted the first sustained, structured program outside of school and gave hope to the care staff that things were going to improve. Mike Karwan, the recreation director, and Louise Johnson provided clinical support. Some of the college students eventually became full-time employees. Susan Reale returned as a social worker, and Carl Sundell can be found in this history filling many roles, including superintendent. Also at this time, Sal Allessi joined the staff as a part-time clinical psychologist who provided clinical supervision to the small staff. Sal quickly became an essential teacher and supervisor, particularly in the area of group psychotherapy. But for the moment, in 1961, progress was painfully slow. In a rather clear reflection of frustration, Whiting’s report for September 1961 contains the following:

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The number of children under 16 is increasing rapidly. The admission rate has exceeded the rate of progress toward development of the children’s program. There has been much misunderstanding between the hospital, the central department and the State Budget Department. As a result, we are still struggling to get positions that were granted by the legislature. There has been an alarming increase in the number of disturbed young people. Almost none of these young people are psychotic but are behavior disordered. However, the other institutions claim they cannot handle them. . . . The boys are a very disturbing influence, with acting out and stimulating the adult patients to do the same.7 In mid-1962, Max Doverman resigned as coordinator, and Whiting asked Herbert Gewirtz, the psychologist assigned to children’s services, if he would like the coordinator position. He accepted, but it was clear to him that the programs had to be unified and brought together in one physical area. This was contrary to the hospital’s position as stated in the Quarterly Report Ending in December 31, 1960: We are unable by any statutory authority, to limit the number of children referred to our hospital for admission from any part of the state. Admissions flow in from general practitioners via 30- day emergency detention certificates, from child guidance clinics, from other institutions, including hospitals and correctional institutions that cannot handle these children, from the Juvenile Court and from frantic parents requesting voluntary admission. We are asked to not only treat them but to evaluate them prior to admission. This does not point to a deficiency on our part but clearly to a deficiency of the various communities of Connecticut, individually and jointly, who are neither prepared nor willing many times to accept the responsibility for the children in their midst who deserve a highly specialized kind of care. We suffer from a lack of sufficient numbers of specially trained professional staff at various levels, including senior staff, nurses and ancillary personnel.8

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There were sixty boys and thirty girls in residence, an overwhelming number in view of the anticipated admission rate. In our 1995 interview, Herbert Gewirtz recalls the situation as he remembers it: The hospital was not interested in having children. They were totally against it. It was imposed upon [the facility] by the governor’s office—they were getting a lot of pressure to provide mental health services for children. The whole thing was just dreaded by the hospital administration. Kids were trouble. They just caused a lot of grief to the administration and so they weren’t interested in them at all. So Max Doverman was operating in a vacuum because he had no power and they weren’t about to give him any. At that time it was basically lip service and window dressing and just hoping it would go away. But Max got some things started. He hired a principal and some teachers and a recreation person. Then he gave up. He had enough and left.9 When Gewirtz was appointed, he set as a priority the task of bringing the children’s programs into a unified service. This was not a popular idea. Nevertheless, he pushed forward, and eventually succeeded. He talks about the process in our interview: The resistance to unification was tremendous. Nobody wanted to give up their domains, nor did anyone want to exert the effort to do so. The only thing that didn’t frustrate the staff was what was happening outside the hospital. People were now interested in this children’s service. Marjorie Farmer, state representative, was very vocal. Others behind it were people in the Mental Health Association; mental health professionals in various administrative positions; child guidance people who needed a place to send a kid; the Institute of Living [at Hartford Hospital]; Dr. Zeller. People started coming down to the hospital to visit, and I always presented the seamy side—never told them what was good—and that was my policy. I told them what we haven’t got and what we need. At this time I had no authority; however, when I found a vacuum I just went ahead and tried to fill it.

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The first real step in unification was the assignment of the assistant superintendent of CvH as responsible for the services for children— Charles Meridith, M.D. That was really a result of all the pressure being put on Whiting (superintendent of CvH). He didn’t want to have anything to do with it so he gave it to Charlie. I developed a good relationship with him, and it was a result of the influence that I could exert on him that we thought about unification—because all we were doing was putting out fires—functioning like an occupational therapy department. So we began to move toward towards unification.10

CHildRen’s seRviCes In November 1962 I had my first experience with the newly formed children’s services. I started work in the Psychology Department of CvH. My training and previous experiences had been with children, and I felt I needed to get some practical experience working with adults. I decided, however, to at least take a look at this new children’s services, vowing only to look and not get involved. When I walked onto the ward in Beers Hall, I was stunned. Having just come from Michigan, where I interned in a state- of-the-art psychiatric program for children, I couldn’t believe my senses. While forty years have passed since that day and recollections fade, the dismal images that come to me are of a large room with some thirty or more beds, high ceilings, dim lighting, and creaky floors, and all I could think of was the movie The Snake Pit.11 For the moment, I kept my vow to stick with the adult unit, but I knew someday I would get involved with the children. By this time all children under sixteen had been transferred from the other hospitals, and with a steady stream of new admissions the population of children’s services had reached fifty-five boys and twenty- eight girls. The first floor of Beers Hall was opened up to thirtyeight boys, with seventeen boys still residing on the adult wards. Soon thereafter, the girls were moved into adjacent housing in Dix Hall. In a River Views interview, children’s services worker Andrea Spaulding recounts, “Things were very chaotic, every patient seemed to exhibit a different problem behavior or psychosis. All you tried to do was keep them in order.”12 The Hartford Courant, in a series of articles about the plight of chil-

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dren in Connecticut hospitals, aroused public outcry when it revealed the use of straitjackets on children.13 This naturally caused a political furor, and the commissioner of the Department of Mental Health ordered an internal investigation. Charles Leonard, who had vast experience in conducting surveys of children’s facilities, volunteered to do a survey if he could do it his way, which was to live on the grounds and be granted free run of the place, both day and night, for a period of one week. The commissioner agreed to ask CvH superintendent Harry Whiting. Harry graciously agreed to Charles’s stipulations and made arrangements for him to stay in a guesthouse. Leonard spent the days and several nights on and off the wards and described meeting “some real good, down-to- earth, competent psychiatric aides at two and three in the morning,” but the Beers Hall facility was an “awful, awful, terrible place—even the toilets were awful, stinky.”14 Another major step in the unification of the children’s programs was the assignment of psychiatric residents. According to Gewirtz, “Previously . . . kids on different wards . . . were assigned to whoever worked on that ward. Each ward had its own personnel. Now residents were responsible to me—not for clinical supervision but more administrative, general strategies around kids. This was historically a first for psychiatrists to come under a non-physician.”15 Fragmentation had been true in all other disciplines—significantly nursing, which, of course, included all nurses and psychiatric aides. Nursing the hospital’s largest department. The hospital structure included a nurse supervisor for males and one for females, each reporting to a director of nursing. In order to add a nurse supervisor for children’s services, Gewirtz established a new position, director of group living, reporting directly to him as director of the Children’s Unit. With this new title, Louise Nelson had more direct responsibility to children’s services and its administration. She therefore became a pivotal person in the program. Also, John Thomas, the medical director of High Meadows, in Hamden, became a consultant. This added to the political pressure for unification of child services. Gewirtz explains: It had political implications because everyone was looking to see what was going on. It was very shaky yet. At that point, Lou

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Perlman completed his residency and came on to help run the children’s services. He started as co- director. There were a lot of problems, however. I thought it could work out because we were good friends. I was looking forward to his coming. We handled it by splitting our domains. Lou had the clinical side and the ward, and I took the outside work (administrative, politicking, etc.). It didn’t work out. Lou became appointed director, and I became assistant director. There were a couple of reasons for that. One had to do with a letter I sent to a doctor in New York. . . . The guy was a big name in the field who talked to Bloomberg [then commissioner of mental health], who called Dr. Whiting, and people were very upset with me. Bloomberg went on to say, “I think we need a medical person there,” so I left, primarily because of that. The idea of co- directors was too problematic. Factions developed; there were too many process struggles. It turned out that Lou Perlman didn’t stay long either. I think he didn’t really want the administrative responsibilities.16 The original planning for the construction of the new Children’s Unit began in the early 1960s, soon after the children moved to CvH. Charles Leonard remembers driving out to the site of the Silvermine Building. Sydney Finkelstein, a member of the hospital’s advisory board, accompanied Leonard. They were sitting on the hillside and looking over the Connecticut River and Middletown hills when Charles said to himself, “This is it, envisioning a beautiful setting for a residential treatment center.”17 And so on 25 April 1963, a report entitled “Proposed Future Hospital Recommendations for Children’s Services” was finalized. It documents the plan: We wish to move as rapidly as possible towards the establishment of an integrated Children’s Residential Treatment Program under one roof. This would allow children to be evaluated, treated and cared for in the setting of the program designed specifically to meet their needs and carried out by the same professional staff at all levels. It is our opinion that a physically

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separate children’s center or section removed from the main stream of the adult therapeutic units is necessary for a well rounded, effective and adequate functioning children’s program in all respects.18 By the end of 1963, administrative integration had been accomplished for girls and boys. Louise Nelson acted as nurse supervisor, and eight new employees were on board. The Children’s Unit was finally a separate service, and the new Connecticut Valley School had been opened. The superintendent’s report for that year quips, “The children celebrated the opening of the school by setting off the fire alarm six minutes after the formal opening, much to everyone’s consternation.”19 Oh, well! School commenced with some seventy children attending.

tHe new CHildRen’s unit (tempoRaRY) sCHool In 1962, when children were first brought together at Connecticut Valley Hospital, planners envisioned and built a separate one-story school building. Thirteen teachers were hired, including part-time physical education teacher Eunice Wiseman and a full-time physical education teacher, Jack O’Day. Eunice describes her experience: I started at the Children’s Unit in 1962 as a part-time physical education teacher. I was told I could take the children each day to either the gym or to the pool. Or I could do whatever I wanted with them. Sometimes I would go and get the children and they wouldn’t be ready. The staff would be playing cards, and I would have to round up the kids and get their stuff and take them to the gym or the pool. Then there was a skating rink and once a week I took them there. One day Jack said, “This is your day to take the van.” I said, “The van?” “Yes, the van. You can take the kids wherever you want to take them.” So I started field trips—to the farm, to the bakery, to differ-

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ent places—so we could make interesting experiences. I told the kids when they got in the van, “You better be good because I have to drive and I don’t want any distractions.” They were always good for me. One of the things I accomplished working there was to convince the superintendent that the kids should be drinking milk. The adults had milk but the children did not. So I went to the superintendent’s office and I told him the children should be getting a pint of milk each day. Finally they agreed with me and so the children started getting milk. The children were not supervised well. I had children that were bigger than I was that had grand mal seizures. One day one of the girls had a seizure on the steps into the pool. Had we been in the pool, I was not told how I could deal with the child. Fortunately, it was on the steps and I called and they sent an ambulance.20 Eventually they hired a principal, Irving Renn, and a few more teachers. Two of those teachers, Betty Flynn, a math teacher, and Willie Fuqua, a music teacher, both fresh out of school, were hired on the same day in the early 1960s (and both retired on the same day in the late ’90s). Until the school was built, teaching took place either on the ward or in small rooms. Robert Miller, chief of professional services of CvH, was hopeful in his year- end report: “[D]uring the coming quarter, we believe that our efforts should be directed toward unification of the service administratively with the goal of integrative planning.”21 In 1964 Suzanne Peplow, a social worker, became co- director with Lou Perlman. Lou assumed the clinical responsibilities and Suzanne took over the managerial/administrative duties. This collaboration lasted for a short time. Lou resigned to take a position elsewhere, and Robert Miller assumed Perlman’s duties in addition to his own. Joyce Aksu was appointed supervisor of group living, replacing Louise Nelson. Marcia Pease- Grant started as an intern at CvH and later became

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social work supervisor—a role she held until her retirement in 1995. Marcia tells about her early days at the Children’s Unit: June 1964: I was hired by the State of Connecticut for $6,000 a year and worked mainly on the Children’s Unit at CvH. The ’60s were a time of political stability under Governor Dempsey and the Democrats. Human services were in vogue, and social workers were in demand. The boys’ ward was in Beers Hall, the girls’ ward was in Dix Hall, and the staff offices were in Shew Hall. These buildings were very old and dark even then, and were condemned within a few years. There were forty boys on one locked ward, their gray metal beds alternating with gray metal cabinets, lined in neat rows in one very large room. The outside wall was covered with large windows, but had thick safety screens, which kept out the light. There was a television room and a large screened sunporch, like a cage, on the second floor of the building. There was one large bathroom with exposed pipes, and one boy burned his back rather badly when he accidently leaned against a pipe. The dining room was in Paige Hall. It was huge, and served many of the chronic adult patients. It was very noisy. Worst of all the boys had to walk to it through a second-story walkway, which had wooden sides, but the roof was wire mesh and there was pigeon shit everywhere. Years later I watched this building and walkway demolished, and I cried with joy at the sight. The school and recreation areas were equally in poor shape; the floors literally undulated from room to room. Overall the girls’ ward was in better, brighter condition, having light beige walls and cleaner windows, bedrooms for three or four girls, a more modern, sanitary bathroom, and access to the outdoors, being on the ground floor. There were usually about twenty-five girls at any one time. The girls’ ward was more violent than the boys’ ward, and at times I was physically afraid of both the girls and the staff. These children, all crowded together, ranged in age from four to sixteen, and ranged diagnostically from autism

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to schizophrenia to conduct disorder to sociopath to traumatized to simply in no need of hospitalization at all.22 In 1964 a blue ribbon committee recommended that the children’s services be moved to the Silvermine Building. In that same year, the state appropriated $1,000,000 to begin construction of a children’s ward.

[ CHapteR 3 ]

a new Home ... In 1965 staff moved the children to a relatively new building, Merritt Hall, where they occupied two wards, the boys’ and the girls’. A third room, a large hydrotherapy room tiled from floor to ceiling, was utilized first as an extension for older boys. It eventually became the Autistic Unit.1 In April 1965 state legislator Marjorie Farmer sent the members of the Children’s Task Force a plan for the organization and operation of the Children’s Unit. Farmer suggested hiring both an administrator and a separate clinical director to enhance the program and to foster a statewide continuum of services. She also recommended shortterm inpatient therapy, long-term inpatient treatment, a treatment program for autistic children, a small closed unit for emergency admissions, bed space for evaluations, a day treatment program, and outpatient services. Additionally, she urged that there be a separation administratively and clinically from CvH.2 Finally, in 1966, an architectural firm, Lee Crabtree Associates, was hired to draw up plans for the proposed Children’s Unit. Once again the Yale Child Study Center, according to a report by Melvin Lewis, showed support for the development of a high- quality program for children, emphasizing the need for “a degree of autonomy within the administrative arrangements in the hospital; a full time psychiatrist, improved training, and more suitable facilities.”3 During these years, twenty-five new staff members appeared in the growing Children’s Unit. Some of those hired remained for many years. Judith Raczkowski McCain started as a summer employee, served as a nurse, returned to school for her master’s degree as a nurse clinician, worked as a cottage coordinator, clinician, and director of group living and, upon retirement in the 1990s, returned as a part-time volunteer through the mid-2000s. 22

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Jerold Langlois, a childcare worker, later became the cottage coordinator and was a “natural.” Wonderfully skilled at working with kids, he was usually called upon to train new employees. Carl Sundell started as a summer recreation worker. His career spanned more than thirty-five years in a variety of capacities in the Department of Children and Families. He returned as superintendent of Riverview from 1991 to 1997. After retirement, he helped write policy and procedure for the Connecticut Juvenile Training Center. Sylvia Gracon eventually became the first full-time intake worker. Sylvia specialized in recognizing those children who could best be served in less restrictive settings and elsewhere in the community. Margery Stahl was one of the first nurses to be assigned to the Children’s Unit. She became nurse supervisor, then director of group living, assistant superintendent, superintendent of Altobello Adolescent Hospital, and finally, superintendent of Riverview following my retirement in 1989. Marge talks about her early days as head nurse on the boys’ unit (Ward 92 in Merritt Hall): I was hired as the head nurse on the boys’ unit. . . . There was no training about how to handle these boys programmatically. We walked them to school, but many of the kids never made it to school because of their behavior. The census hovered around thirty, and we slept kids off the wards when we ran out of beds. Many mornings I was alone with the whole crowd. They lined up for meds and walked in a line to breakfast. When the other scheduled staff didn’t show up for work I was offered help from the adult ward staff, but I usually turned it down as [the boys] didn’t want [adult staff] to be there.4 In 1967 Mehaden Arafeh accepted the job as superintendent of CvH. Arafeh took a keen interest in improving children’s services. Also in that year, Suzanne Peplow became acting director of the Children’s Unit. Peplow’s quarterly report summary, April 1967, states: [One] advantage . . . we have during this quarter is the allocation of specific positions to the unit so that we no longer are unclear as to how many positions we have available to us. Con-

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sidering the entire year since July 1st, we have made progress in nearly all areas: staffing; programming; structuring and treatment. We still need to continually refine all our programs so that they will more nearly meet patient needs and we most assuredly need to begin research projects, which will help us to chart our future course more effectively on the basis of past experience.5 A memo from Peplow to Arafeh questions whether the admission age should be reduced from sixteen to thirteen or fourteen, since there was talk of developing an adolescent unit. There was no reported response to this memo.6 In October 1967 the site for the Children’s Unit was dedicated, and the quarterly report indicated that the architectural plans were almost complete and bids would be announced early in 1968. All admitted children were assigned a social worker. It wasn’t unusual for a social worker to carry a caseload of more than twenty children. And then each child was placed on one of four teams, or groups. The psychiatric staff consisted of one half-time psychiatrist and one resident from CvH on a three-month rotation. Most children attended school on the hospital grounds. In 1968 Margery Stahl became director of residential care when Joyce Aksu resigned. Marcia Pease- Grant acted as senior psychiatric social worker. During these formative years, the clinical staff consisted of a full-time social worker and a few caseworkers. Interns from the CvH Psychology Department would often volunteer part of their time, and psychiatric residents would rotate through the service during their last semester of training. Caseworker Susan Reale describes her experience during these years: I started in the Children’s Unit as a summer worker in 1965 and 1966 and, along with Carl Sundell, went to Camp Quinebaug when the children were invited out there for two weeks. Upon graduating from college I came back to the Children’s Unit as a caseworker. There were so many kids on the boys’ ward. At one time we had forty kids, and the ward was built for twenty—

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retarded, emotionally disturbed, conduct disorders, brain damaged, autistic, and so on. All admissions would come through adult services. There were serious language problems because many of the residents were foreign trainees with little English language. It was very scary. As a caseworker I had to try and help communicate. We would be asked what kind of meds to give. When kids got sick we had to send them to the [only] infirmary—along with all the chronic geriatric patients. It was terrifying. In spite of this, however, all the inadequate facilities and challenges, we had a great team. Working together, we did some good things for kids. I remember when I first started. There were pictures of the proposed new Children’s Unit on Suzanne Peplow’s wall [Peplow was the acting director at the time]. That gave us hope. The philosophy in those times was to rescue kids from their families, but we tried to work with the families and get the kids back home. I remember a girl I was working with. She hadn’t seen her family in several years, so I took her to the address we had. I knocked on the door—no answer. Next door, the neighbor answered. There were a lot of kids there. Someone told me the family had been evicted and was living in a hotel in Hartford. So I went to this hotel—an old run- down place in the North End. Some guy, drunk or on drugs, gave me directions and I finally found the place. They were very happy to see each other.7 In an effort to get a better picture of the population and program, T. Wayne Downey, a consultant to High Meadows, published his study “A Comparative Study of Residential Treatment Populations: Children’s Unit of Connecticut Valley Hospital and High Meadows, Hamden, Connecticut.” The article paints a rather dismal picture, describing the patient population similarly reported in other studies (the chronicity of diagnoses such as chronic brain syndrome, childhood schizophrenia, severe behavior disorders, social pathology, mental retardation, and severe, aggressive behavior). In comparing the treat-

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ment milieus at High Meadows and the Children’s Unit, he writes about his bias as a consultant to High Meadows and describes his observations: High Meadows appears to be functioning at near optimal efficiency in terms of its treatment plans and goals, staff morale, and maintenance of physical plant. At the time of [this] study, conditions in the Children’s Unit provided a stark and dismal contrast. The staff was laboring dedicatedly and valiantly under enormous handicaps, inadequate staffing, a deteriorated physical plant both improper and inadequate for the needs of disturbed children, and a lack of high-level professional and administrative support. The school program at Connecticut Valley Hospital seemed the strongest part of the treatment program on the Children’s Unit. In most cases (and in spite of the efforts of an earnest but overwhelmed staff), treatment at Connecticut Valley Hospital consisted of little more than holding the child securely and waiting for time to cool off the crisis situation, allowing for disposition home or to another institution.8 In an addendum to the article, Downey expresses his dismay over the mental health system and care for these children: While some children at Connecticut Valley Hospital would have benefited by long-term intensive treatment in a closed setting, a significant number of children were there as testimony to the glaring lack of acute children’s psychiatric inpatient treatment facilities. Perhaps ten to fifteen percent of the children at Connecticut Valley Hospital and five percent of the children at High Meadows were being “over treated.” These children were not in need of long-term treatment or hospitalization, but were there by accident, default, or artifact. Some children carried the label of psychiatric disorder primarily because no child shelters or domiciles were available in their communities where they could be harbored for the forty- eight to seventy-two hours

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until the crisis had passed, so that psychiatric treatment and social work intervention could be continued with them and their families in a more meaningful home situation. Certainly the lack of acute psychiatric inpatient facilities serves to perpetuate symptoms in degree and chronicity until separation of a child from home and community under emergency conditions is the only option. The child’s separation from his family then becomes undesirable in terms of what we know about the psychiatric treatment of children and the need for maintenance of family and community ties with individual, milieu and family therapy as modalities to re- establish relationships on a more stable, mature level. This task is infinitely more difficult under the present centralization of child treatment facilities in the state. The twenty-five percent of children in this study from Fairfield County are one to two hours from home, mitigating against consistent close contacts with their families. Acute psychiatric treatment centers for children on a decentralized community basis are called for. Additionally, attention must be given to the special needs of the disturbed, mentally deficient children in the Connecticut Valley Hospital population. They require a special program oriented to the specific needs, capabilities, and tolerances of these children. They require a program, which bridges the gap between their retardation and their emotional disturbance, with special education and therapeutic approaches which a general children’s psychiatric service cannot provide. A final impression is that many of these deficiencies could be resolved or avoided, were there a central agency or agent charged with and committed to the care and treatment of emotionally disturbed children in the State of Connecticut.9 Downey’s analysis clarified the need for massive amounts of help from the government, the community, and the hospital. Arafeh, superintendent of CvH, requested assistance from the Connecticut Council of Child Psychiatrists, asking them to review the Children’s Unit

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program and make recommendations not only on how to improve its functioning but on how they could help provide psychiatric leadership for the unit. Partially in response to this request, in February 1969 the Council and the New Haven–Middlesex Chapter of the Connecticut Psychiatric Society submitted a report to the Ad Hoc Joint Committee on the Children’s Unit. In it they reiterate the conclusions of the previous studies and describe their own observations: The wards have a markedly institutional character, they are cold and generally forbidding, and there is already a sense about them of considerable dilapidation. Clearly they were not designed to withstand use by a fairly active group of children. Some of the rooms are exceedingly overcrowded and there is about them a sense of starkness, which is distressing. There are few personal possessions in evidence and very little sense of any kind of privacy. With one exception, the recreation or public rooms are empty and bare. The one exception is a recently established combined recreation and snack shop which the patients established themselves, which they run, and which has a somewhat more festive, livable and desirable air about it.10 The report went on to conclude, “The Children’s Unit must have full autonomy. This includes full administrative and program control and in the management of all services with all staff reporting directly to the superintendent of the unit, rather than to the CvH chiefs.” They also recommended a salary level that would attract a qualified person, “optimally a child psychiatrist.”11 Some support came from the judicial side of government with the appointment of a new juvenile court judge, Margaret Brenneman. Judge Brenneman was a strong advocate for children and over the years supported the development of children’s mental health services.12 Unfortunately, the judicial system changed eventually, and juvenile court judges were replaced with superior court judges who rotated through the juvenile courts, making it difficult to get to know the judges and vice versa.

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Early in 1969, Suzanne Peplow resigned, partly because of poor health but certainly out of frustration with not having moved up from the acting- director designation, as well as a sense of futility based on what she perceived as a failure to move more quickly in meeting the needs of the children. One of Suzanne’s final acts was to recommend an increase in childcare staff from an average of two staff members per shift per ward to an average of just under three staff members per shift per ward. A ward consisted of an average of thirty children. This would raise the number of childcare staff members, including nurses and supervisors, from thirty-seven to fifty-nine, with an average daily census of eighty children on two wards and an “annex” for the autistic kids. This increase would also accommodate the change from a forty- to a thirty-five-hour workweek. Suzanne also recommended an increase in social service staff in order to decrease the caseload of each staff member to fifteen. Upon Suzanne’s resignation, Margery Stahl, supervisor on the boys’ ward, moved up to acting director of the Children’s Unit, and Marcia Pease- Grant accepted a promotion to senior psychiatric social worker. Marge Stahl took charge and brought immediate order to a rather dispirited situation. In an interview she describes what it was like at the time: The hospital really didn’t like the children being there. [The children] broke things, were noisy. We had a child who could pull up a tile in a second. They didn’t like that very much. But basically, the wards in Merritt Hall were very sterile. They had a bed and a locker. And the thing that bothered me most as the nurse on the unit was that the kids had nothing to play with. They didn’t have games, and if they did you were constantly looking to find the pieces. One of the mothers of one of the autistic kids who used to come up to the unit to help with the autistic kids wrote a letter supporting us.13 Judy Raczkowski McCain began at the Children’s Unit in 1968 and was assigned to Wards 91 (girls) and 92 (boys) in Merritt Hall. She describes a similar situation:

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There were minimal resources for kids. I remember one of the seven-year- olds gravitated towards the autistic kids and began to act autistic because their unit had some toys and he saw that as his way to be able to play with their toys. There would be two people on with forty kids. These children were extremely mad and aggressive. They hated being there. They would say things to me that I didn’t even understand—especially about my mother. But even though I didn’t know what they were saying, I could tell just how upset they always were. For a while there was no recreation for the kids. However, they finally hired recreation workers who organized activities and paid attention to the kids.14 This frustration soon reached its boiling point. On 23 May 1969, a particularly frustrating day for staff, Marge Stahl remembers going home and sitting on her front stoop and writing a letter to Governor John Dempsey. She pleaded for recognition of the plight of the unit, recounting the various studies cited above without any recognizable results, the promise four years earlier of new facilities, and the immediate crisis of summer approaching, a camp program ready to go, and yet no approval for the necessary staff. The next day the entire staff of the Children’s Unit signed the letter. On Sunday morning the Hartford Courant headlined the story and Marge received an urgent call from the superintendent, Mehaden Arafeh. He asked Marge to meet him at the hospital. In any case, according to Marge, “for the staff, it formed quite a bond among us at the time and was a catalyst for moving the development of the construction for the new facility.”15 A search committee—composed of Margery Stahl; Mehaden Arafeh; Charles Leonard, superintendent of High Meadows; Tom Frank, child psychiatrist and consultant for the Department of Mental Health; Albert Solnit, director of the Yale Child Study Center; and Ned Graffignino, director of the Institute of Living’s children’s program— began working to find a permanent director. Following much discussion and failure to find an appropriate or available psychiatrist, two men were approached: Peter Marshall, chief social worker at Highland

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Heights, a residential treatment center in North Haven, and myself. We were told that the committee was interested in both of us, that we had complementary skills, and that they would like us to get together and decide who would be the clinical director and who would be the administrator. After meetings at our homes, our offices, and atop a raft at Camp Quinebaug, where I was still working, Peter and I clearly felt our compatibility and decided to go for broke. We made several demands, among them to be appointed as co- directors, with equal pay and shared responsibilities, and to become independent of CvH, reporting directly to the commissioner of the Department of Mental Health. These proposals require some explanation: (1) The concept of co- directors was questionable. We reasoned as follows: There was a very big job ahead of us, and sharing that with someone would make the stress manageable and provide mutual support. We recognized that we could be vulnerable to staff members working one against the other. However, we also recognized that our shared position could work only if we had the utmost trust in each other. We felt we could develop such trust. We would have to define very clearly our separate areas of responsibility, those that we shared, and how we would resolve differences. (2) It had been the custom at the hospital to pay people according to their professional classification. Thus, the previous administrators had been paid as social worker, psychologist, or psychiatrist, with vastly different salary ranges, even though the expectations of the job were the same. Additionally, since we were going to be sharing the responsibility equally, we felt we should be paid equally. We also knew that a comparable salary level sent a message of equality to others in the state organization. (3) We decided that it was important to establish that the Children’s Unit was a major program of the hospital and that its leadership be accorded the rights and privileges of other major areas, which were led by psychiatrists. We felt strongly that the philosophy underlying the children’s program must be different and separate from that concerning the adults.

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(4) We wanted a voice in the state hierarchy comparable to that shared by the other facilities of the department. This included sitting in on the monthly meetings of the superintendents with the commissioner of the Department of Mental Health. (5) We needed complete control of all program decisions, with the authority to implement them subject only to the veto of the deputy commissioner for children who would be our direct supervisor. (6) We wanted to dissociate the children’s program from the stigma associated with adult psychiatric hospitals. (7) We wanted to make a statement that children’s mental health needs were very different from, but at least as important as, those of adults. To the credit of the committee and Commissioner Bloomberg, all of our proposals were accepted. While they had some difficulty with the concept of co- direction, they eventually agreed to it with the understanding that we would report directly to the newly appointed deputy commissioner for children’s services, Charles Launi. Charles would work closely with us and would act as arbitrator of any differences we could not resolve ourselves. The second issue caused some difficulty because it meant creating new job specifications rather than using the traditional ones. The creation of new job specifications in a state system is never an easy task, but the committee agreed to pursue it. In the meantime we were placed in “temporary” positions. It was three years later that a position called director of the Children’s Unit was created. The issue of autonomy from the adult hospital was a very ticklish one that had various emotional and political implications. The separation had been heatedly discussed in various circles between the child advocates and the greater number of mental health professionals who were not in favor, since it implied that children’s needs required special training or programming. We knew, however, that several members of the committee, as well as members of the Connecticut Association of Child Psychiatrists who had strong voices in the state, were outspoken in their endorsement of such separation. Commissioner Bloomberg, in a letter to Mehaden Arafeh, super-

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intendent of Connecticut Valley Hospital, dated 25 September 1969, officially announced the appointment of the co- directors and clearly spelled out the condition: “Both individuals will have equal and comprehensive authority to operate the children’s services program.” And a separate budget was established. The letter also pointed out that the commissioner had asked the attorney general about the possibility of establishing children’s services as a separate unit of the department. He was informed that it required legislative action and an amendment to the statutes. The letter continues, however, “This amendment will be presented to the 1971 Legislature, and I believe there will be no difficulty in securing approval.” In the meantime, while legally still a part of CvH, Peter and I would have full responsibility for the program philosophy and implementation and, while reporting to the deputy commissioner for children, would also participate in the CvH administrative staff meetings. This arrangement worked out very well as an interim measure. Arafeh supported our goals and accepted us as members of his administrative staff.

[ CHapteR 4 ]

a new diReCtion ... We assumed our new posts on 1 November 1969 and used that first month to get to know each other, to visit various children’s hospitals in Massachusetts, Rhode Island, and New York, and to begin to identify our various roles and responsibilities. While I had some experience both with CvH and with the Children’s Unit as a result of our working together on our camping program, Peter was relatively new to state service and the Children’s Unit. We found this first month, a period of looking at other programs, developing trust in each other, and sorting out problem-solving ideas and strategies, to be very productive. We decided that we would meet at the end of each day, discuss what issues arose, and how we had handled or would handle them. We agreed that whenever possible we would talk about solutions to problems before implementing them; but when decisions had to be made in the absence of the other, complete support would be given, with any differences discussed privately. Any unresolved differences would be brought to the attention of the deputy commissioner for children, Charles Launi. We also used this time to review the functioning of the Children’s Unit—how it came into existence and what had happened to it in the succeeding years. We identified the key players and generally figured out what was in store for us. Later in November 1969, after giving us the chance to get the lay of the land, the ad hoc subcommittee of the hospital’s Advisory Committee, which had been formed to develop a children’s program, invited the newly appointed co- directors to its meeting. Issues of construction were discussed. The plans called for three phases, each with its own bond issue. The first phase, which had already begun, was the building of three 16-bed cottage-type facilities and renovating the Silvermine Building as an administrative, clinical, and dining facility. The second phase was the construction a new school, and the third was the con34

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struction of four additional cottage-type residential units, totaling 112 beds. Prior to the meeting, Peter and I surveyed several children’s programs nationally and found there was nearly unanimous agreement that the maximum size of a children’s psychiatric hospital should be no more than fifty or sixty beds. Also, while we supported the cottagetype facilities, we were concerned about the security of the design, especially for the autistic children and for those who might need a more secure setting. We also recognized that there was a need for additional beds but felt that they should be built in two different areas of the state. As a result of this discussion, the commissioner sent a letter to the Department of Public Works to stop planning the additional four residential units but instead to use the money to construct a specially designed facility for children with autism and an intensive care division. Since the latter would obviously take much more time, interim plans had to be revised to accommodate those children. Consequently, we made temporary accommodations in the Silvermine Building. We divided the third floor into an autistic unit and administrative offices, a medical records room, and a conference room. The middle floor became an intensive care unit. We discussed plans for the new school to accommodate up to one hundred children in order to offer a partial hospitalization program. Up to this point, children would arrive in an ambulance, without notice, and be automatically admitted by the resident psychiatrist on- call on the basis of “cautious clinical judgment.” We assumed authority to control admissions, which now required a call to the hospital intake staff and a discussion with the referring agency. Our staff discussed each pending transport and assessed with the referring agency the appropriateness of hospitalization. In many cases alternative solutions made more sense. According to the statistics for that year, 324 children had been served, with 225 in residence, 157 new, and 148 discharged. As of the end of June 1970, the census was 74, that is, 59 boys and 15 girls. Peter Marshall and I were acutely aware of Marge Stahl’s work to bring some sanity to the Children’s Unit. She had a strong, positive, and loyal relationship with her staff and we were newcomers, taking

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over her territory. Initially assuming we would have to win her over, we soon learned that this concern was unnecessary. Marge welcomed our help, support, and initiative. Thus began a new era and an enormous challenge for all of us. Since I had worked previously in the Psychology Department of CvH and the central office of the Department of Mental Health and knew the various departmental heads, it fell upon me to do most of the administrative work, dealing with old friends: Eugene O’Brien, the CvH business manager; Donna Dickson, the personnel director; Dwight Shuman, the director of nursing; and various others at the hospital and central office where I had previously worked. Peter would be responsible for the education program, given his experience with boards of education and school operations. Marge reverted to her role as director of residential care. This group, along with Jacqueline Reardon, our secretary, became the administrative staff. Soon, the Yale Child Study came through for us again by assigning as consultants two child psychiatrists, Alan Gurwitt and Norton Garber. They not only gave guidance to our few clinicians but also were enormously supportive of Peter and me. Yale’s Psychology Department assisted by assigning one full-time psychologist and two part-time psychology interns.

stRuCtuRe Early in our talks, Peter and I had discussed the importance of milieu therapy, an approach we each had experienced. Milieu therapy embraces the need for the children’s entire environment to reflect a therapeutic mission—the landscape, the buildings, the staff, the policies and procedures, and in particular the residential units, where the children spend a good part of every day and night. To ensure that a milieu approach was taken, we chose to take direct responsibility for this segment of the program and philosophy. The book The Other 23 Hours by Brendtro, Whittaker, and Trieschman became our bible.1 One of our first concerns, therefore, focused on the basic structure of the unit. As strong advocates of the other twenty-three hours (meaning the time spent between therapy sessions), we felt it important to devote most of our energy to revamping residential units, recre-

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ation, and schooling. There were three residential units. Ward 91 was a twenty-bed, all- girl unit. Peter Marshall, because of his previous extensive work with young adolescent girls, became the coordinator. Because of my previous work with autistic children, I became coordinator of the Autistic Unit, and Peter and I shared coordination of the boys’ ward. Marge Stahl took responsibility for the basic needs of the units, such as scheduling work hours and overtime, supervising staff, organizing medications, and providing all the other daily necessities of group living. Clinical services were provided primarily by social workers and caseworkers, with Marcia Pease- Grant as their supervisor. Additionally, psychology interns and resident psychiatrists were minimally available. In our first annual report, we noted new members of the staff. David Hickox, a part-time pediatrician, proved to be an invaluable asset to the program. Each morning he would see any child on sick call, examine new admissions, and generally provide tlC to children and staff. He made himself available in emergency situations from his group practice in Middletown and was our primary liaison with Middlesex Community Hospital. This was a big improvement over a visit to the CvH infirmary serving primarily adult patients, a frightening experience for our kids and staff. We also hired during this period a caseworker for the Autistic Unit, Judith Deras; a psychiatric consultant for the Autistic Unit, Virginia Suttenfield; a behavior modification consultant, Joseph Cautella; two social group workers, David Merry and Roger Wehage; and two nurse clinical specialists, Diane St. Jean and Karen Fredricks. The first fieldwork placement from the University of Connecticut School of Social Work—Esther Adam—and three psychology interns—James Tracy, Margaret Hull, and Peter Bishop—also joined our growing clinical staff. As encouraging as it was to welcome new colleagues, serious concerns were also reflected in our annual report: By far the greatest problem we have encountered as co- directors of the Children’s Unit has been the great discrepancy between what is expected of our staff and what is possible given the resources available. Further, the coordination of ser-

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vices is often obtained only after interminable delays, unimaginable expenditures of time, energy, skill and paperwork. Even when the proper documents are forwarded to all parties concerned, there is no guarantee that the finances requested will be approved on time, in sufficient amount or at all. Under these circumstances, we understand why there is so much professional resistance to the need for change and a lack of commitment to our program and children; yet we are seeing an encouraging development of openness, of feelings and sharing of advocacy for our children by our staff. The great shortage of skilled psychiatrists has made it mandatory for us to use non-medical psychologists, social workers and psychology interns to carry out the major clinical responsibility of diagnosis, treatment and discharge planning. Our psychiatric coverage has been poor, necessitating our decision and need to plan for and develop a Residency Training Program.2 On the other hand, Arafeh’s superintendent’s quarterly report of July–December 1970 stated: “The autistic program has improved greatly. It can be said that it is now one of the best such programs in the northeast. There is also evidence of improved overall programming. . . . . This Service has succeeded in recruiting high level and dedicated staff and consultants, and enlisting the cooperation of the Association of Child Psychiatry and the Association of Child Psychiatric Clinics in the state.”3 These encouraging words gave us a significant boost in morale. It was clear that the Children’s Unit was viewed by staff as a place for children to stay while a residential treatment center or other childcare facility was sought. There were at this time very few public or private psychiatric units in Connecticut equipped for children or adolescents. Psychiatric emergencies were dealt with in ill- equipped emergency rooms, and from there the children were sent to the Children’s Unit with a physicians’ fifteen- day certificate. This gave the hospital permission to accept a child without either the child’s or the parent’s approval. The hospital in turn had to decide whether or not the referral

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was appropriate. The policy at the time was to use “cautious clinical judgment.” Also, as the on- call physician was likely to be a resident in training with little or no previous training with children, admissions were almost automatic. Because children were sent to the Children’s Unit after failing in other placements, and were generally felt to be untreatable, they often stayed for many months and treatment consisted primarily of trying to hook them up with another program or with a family. The intake process improved when we created a position for our own intake staff. A short conversation about a child marked a turning point in treatment philosophy at the Children’s Unit. When the assigned clinician asked, “This child could really benefit from treatment. Where can we send him?” I replied, “I thought that’s why he was sent here.” Until now, our staff members had thought of themselves as custodial/placement persons rather than as treatment agents, and the excitement they now felt was obvious. From this simple dialogue, a treatment philosophy gradually developed in which the role of the Children’s Unit was to provide extended treatment for children who needed more than a brief stay, and community hospitals, not us, needed to develop emergency, short-term treatment. This enthusiasm fed our goal to develop a milieu program and a residential facility, as we encouraged local hospitals to develop short-term emergency programs. In fact, eventually, we would not accept children unless all community resources had been exhausted. We actively helped local hospitals develop children’s units. At Saint Raphael in New Haven, for example, we helped develop aCute, a short-term emergency setting for children and adolescents. We had an understanding that, should they make a referral to us, we would accept it unquestionably because we knew they had done their job. Similar agreements were made with other programs as they developed. Our annual report of 1970–1971 reflects this effort: “The reduction in admissions [from 157 in 1970 to 115 in 1971] reflects the new admission policy encouraging admissions of 14 and 15 year old boys to the community hospital serving their town of residence.” This not only reduced direct admissions to the Children’s Unit but improved commu-

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nications and working relationships with community resources. Our report adds, “The referrals in general are also more appropriate.”4 Interestingly, despite the fewer admissions, a new category of “total children served” shows a significant increase from 324 in 1970 to 447 in 1971, signifying an increase in work with children, families, and family members, including pre-admission interviews and aftercare (a program requiring clinicians to follow up for brief periods after discharge). Part of the 1970–1971 report, “A Philosophy of Treatment and Education,” set forth our commitment to placing greater importance and emphasis on the residential component, or the milieu, and redefining the role of the childcare staff as an integral part of the total treatment program: “Our psychiatrists, doctors and clinical staff must work patiently towards delegating to nurses and aides an important wider spectrum of authority to make decisions than they are accustomed to accepting—or that doctors are accustomed to granting. By the same token, nurses and aides must learn to assume authority they have not had before.”5 Also, we emphasized the importance of including parents in all aspects of the hospital experience—intake, residency, and discharge. To complement our emerging philosophy, Peter and I offered a course called “The Life Cycle” to the entire Children’s Unit staff as well as staff members from CvH, Long Lane School, and the Department of Children and Families. We addressed our educational philosophy, too, and modeled it after William Glasser’s Schools Without Failure,6 as was our basic principle: No child will be considered too sick emotionally, or too disturbed, or too unmanageable to be deprived of an opportunity to learn. Summer school was very limited—half days, with special education graduate students from Central Connecticut State University providing the bulk of the work. Children’s Unit teachers were on a regular school schedule and not necessarily certified in special education. This was the fourth year that Central Connecticut State University provided this service, but the head of the program indicated it could not continue without supervising teachers. Recreation for the summer was equally short staffed. We had hit a hiring freeze and lacked the support of the Service Corps, which had been available the previous five years.

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Also, Camp Quinebaug was no longer available, because of a new rule that required overtime pay, despite the many staff members willing to give of their time and skills and work more than the mandated eight hours. Upon the election of Governor Meskill, everything was put on hold—as is often the case with a new administration—particularly our ability to fill staff vacancies or to hire new employees. The timing couldn’t have been worse for the Children’s Unit, as we could not move forward or continue pursing plans to move to our new facility without the necessary staff. Construction was completed and the Silvermine Complex was officially turned over to the hospital. However, staff shortages, as well as delays in the shipment of furnishings and equipment, postponed the move even further. We requested for the new facility fourteen psychiatric aides, one psychologist, and one psychiatrist. There was, at this time, no such title as “child psychiatrist,” and child psychology was not considered a specialty. Also, since CvH’s personnel office was not familiar with hiring people to work with children, there was large turnover of staff. Most had come from adult services. We therefore requested that we handle our own prescreening of applicants and set up our own personnel office. The prescreening was reluctantly agreed to and was cause for a lot of friction over the years between the Children’s Unit and CvH’s personnel office. Also, while the idea of setting up our own personnel office was rejected, CvH assigned one personnel officer to handle our matters, and this greatly improved our relationships with the office. Mehaden Arafeh’s quarterly report optimistically concludes: “[T]he new program structure could not open without the addition of some seventeen direct patient care positions (supportive staff positions are also deemed necessary). The Department of Mental Health was able to obtain a commitment on the addition of some $150,000 to the total hospital budget for this purpose. This is a notable exception to budgetary reductions in other areas, which will have the happy effect of making it possible to use the new structures without delay.”7 The money did not come. In the midst of all our frustrations, Governor Meskill, in trying to downsize state government, apparently decided that two heads were

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not better than one. He declared that one of the co- directors be dismissed. Fortunately, the commissioner fought hard to keep both Peter and me, but he had to compromise by making one of us director and the other assistant director. We were told that we had to “work it out.” After many hours of meetings at our homes, looking at our respective duties, trying to find some logical solution, we finally had to agree that the decision must be made by the commissioner. Several days later, Deputy Commissioner Charles Launi met with us to inform me that I had been selected as director. This was a very difficult time. Peter and I had worked hard to develop a trusting, rewarding relationship and cooperative working arrangement. We had taken what we knew was going to be a tough job and made the commitment that no matter what we would stick with it for at least five years. This split changed everything, and we agreed that should Peter be offered a directorship at another facility he would be free to accept it. In fact, it was not long afterward that such an offer was made and accepted and our unique working relationship ended. The sense of frustration during this period comes across in the July– September quarterly report: This quarter was one of the most difficult and frustrating periods of our experience. We had no idea of what was happening in the Department of Mental Health or the direction of the commissioner. . . . A great deal of our time was devoted to the many problems of our staff concerning their repeated frustrations in trying to run an effective program with the limitations of staff vacancies, facilities, etc. Although we were repeatedly told that the new positions would be available for the relocation of the unit, that vacancies would be filled, and that the $150,000 would be forthcoming—there was no clarification on any of these issues. During this period we were asked to work on a new budget for the ’71–’73 biennium, when we had no idea of our current budget or operating expenditures. We were asked to reorganize our unit (the new Table of Organization), to change the role and function of the co- directors, to develop our Philosophy of Treatment and Education, and the role of the pro-

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gram coordinators. Requests for new positions and the filling of old positions were repeatedly lost through the bureaucratic process. We were repeatedly asked to submit new priorities for staff vacancies after each new deadline was passed.8 Early Sunday morning, 2 May 1971, I received a call from Commissioner Ernest Shepard, who had replaced Wilfred Bloomberg at the Department of Mental Health. He asked if I had read the front page of the Hartford Courant, which basically quoted a letter signed by many of the Children’s Unit staff deploring the governor’s action in holding up the funds to open the new facility. I had not read it but he said he would like to meet me at the hospital at 10 a.m. He was obviously very upset and angry. It took a lot to convince him that I had no idea (and I didn’t) who had called the paper with the story. That afternoon the governor was on television announcing that he fully intended to fund the necessary positions so that the children could move to their new facility. He told the reporter that he had ordered that the $150,000 be released for such purpose. In July 1971, my “Six Year Progress Report of the Children’s Program,” as a follow-up to the 1965 Task Force on Mental Health Services for Children, expressed my philosophy of treatment, including “giving more responsibility to group living, those with the most direct patient contact.” I added, “To accomplish this we are considering the concept of program coordinators within each cottage.” This would mean opening the position to childcare workers (psychiatric aides) instead of restricting the positions to RNs. Additionally, in order to curb overcrowding and decrease the age range of kids living together, we limited the age of admission to fourteen for boys and sixteen for girls. It was also at this time that I reiterated my suggestion that the department’s future goals be to create several mental health centers, one in each third of the state, with the Children’s Unit serving the middle third, and to provide a full range of mental health services, both inpatient and outpatient. In October 1971 we were able to hire our own child psychiatrist, Charles Rich, just after his discharge from the air force. It had taken

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us more than a year to convince the state personnel office that a child psychiatrist was needed and in fact, as mentioned earlier, there was no such job description. Rich describes what it was like for him at that time: I was the only psychiatrist for over fifty kids and there was little control over admissions. Some parents would just drive up late at night with their child and would just leave them at our doorstep, just saying they couldn’t take it another second and had lost complete control of their child. Because of this large demand and lack of space, a lot of kids ended up having to stay on the adult ward. Arafeh called this “the red zone on the thermometer,” so at least that started to serve as a buffer to the amount of admissions. I was trying to receive new kids, deal with meds and acute management. I had to keep up with all the problems kids presented and I could not do it all. It was totally overwhelming. When I returned [seventeen years later] I really felt Riverview had evolved a lot.9

[ CHapteR 5 ]

CHildRen do not Belong in psYCHiatRiC Hospitals! ... A dedication ceremony for the RiverView School took place on 8 October 1971. The quarterly report covering October–December 1971 describes “an elaborate program in which a large number of community representatives interested in the mental health of children participated.” Governor Meskill and Edward Zeigler of the Office of Child Development Health, Education and Welfare headlined the bill. In his introductory remarks, Mr. Abraham Lippman, chairman of the board of trustees, emphasized the board’s strongly expressed position that the children’s program continue as part of Connecticut Valley Hospital. The actual move to our new facility happened on 11 November 1971. Finally. After the entire administrative and clinical staff moved, the children were moved to their new dwellings. First, the autistic kids, with the help of their parents, occupied the top floor of the Silvermine Building. Then, assuming the girls would be better able to handle the round configuration (wrong), we placed them in the round cottage, simply named Cottage A. Next came the boys: younger kids to Cottage B, older kids to Cottage C. By the end of November, new staff members joined Charles Rich on the Children’s Unit. Among them were a psychologist, Randy Burnham, who had volunteered on the Children’s Unit while interning at CvH, and, shortly thereafter, another psychologist, Clara Chapman. But wait! Let’s step back for a moment. This seems like a good place to articulate more fully my philosophy, or point of view, about children with emotional, behavioral, or psychiatric disorders: Children do not belong in psychiatric hospitals! Sound heretical? It is. Many believe unstable children should be hospitalized only as long as necessary, but most people believe hospitalization is a necessity some of the time. I disagree! The psychiatric 45

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hospital, formerly known as “insane asylum,” is a concept that applies to adults. Historically, the “insane” were eventually seen as diseased and therefore the purview of physicians and the medical profession. Children were more likely to be tolerated, kept at home, or, when necessary, placed in children’s homes or residential treatment centers. It wasn’t until much later that adult hospitals began accepting children as “patients.” This was a mistake! Instead of developing more comprehensive community services or increasing the capacity of residential treatment centers, adult psychiatric hospitals developed children’s wards, utilizing the same adult/ medical model of treatment—primarily, I suppose, because it was the only way insurance companies would pay for the service. In fact, when we were rewriting the state statutes to transfer the Children’s Unit of CvH to the Department of Children, Youth, and Families, the question arose as to our name and description. My preference was to describe the new program as a children’s community mental health center, including the widest range of inpatient, outpatient, emergency, and outreach programs. This was consistent with my argument that two similar facilities should be built in the eastern and western parts of the state. It would also avoid the stigma associated with psychiatric hospitals. However, the state required that there be a “hospital” for children, and so Riverview Hospital came into being. A “hospital” qualifies for higher-level medical and nursing staff and is eligible for Medicaid reimbursement. Money aside, several key experiences inform my point of view. The earliest was my experience as a high school camp counselor, when I learned the value of working in a natural setting as a way to help a child through real-life struggles. Terry was a seven-year- old, beautiful, terrified boy who obviously found himself in strange, unfamiliar surroundings. Afraid to interact, he avoided any contact with other children and stayed next to me. He also didn’t want to go near the lake. Since we had enough good counselors, I took sole charge of Terry. We watched other kids eat together, play games, and swim. I finally got Terry to go near the water, then put his feet in; and very gradually, over days, he put his head in. With the encouragement of the other kids, he joined in games and actually learned to swim. Needless to say his par-

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ents were happy when they picked him up after camp. As for me? Terry helped me pick my career direction. At Children’s Village, first as a recreation director, then as a house parent, I saw the importance of daily interactions: modeling appropriate behavior, teaching social skills, dealing with problems as they arose. I knew my daily actions and interactions were at least as, if not more, important than the one or two hours per week the children spent in therapy. As mentioned earlier, this prompted me to seek further study.

lesteR At Michigan State University (msu), working one- on- one in a play therapy mode, I discovered the dynamics of play and its meaning for children as a way of expressing some inner turmoil. The msu Psychology Department, as part of its community service and training program, operated its own child guidance clinic. While completing my practicum course in play therapy, I volunteered to work with Lester, a sixyear- old autistic child whose parents had requested a psychological evaluation. Working with that little boy turned out to be one of my most valuable clinical experiences at msu. When I opened the door and entered the waiting room to greet Lester and his mom on that first day, I found Lester cowering in the corner. Instead of approaching him too closely, I told him who I was and invited him to a playroom down the hall. I then moved aside so he could pass me at a distance. He ran through the waiting room and into the play area. He quickly surveyed all the room’s features, making sure to keep distance between us. After opening and closing every cabinet and drawer, he pointed at each animal picture hanging on the wall as he said, “coowwwmooooooo,” “sheepbaaaa,” identifying with, or “becoming,” that animal. I asked him if he wanted to sit down at the table and draw a picture of a person—a standard testing method. He ignored me and continued to investigate the room and its belongings. Finally satisfied, he sat down at the table, picked up a pencil, and began drawing. At first I saw no connection between his illustrations and my request. It wasn’t until I 1ooked closely that I could see that, in fact, he was telling me

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exactly what I wanted to know. Lester drew Humpty Dumpty having fallen off the wall and broken; a cracked Easter egg; and several balloons, some with faces and others that had popped. The image of a fragile little boy was obvious, but I had no idea yet of the profoundness of this feeling. During our sessions over the next several months, once a week for one hour, Lester became more and more preoccupied with the balloon imagery. He wanted to play with balloons, but would not let me blow them up, although he would pretend to do so. I learned from his mother that he had a closet full of balloons at home that nobody could go near without setting off a panic in him. One day, someone who had previously used the playroom left a filled balloon in the room. Lester was terrified. He kept one eye on it all through the hour from the opposite side of the room; and he would not allow me to go anywhere near it, even when I offered to retrieve and remove it. As time went on, the balloon imagery began to include a person contained inside something. Eventually Lester started playing with an airplane, which he placed in one hand while the other hand pressed a small doll against the bottom of the plane. During the first ten months, Lester pretty much did as I asked, while I did a running commentary, trying to be supportive and interpreting what I perceived to be the feelings, worries, and fears behind his activities. If he needed help with something, he would simply take my hand or push me toward the task. However, he did not respond verbally to any direct question. One day, after a long Christmas recess, Lester returned to the playroom and I greeted him with a casual, “Well, what did you do over the Christmas vacation?” Without uttering a word, he went to the blackboard, which covered one whole side of the room, and began drawing. There was the YmCa swimming pool, a bowling alley, a Christmas tree, Santa coming down the chimney, presents, Lester opening one. He drew until he got to the end of the board. Since he hadn’t finished his story, he turned around and walked back to the beginning of the blackboard and simply continued to draw over what he had first drawn. Occasionally, he would realize something was not clear and fix it. This form of storytelling took Lester the entire hour. When he was

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finished, I thanked him for telling me about his vacation. He was very pleased—and so was I! It was the first time he had communicated directly with me in response to a question. As the weeks went by, the airplane with a boy clinging to the bottom began taking more and more precedence in his activities. He’d fly the plane and doll back and forth “to California,” making sure there was no separation between the two. I began commenting about the imagery: telling Lester how it was like a boy being in a balloon or like a baby being born. I suggested that it was all right for the boy to come out of the plane. The boy would be safe because I was there to help him. Then one day it happened! After flying around the room several times, holding the boy tightly against the belly of the plane, Lester took hesitating steps to separate the two, and with further encouragement on my part, he finally pulled his hands apart, separating the boy from the plane. He was ecstatic, jumping up and down and brimming with self-satisfaction. He then walked up to me said, “You say to me ‘What’s your name?’ and I will tell you ‘Lester!’ ” I said to him, “What’s your name?” And he very proudly replied, “Lester!” After repeating the entire scenario several times, he said, “I will say to you, ‘What’s your name?’ and you will say, ‘I am Mr. Wiseman.’” And so I did. After repeating this several times, he went around the room, pointing to each animal picture on the wall, saying, “This is a picture of a cow” and “Here’s a picture of a lamb,” until he identified each of the animals. I said to him, “It’s like you are seeing them for the first time.” He looked at me and smiled. Lester was born. During the next several months, Lester used personal pronouns and began to lead me through his developmental stages—right out of Freud’s books. Lester took complete control of our sessions, taking me by the hand and instructing me on my role in the various scenarios that he wanted acted out. For example, first I was to be a “mommy bird” as he would chirp around the room, come back to the nest, sit on my lap, and open his mouth for me to feed him. This scenario became part of every session for several weeks. Gradually the emphasis

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changed, and I became the “big bad wolf ” and would have to chase him (and not catch him). Scenes were enacted with big “daddy bears,” nighttime monsters, airplane trips to California, all having a theme of horrible things happening from which I was to protect him. On one very dramatic occasion, Lester told me he had to go to the bathroom and asked me to go with him. When he flushed the toilet, he showed obvious distress and we quickly returned to the playroom. He then said, “Pretend I’m falling into a big hole.” He began sinking slowly to the floor. I went to him and said, “I will help you,” and extended my hand. He grasped firmly and pulled himself out. Eventually, we managed to get Lester into mainstream school classes, where he prospered. One day he proudly announced to me that he was president of his class, which meant he led his classmates in the pledge to the flag, lunch count, and so on. During my appointments with Lester, my faculty adviser treated Lester’s mother using hypnotherapy, with apparently equally dramatic results. Interestingly, Lester’s father was a professor of communication skills at the university.

on to ConneCtiCut valleY Hospital and tHe ConneCtiCut seRviCe CoRps Upon graduating from Michigan State University I landed a job at CvH. After two years of doing psychological testing on adults, I grew tired of the emphasis on testing and the deemphasis on the patients themselves. It was during this period that I decided one day to accompany a fellow psychologist who did some volunteer work on the new Children’s Unit, as discussed earlier. The horrifying images are still vivid. The fact was, I was told, this setup was a big improvement over previous conditions! The children there had come from the three adult psychiatric hospitals, always living on adult wards. Having just come from the Hawthorne Center in Michigan, a new, state- of-the-art children’s program, where I worked with Lester, I was appalled. Two years after accepting the position as a CvH psychologist, I accepted a new position: director of the Connecticut Service Corps, which included running a summer program for adult patients from

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the hospital’s back wards (occupied by long-term patients whose condition was considered chronic). That first year we rented a Girl Scout facility, Camp Laurel, and the next year we began building our own on an abandoned reservoir site in Danielson, what would become Camp Quinebaug. During my four summers living in a tent, I witnessed the devastating effects of long-term hospitalization. Being a “patient” was self- defined, a way of life where one must act accordingly. I soon learned that the Connecticut Service Corps was an offshoot of the newly formed Peace Corps. Dave Boynick, the public relations contact from the Department of Mental Health had gone to Washington, DC, and talked with Bobby Kennedy, proposing that the Peace Corps be expanded to include projects at home. He offered Connecticut as a possible host for a pilot project. Boynick outlined a plan whereby college students would volunteer to spend summers at the state psychiatric hospitals, providing companionship and social activities for chronic patients from the back wards. Kennedy liked the idea and sought funds through the Peace Corps. As the bureaucracy would have it, funding was slow in coming and so Connecticut decided to go it alone. The Service Corps was founded when the first group of thirty volunteer college students accepted their assignments to spend the summer at Norwich Hospital. The students lived in the nurses’ quarters and, in the final two weeks, accompanied the patients to Camp Laurel. The students brought new life to the hospital, and their experiences spawned their own professional careers. The success of the program allowed three more hospitals to join Service Corps programs, and an expanded summer program was ordered. That’s where I came in. Camp Laurel, located in Andover, Connecticut, became home for my wife, Eunice, and me; our two children; fifty elderly, chronic, schizophrenic patients; thirty college students from the Connecticut Service Corps; and a few select staff members from the hospital. The students and staff knew the patients, which was a big help. One of my fondest memories of that period, however, had nothing to do with experience or expertise. It had to do with a very lonelylooking, extremely withdrawn white-haired man called Sam and my young son, Ken. The two would sit on the bank of the lake and talk for

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hours. Well, at least Ken would talk. Sam just listened. One day, Sam brought along a piece of paper and a pencil and proceeded to draw a portrait of Ken as he talked. The drawing was beautiful. It turned out our elderly camper was an artist and writer, yet hadn’t revealed this to anyone in years. Eventually, Sam started a camp newsletter.

Camp QuineBaug Our Camp Laurel experiences paved the way for the challenges and deep rewards ahead of us. For the next three summers we would build Camp Quinebaug. Shortly after we closed down Camp Laurel, I immersed myself in recruiting college students for the next summer. I had the authority to hire thirty students for each of the large hospitals (housing approximately 2,500 patients)—Norwich Hospital in Norwich; Fairfield Hills Hospital in Newtown; Connecticut Valley Hospital in Middletown, plus ten for the Children’s Unit—and twenty for the smaller hospital in Meriden, Undercliff, and thirty who were to be groomed for the intricacies of camping with patients. The camp group included fifteen American Friends, a Quaker organization led by Mr. and Mrs. Paris. I also needed a supervisor for each group. I hired Alex Sotir, assistant football coach at Wesleyan University, as program director. Alex, his wife, Norma, and their three children were family friends, and having them with us that first summer was invaluable. Eunice became my volunteer business manager, food service director, and waterfront director. In short, she was my organizer, right hand, lifesaver, partner, and compassionate saint working with students from around the world and, of course, “patients.” That first summer we encountered a slight problem. Although during my own recruitment I was shown elaborate plans for a new summer camp in a reservoir and wooded area in Danielson, Connecticut, time went on and nothing materialized. When time ran out, I made an impulsive comment at one of the commissioner’s weekly meetings: “Well, I’m going out there even if we have to live in tents!” Plans, funding, and promises fell through, and I had to eat my words. Next thing I knew we were calling the National Guard at Camp Dempsey asking to borrow tents. We asked Norwich Hospital to build us some platforms and picnic tables, rented some portable toilets,

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tapped into a freshwater pipe running along the road, and away we went. Only one major problem loomed: how to feed eighty people three meals a day with nothing but a fire pit. Fortunately, we were able to arrange a meal plan with Danielson’s technical school, otherwise closed for the summer. We transported two meals a day, one on weekends, to the campsite via the Blue Bomber, our antiquated school bus. We handled our own breakfasts and organized weekend cookouts. On Sundays, I cooked eggs for everyone! With all the enthusiasm of those about to embark on an unknown venture, we sang as we put up the platforms and our tents— two 16-by-32-foot tents for the students, a smaller one each for the Friends’ supervisors, Mr. and Mrs. Paris, and one for Alex and me. By late afternoon we took a break and discovered the beautiful, clear lake. We picked a site overlooking the water for our dining room, a 100-foot-long army tent adjacent to a large, natural pit about 20 yards in diameter. This became our kitchen when we built a rock fireplace in the center. Eventually, we cleared brush, trimmed and cut down trees, and built an amphitheater. This gathering place hosted morning and noontime planning pow-wows and evening campfires. Two days later our families arrived and settled into our new summer tents—one for Alex, Norma, and their three children, Ted, Paula, and Michael, and one for our family of five, which now included our Dalmatian, Polkadot. This was our overall plan for the summer: Week 1: We would focus on orientation and team building for the staff and Service Corps volunteers, pretesting for the research project, and camp preparations. Week 2: Twenty “permanent” campers were to arrive, five from each hospital, presumably selected for the purpose of working with us to build the campsite, and stay for the entire summer. Weeks 3–8: Every two weeks, forty new campers would arrive from the various hospitals, along with a few aides or nurses. Weeks 9 and 10: The children from the new Children’s Unit at CvH were invited to attend the camp. Week 11: We would spend a few days of breaking camp and falling from exhaustion.

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Most of the patients/campers in the “permanent” group were fairly docile, friendly people, most more than fifty years of age, with diagnoses of chronic schizophrenia and having a variety of bazaar delusions and behaviorisms. Unfortunately, they arrived before we had a lot of our necessities, and I was still running around the state trying to get someone to respond to our requests. In fact, I put almost two thousand miles on my car in those first three weeks, while trying to run the camp and conduct some basic training for the students, who at first were overwhelmed by the variety of symptoms. Looking back, their inexperience actually helped. The student volunteers just ignored the strange behaviors and treated the patients as campers. Nevertheless, because the days were so busy, our staff meetings usually started at 10 p.m. and lasted for an hour or so. By the end of the third week we were each averaging seventeen-hour workdays. Although I felt personally responsible for the fate of some sixty people, I was neglecting the needs of the students and staff who needed help. Finally, some of the students approached me and said, “We need more time to talk to you about the campers.” So we scheduled a meeting that evening. At midnight we sat at tables in the dining room tent and I began answering questions. At one point, while in the middle of answering a question, I noticed puzzled looks on the students’ faces. I suddenly realized that I was in the middle of a sentence and had no idea what the question was that I was trying to answer. I stopped, apologized, muttered something about being tired, and said I would talk to them in the morning. Shaking, I went back to my tent and woke Eunie. After we talked for a while, Eunie finally offered, “To hell with the department. Stop trying to depend on them. You can’t keep running around the state, beating your head against a stone wall. We’ll make do with what we have.” The next morning I basically told that to everyone: “What you see is what you got. We all have to pitch in and not depend on the state to get things for us.” That was the turning point. We no longer held out hope of getting supplies and just went about our business building our camp while concentrating on the students, staff, and campers. I abruptly stopped going to Hartford or even making phone calls except to check in. I later learned that the department did not believe that

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the project was possible and wasn’t about to invest more money than it had to. If it hadn’t been for Eunice, Alex and Norma Sotir, some key staff members like Matt Lamstein and Brett Seabury (two Wesleyan grads), and a fantastic group of volunteers who kept things moving, the project never would have been possible. We simply ran our camp and followed our own agenda. We designated a specific project for each group of campers to call their own. We built a dock and float, with one camper spending his two weeks constructing a diving board. One group cleared an area for an arts and crafts station; another cleared an area across the lake for an overnight camping outpost. We built a chapel by clearing a natural amphitheater in the woods. The chaplain from CvH arrived one day to add a rock altar. Eunice and Norma became experts at soliciting needed supplies from Danielson’s generous merchants, who were very sympathetic to our cause. One morning, at our usual gathering, Alex asked, “Who would like to play a game of baseball?” There were loud cheers and obvious enthusiasm, and so he said, “OK, first we have to build a field!” We passed out saws, axes, rakes, and shovels, marched off to a heavily wooded area, and said, “This is where it will be.” It turned out to be an enormous job, but we managed to clear a very small field, big enough for a carnival, volleyball court, and various other activities, but it was not big enough for a softball game. For that we secured the town’s permission to use a local ball field. About midway through the first camping season we had a visit from the big wigs of the Department of Mental Health. We greeted them in our newly built chapel, where I was conducting a daily workshop with the students. They were completely dumbfounded and said they couldn’t believe what they saw. From then on we got whatever we asked for. This eventually included cabins to replace some of the tents, a large dining hall, a recreation building, real toilets, and a real kitchen. One Friday before all these modern conveniences were bestowed on us, the electrician from Norwich Hospital arrived to wire our 100foot army tent, better known as the dining room. They didn’t finish the job, so they put up a temporary string and promised to return on

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Monday. That Sunday, a group of women from the local church arrived to provide an evening cookout for us. After supper, a storm brewed and we all crowded into the dining room tent. As the thunder boomed and lightning streaked across the blackened sky, the temporary lights began to flicker. One of the elder campers, known for her high-pitched “cackle,” began to do her thing. I happened to glance over at the church ladies, who had huddled closer together. One woman had turned completely white. I quickly proposed, “Why don’t we sing a few camp songs?” We did, and pretty soon some color returned to our visitor’s face. I can imagine that, like me, she is still telling that story to whoever will listen. The rent-a- cans (outhouses) have stories of their own. When they first arrived, Norma was impressed by how clean they were. “They even have a place to put your toothbrush,” she said. After picking ourselves off the floor from laughing, we had to explain that she was referring to the urinal. Soon the joke was on me. The toilets needed to be emptied rather frequently, so calling the porta-potty company was a regular event. One time they didn’t respond, even after several calls, and things were getting desperate. Finally, at midnight, I heard a truck rumbling up our road. It stopped next to our tent. Putting on a bathrobe, I saw the truck with a lone driver who needed an assistant to do his job. So there I was holding the hose, mumbling to myself, “Eleven years of college, and here I am cleaning a rent-a- can, at midnight, in my bathrobe, at a camp with sixty psychiatric patients. There’s something ironic in this.” The first summer came to an end for our adult campers, and we began preparing for the children to arrive. As we said good-bye to our “permanent” campers, preparation to go back to the hospital took the form of the campers returning to their patient statuses— that is, there was an increase in hallucinations, slouching, muttering, and so on. This is best exemplified by Stanley. The campers decided that they wanted to put on a church service, run completely by themselves, in our new chapel. Stanley, after six weeks at camp, had almost completely lost his symptoms, at least superficially. In fact, he often helped other campers through rough times, was a hard worker, and functioned like an extra staff member. It was to be his job to give the

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main good-bye speech. As he talked, he gradually became more and more incoherent, religiously delusional, perseverant, and unable to stop. I finally had to intervene, thank him for his kind words, and end the meeting. A small group from the Albany Avenue Child Guidance Clinic in Hartford, led by David Frieze, who later became assistant to Charles Launi, deputy commissioner for children at the Department of Children and Youth Services, arrived for a brief stay. The final group to come to camp that summer included the children from CvH. Having the children as our campers was a totally new experience. No more urging participation in activities. No more restful after-lunch naps. Rather, it was nonstop activity, games, swimming, boating, campfires, singing, and total exhaustion. It was my first real taste of what it would be like to work at the Children’s Unit. Six of the autistic children were included in this group and were able to benefit from the full period at camp. A memo was sent to me, as director of Camp Quinebaug in Danielson, Connecticut, listing the staff and children going to camp. The staff included Rosemary Wissier, Marilyn Willard, Donna Hirshman, Roland Chase, Jerry Langlois, Mike Karwan, Ann Wild, Sarah Sigel, Kathy Flood, Carl Sundell, Bob Davis, and Connie and several Service Corps students. This was a most successful experience for children and was certainly the highlight of the summer. Six of the autistic children were included in this group and were able to benefit from the full period at camp. When the children returned to the Children’s Unit, CvH dedicated an area near one of their reservoirs as a camping site. In 1968, under the direction of Mike Karwan, the director of recreation, the State Department of Education awarded the Children’s Unit a grant to develop a residential camping program for the autistic children. They used the money to build two cabins in the reservoir area of CvH and the summer program commenced. The camp was dedicated as Camp Pioneer on 31 July 1968, and twelve children accompanied by Connecticut Service Corps students, led by Cindy Niedoroda, a second-year Service Corps volunteer, experienced camp that first year.

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The two-week camping experience was described as follows in the quarterly report: “Forty-six children were able to spend ten days at the mental health camp in Danielson CT.”1 Nothing more was mentioned. Finally, in 1969, when I became co- director of the Children’s Unit, I saw directly some of the effects on the children of being in a hospital. Those people who had the most opportunity, in terms of time to affect the lives of the children, the childcare workers and recreation staff, were the lowest members in the hierarchy, had the least (officially) to say about the treatment of the children, and had no sense of “ownership.” The kids were referred to as “patients”—a clear attempt, it seems to me, to put them in their place as submissive, dependent, sick individuals who must listen to their doctors and nurses. I decided, therefore, that I would do everything I could to make our new facility as unlike a hospital as possible, utilizing the best parts of the medical model and the best parts of the residential treatment model. I knew I could make a difference in kids’ lives. A healthy therapeutic milieu, like the people in it, is a dynamic, constantly evolving entity. It is easy to draw an analogy between such a milieu and human development—challenges lead to growth and growth leads to higher developmental levels, which create change. This new ego influences and is influenced by cultural surroundings in ways that it could not have been before.

Jimmy. We met when I began work at the Children’s Village, and we continue to enjoy a lifelong kinship. Photo: Eunice Wiseman, 1957.

Camp Quinebaug, Danielson, Connecticut. With Service Corps volunteers and patients from Connecticut Valley Hospital, we built a summer camp enjoyed by patients from the back wards of the state’s four hospitals, including kids from Connecticut Valley Hospital. Photo: Eunice Wiseman, 1966.

Patients no more. Outside the hospital setting, patients became campers and lost many of their symptoms. When they got on the bus to return to the hospital, their mental disorders returned. After witnessing this phenomenon over several summers, I coined the term “patientitis.” Photo: Eunice Wiseman, 1966.

Service Corps volunteer and camper. The two cross the bridge they made together. Photo: Eunice Wiseman, 1966. 

Breakfast line at Camp Quinebaug. Photo: Eunice Wiseman, 1966.

The Blue Bomber. We used this trusty old bus to transport campers and bring supplies to our fledgling campsite in Danielson, Connecticut. Photo: Eunice Wiseman, 1966.

Service Corp pamphlets. Photo spread: Eunice Wiseman, 1970.

Shew Hall, 1860. This is one of the few remaining photos of Shew Hall before alterations were made in 1939 and 1967 to the original French Second Empire design by Samuel Sloan & Addison Hutton. Photo courtesy Connecticut Valley Hospital Archives.

Shew Hall. Beers Hall, which is located within Shew Hall, is the first place Connecticut Valley Hospital children were brought together. Prior to this move kids were assigned empty beds throughout the adult psychiatric wards. Beers Hall was named after Clifford Beers (30 March 1876–9 July 1943), a Yale student who was a patient at Connecticut Valley Hospital. When Beers was discharged, he went back to Yale as a graduate student and wrote A Mind That Found Itself, an exposé of the horrid conditions. Photo: K. Ohno, 1984. Courtesy National Register of Historic Places Inventory.

Weeks Hall. Adjacent to Beers Hall, Weeks Hall (1896) was also a part of Shew Hall. Shortly after the boys were moved from the adult hospital to the newly formed Children’s Unit in Beers Hall, the girls were moved to Weeks Hall. Photo: K. Ohno, 1984. Courtesy National Register of Historic Places Inventory. Paige Hall. At first, children confined to Connecticut Valley Hospital dined with adults in this building. Photo: K. Ohno, 1984. Courtesy National Register of Historic Places Inventory.

Noble Hall. This building was used for recreational activities, including roller skating, before the Children’s Unit was built. Photo: K. Ohno, 1984. Courtesy National Register of Historic Places Inventory.

Driveway from Silver Street. The tree-lined drive served the hospital for more than a hundred years. In 2014 the River Road entrance became the main driveway to the new Albert J. Solnit Children’s Center. Photo: K. Ohno, 1984. Courtesy National Register of Historic Places Inventory.

Silvermine. The Silvermine Building, presumably named after an abandoned silver mine, is a three-story stand-alone building. In 1970 it opened as a central facility for the Children’s Unit. This view from the Connecticut River features the Silvermine Building and the top of Alpha Cottage. Photo: Frank Michael Winiski, 2012. Silvermine to Connecticut Valley Hospital. Eventually, the unit for the autistic children occupied the third floor of the Silvermine Building; the second floor housed offices, and the dining room was located on the first floor. The round cottage is just down the hill, and Connecticut Valley Hospital is in the distance. Photo: Frank Michael Winiski, 2012.

[ CHapteR 6 ]

a new name ... Midway through 1975, Governor Grasso signed Senate Bill 1446, An Act Concerning the Transfer of Children’s Mental Health Services to the Department of Children and Youth Services. With this bill, all mental health services for children and adolescents, including all the facilities, were transferred to the Department of Children and Youth Services (dCYs). While full implementation took some time, preparations began immediately. In 1977 full independence brought these major corollaries: No longer could a person under the age of eighteen be admitted to an adult mental health facility. All new admissions had to be to the Children’s Unit or to the Adolescent Unit at CvH or to those at Fairfield Hills Hospital and Norwich Hospital. No longer could a child sleep in an adult ward when our beds were filled. While this forced us to limit admissions, it also made it possible for us to eliminate a very unhealthy situation for our children. The first order of business was to give the Children’s Unit a new name. Since our school had already been named Riverview, we decided to keep that name in our title but to capitalize the “v,” just to be different. Finally, it became official with Public Act 77-43, An Act Changing the Name of the Children’s Unit at Connecticut Valley Hospital to Riverview Hospital for Children, signed on 20 April 1977 to be effective on 1 October 1977. As noted earlier, my preference was to omit the “hospital” designation, but it didn’t happen. The next order of business was to develop new statutes for the changing admission criteria. We formed a committee consisting of 59

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the senior children’s judge in Connecticut, an attorney from Yale Law School, a prominent children’s lawyer from Hartford, the deputy commissioner of mental health, Charles Launi, and myself. The lawyers in the group immediately put forth the position that only the child could admit himself or herself voluntarily, thereby denying the parents’ right to sign their child in, as was the case at the time. Eventually, after much discussion we agreed that some age limit should be established to give the child the right to make the decision for a voluntary admission. But at what age? Six? Ten? Eventually, it became a practical issue. Since Riverview’s age limit was thirteen, that became the dividing line. For children fourteen and fifteen, the parent was able to sign the child in but the child would then have the right to either voluntarily agree or file for a probate hearing. Sixteen-year- olds would be under the adult statutes, permitting them to sign themselves in and out voluntarily. Within five days of the request for discharge, the hospital would have the right to file for a probate hearing. Additionally, all new admissions or medical issues were served by on- call staff from CvH on evenings and weekends. Now these services were provided by our staff. The next major issue was how to apportion the money to be transferred from CvH to the new Riverview and to constitute our budget. Melodie Peet, a graduate student in the Yale School of Public Health Administration, became our first intern from that program. Her task? To sort out how much money should be transferred from each department at CvH. The completion of her project gave us our own budget, another major stepping-stone to independence. Other changes included the fact that personnel functions were to be run out of the dCYs central office rather than CvH. I had hoped that we would have our own personnel officer but that was rejected. However, again central office assigned a staff member as our own point of contact. Medical records were transferred to the Silvermine Building with Loretta Hodge in charge. Terry Russo, her assistant, later became medical records director. Lyle Ressler now oversaw all business operations, including budgeting, food service, maintenance, and clerical functions.

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Maintenance fell under the supervision of two new hires, Carmelo Milardo and Michael Bartolotta. It should be noted that when a vacancy occurred at Connecticut Children’s Place (formerly named Warehouse Point), Mike became maintenance chief at that location. After the merger of the hospitals, he transferred back to Riverview. With the exception of police, fire, and grounds maintenance, all maintenance functions were transferred to us. Thanks to a good working relationship with the CvH business manager and head of maintenance, specialty craftsmen voluntarily assisted until necessary connections were made with community services. By August 1977 the final steps were taken to complete the separation from CvH. All facility chiefs were now designated as superintendents. This was an interesting experience for me. Since I had been working under the “temporary classification” of director of the Children’s Unit, I now had to apply for the new position of superintendent of Riverview Hospital for Children. The state personnel office created a job description, published specific qualifications (which pretty much described what I was doing), and initiated a statewide search. Also, interviews had to be set up, presumably with neutral persons who did not know me. This was a bit difficult, but not impossible, since by now I was at least familiar with people in the field. Anyway, they found a child psychiatrist and a psychologist, and their interview consisted of “Tell me Dick, what have you been doing in the past few years?” I told them and apparently they were satisfied. They officially hired me as superintendent of Riverview. In the dCYs central office, Mark Marcus replaced Frank Maloney as commissioner, Charles Launi stayed on as deputy commissioner, and David Frieze was appointed director, assisted by Ellen Ryder, former director of the Adolescent Unit now closed at Norwich Hospital. Frieze held monthly meetings with all the superintendents of dCYs facilities. These proved to be valuable communication forums for coordination and advocacy for children and youth with mental health issues. The next few years were times of change and growth for the new hospital. In addition to the above, we hired new staff, developed new functions, and assigned new titles and new roles.

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Charles Rich left Riverview for the Institute of Living and was replaced by Louis Salcedo, one of the first full-time residents of the joint child psychiatry–training program with the Yale Study Center. Within the year Salcedo left for warmer weather in Florida. A national search was completed, and we appointed Yvonne Johnson as clinical director with supervisory responsibilities for all clinical services. This was a major change in the dynamics of the administrative staff since previously the chief psychiatrist, senior psychologist, and senior social worker functioned as peers, constituting the clinical administration and participating in administrative staff meetings. We hired child psychiatrist William Taylor as a consultant and added Lewis Goldberg to the psychology staff (1978) and psychiatrist Alton Allan part time (1980). Also, we brought on board a speech therapist, Rita McDermott; an occupational therapist consultant, Virginia Rollefson; and a part-time dietician, Kathy Duffendack. Additionally, a psychology internship was initiated with Michael Hayms, Eleanor England, and Robert Block. Michael Hayms later joined us as a staff member. As director of education, we appointed Ronald Quinto, formerly our teacher of the autistic kids, while Allan Spaulding continued as school principal. Midway through the year, we instituted a major reorganization of the unit’s administrative structure, redesigned to provide greater accountability and closer, individualized, clinically oriented supervision for all patient care staff. This significantly improved the channels of communication between different areas of the program. The hospital received some national recognition when four staff members were invited to San Francisco to present an all- day workshop at the American Association of Psychiatric Services for Children on the Behavioral Learning Environment Unit (Bleu). The presentation was well attended and there were numerous requests for copies of the program. Carl Sundell assumed quality assurance responsibilities. Governor Ella Grasso dedicated our new playground donated by the Xerox company. The Joint Commission on Accreditation of Hospitals gave us full accreditation—our first accreditation as a facility separate from CvH. In May 1977 Carol Cook, a Riverview social worker, and Susan

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Walker Huff, a volunteer, formed the Riverview Auxiliary—a community support group. (Susan was our foster child—the girl who had lived with our family for two years when we were at Michigan State University. In 1977 Susan and her family moved to Portland, Connecticut, to be closer to us.) The group basically engaged in fund-raising activities for special treats for the children.

[ CHapteR 7 ]

tHe evolution of a milieu ... autistiC/alpHa unit In 1969, when Peter Marshall and I took over, the Autistic Unit consisted of sixteen boys residing in the converted hydrotherapy room in Merritt Hall. The boys were, for the most part, nonverbal and selfabusive and ranged in age from nine to fifteen. It was a very noisy and crowded place to live, as sound reverberated off the cold tiles. During the day these children would follow their school program with specially assigned teachers who had responsibility for them through lunch and early afternoon. They would then be turned over to the childcare staff for evening and night duty. There was relatively little communication between the two groups of childcare workers, except during their weekly team meetings and the brief transfer time. I agreed to attend the weekly meetings and generally oversee the program. During our first meeting together, the more vocal of the psychiatric aides, a young man who was also attending college part time and learning behavior modification techniques, had instituted evening procedures that he wanted continued during the school day. The senior teacher, however, was vehemently opposed to such an approach, and it soon became clear that this disagreement had been going on for some time. Shouting and accusations ensued, and at one point I thought there was going to be a fistfight. I finally had to say, “Hold it, that’s enough for today! From now on I’ll take over as team leader for this program.” As I got to know the kids and the staff, I found a very dedicated group of people, on both sides, with no assigned leadership, no formal training, doing the best they could against impossible odds, developing procedures out of necessity for the safety of themselves and the kids, and whose frustrations, thankfully, were taken out on each other rather than the children. I also learned something about the kids, and their parents. These were not children with deep, unresolved, psycho64

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logical issues, as I had been told, nor were these “refrigerator” mothers and uncaring fathers, as the theories on autism had suggested. In fact, at one of our regular meetings with the parents, I said, “These difficulties are not your fault. Your children learn differently, and we need to find different ways to teach them.” At this point, I introduced them to behavior modification. With tears of relief, they told me they had been accused of being the reason for their children’s strange and disturbing behaviors. Now they could finally put that notion aside and get to work. To convince the staff that behavior modification techniques were worth trying, we brought in a specialist from Boston, Joseph Cautella, and focused on a particular boy who was the biggest threat to the staff. He was a good-sized child—bigger than some of our staff members and very intimidating. On one occasion, he literally held one of his teachers against the wall and needed to be pulled away by the other staff member. With the consultant’s help, we developed an intervention that basically rewarded the boy’s appropriate behavior and dealt with his aggressive behavior in a minimally intrusive way: by withdrawing the positive attention he was receiving. Within weeks the boy’s behavior improved. His teachers’ confidence in dealing with him progressed just as quickly. It was the beginning of a major change in the way the children were treated at Riverview. We began holding meetings after supper with a consultant, George Durham, who directed a special education school for children with higher-level autism and learning disabilities in West Hartford. We met every Thursday night and discussed theory, techniques, measuring, reward/punishment strategies, and the like. It was a very productive, enjoyable time that helped bring us together as a team. In 1970, for their summer recreation program, the children were divided into three groups, each with their own program, with two making full use of Camp Pioneer—a site built by staff and kids with the help of a few Service Corps women. The third group of six children and four staff members (two per shift) used the school area called Haviland Hall, a CvH building with a large, vacant room. Using donated furniture and supplies, we divided the space into a living room, dining room, kitchen, play space, and area for a variety of pets. The six

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children were picked up on the ward before breakfast and returned at 8:30 for bedtime. They spent the entire day in a highly structured program designed to teach a complete daily routine in a more homelike environment. On 11 November 1971, with the move to the Silvermine Building, the Autistic Unit now occupied half of the third floor. For the first time, every child had his or her own room, with his or her own belongings, decorated by his or her own parents. The unit was to be temporary until a new, specially designed unit could be constructed. Each of our autistic kids had an idiosyncrasy, often sad but sometimes humorous. There was Will, who made up his own name for everyone. Eunice Wiseman, for instance, was Elephant Walk, or E.W. Then there was Mike, who was obsessed with strong odors, like paint, tar, glue, and cleaning fluids. All such things had to be stored under lock and key, to be accessed when Mike wasn’t nearby, because he was very quick and could be inside the door before you knew what was happening. Another boy, John, was adept at picking locks. One day after painting the ward, the staff put the remaining paint in a closet and locked it. When no one was looking John picked the lock to the closet, Mike got in, and before the staff could get to them, Mike had opened the cans and covered the floor and walls—and himself—with paint. Mike was also adept at picking loose tiles off the floor to get at the tar beneath. If while walking down the hall he saw what looked like a loose tile he would run over and with a flick of his finger pop it out. The staff would often joke about hiring him out to maintenance when they needed to remove tile from a floor. Finally, there was Henry. At fourteen, Henry was a bed wetter. No matter how many times you would get him up, no matter what meds he was taking, he was always wet in the morning. After learning something about rewards and punishment, the staff realized that Henry actually liked the cold showers he had to take after wetting the bed. The showers were rewards for him. So the staff reversed things. From now on, he would get a cold shower only if he remained dry throughout the night. Within weeks he was getting a cold shower every morning, because he had stopped wetting the bed. Staff, too, had interesting stories. Many new employees were re-

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cruited by current employees. For example, Fred Miller, who started in 1970 on the Autistic Unit, later became cottage coordinator of the older boys and, with the merger and the change to a medical model, worked in the staffing office. He tells how he was recruited: My first day was memorable. I was working cleaning floors in a church in Cromwell when a friend, I think it was Jim Murphy, came up to me and asked if I wanted to start work at the hospital this afternoon. I came to Riverview that day. I don’t remember how I got the keys or anything like that. Beginning of my shift, Dave Kennedy came in with one of the patients from the Autistic Unit and told me that the boy needed to sit there [on the toilet] until he goes to the bathroom. This was at Merritt Hall. The patient comes out with what he was supposed to do in his hand. Having been a friend of Dave and knowing what the kids were like, I said, “No, no, that goes back there where you came from.” So that was the beginning of my career.1 Ed Shukis, one of our teachers, began as a childcare worker in the Children’s Unit in 1972, assigned to the Autistic Unit. He had graduated from the Human Services Program at Middlesex Community College. Amy Wheaton, Ed’s professor, recommended him. Ed recalls, “Believe it or not, I could probably name most of the kids we had then. It was a time of—you know—when everyone was idealistic. It was an eye opener for me actually working with these kinds of kids. My thoughts are all kind of positive about what we did.” He goes on to describe the variety of activities outside the hospital that he and the kids participated in while he was still a childcare worker: We used to take the kids all over. We would take them home for holidays. I remember taking C.A. home for Christmas. We had nine kids in our family, and C. would start banging his head and my brother would ask, “Why is he banging his head?” and I would say, “I don’t know. Maybe he wants some more mashed potatoes.” It was just the kind of thing we did. We didn’t want to hide the kids away. We would take them to the beach, and

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people would look at us and sometimes come over and give us some money and tell us to buy the kids some ice cream on the way home. Then there were those meetings with you [Dick Wiseman] and George Durham. We would meet every Thursday night and talk about behaviors—behavior management. We would bring the kids over to Beers Hall at first, then to Haviland Hall for their education, and we worked with the teachers. I remember bringing the kids over and I thought, this isn’t a bad job, being a teacher, so I went back to school and got my teaching certificate.2 When we decided to break up the girls’ unit in the round cottage and make each of the units coed, the autistic kids were moved to the vacated round building, which was renamed Alpha Cottage. The structure of the round cottage, while visually interesting, posed organizational dilemmas, but we reasoned that because these kids tended to isolate themselves, perhaps the round configuration would effect an increased interaction, while at the same time providing the closer supervision they needed. It actually worked out very well. I remember our unit coordinator, Steve Hodge, telling me that the staff actually found the round style more disorienting than the kids did. One of the bigger problems had to do with the carpeting rather than the architecture. It seems that some carpets produce static electricity—an added complication for children who don’t like to be touched. Fortunately, the maintenance staff found a solution and applied some sort of static guard to the floors. The staff was always looking for new techniques for reaching and teaching the kids. Through an education grant a motor-math program was developed, which basically involved multisensory experiences. We even hired an actor to help teach nonverbal communication. The young woman was a member of the Long Wharf Theater in New Haven. This group had a clown routine. She worked out wonderfully and the kids loved her. Once, while working with Mike, a nonverbal child, she heard him speak. She had been singing a little song each day as a closure routine. One day, she stopped singing before the end

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of the song. Mike chimed in and finished the lyrics. As I witnessed over and over, these are the types of breakthroughs that happen when staff is given the latitude to be present for the children. Several innovations were taking place inside Riverview and nationally. We began looking at the future prospects for our kids. Our behavioral strategies based on psychological learning theories were working to some degree, but by the time children arrived at the hospital they had already developed very ingrained behaviors. Then, they were with us only until they were old enough to go to the adolescent programs. From there, because they were in the mental health system, they often moved on to adult psychiatric hospitals, where they would eventually end up in the wards for chronic schizophrenic patients. We reasoned that the mental health approach was the wrong direction to take for these children and that an educational environment was more appropriate than a psychiatric one. Around the same time, nationally, the trend toward redefining the nature and cause of autism began to change. The diagnosis “pervasive developmental disorder” was utilized with clear implications: autism is caused by physical, biological, and chemical factors rather than by parental/environmental dysfunction. We decided, therefore, to close admissions to children diagnosed with autism unless there were clear indications that in addition to the autistic behavior there were psychiatric issues to treat. In 1973 Governor Meskill had appointed a commission to look at responsibility for autism. I was appointed to represent the Department of Children and Youth Services and co- chaired the committee with a representative of the Department of Mental Retardation (dmR). I argued strongly that autism is not a psychiatric disorder and that children should not be in a psychiatric hospital or mental health department, but in a place where education is the treatment approach. The outcome of these deliberations was a clear mandate that the dmR, which used an educational approach rather than psychiatric hospitalization, would be the lead agency for autism. While this was apparently agreed upon, it was very slowly implemented. In reality many children formerly diagnosed as “autistic” and now given the label “pervasive developmental disorder” have other mental health issues

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as well, and which agency is responsible—whether it be the dmR or dCf—is still debated.3

intensive CaRe unit When we moved to our new facility and after the Autistic/Alpha Unit children had settled in, the next group of kids to move were those designated for the Intensive Care Unit (iCu), located in a wing of the Silvermine Building that previously housed clinical staff offices. We identified twelve boys and girls who could not manage open cottages: angry, assaultive, destructive kids with little insight; experts at setting themselves up to be punished and then feeling justified to act out further; constantly projecting blame onto others; often described as “not amenable to psychiatric intervention,” meaning perceived as poor candidates for psychoanalytically oriented individual therapy. These kids usually had to be kept back on the ward, missing school and recreational activities and often confined to minimally furnished rooms. They became the first residents of the iCu—a beautiful euphemism for a locked ward without a program. Within a month, the newly painted ward was a shambles. Property destruction was rampant and included such fun as taking the furniture or beds apart and using the parts to bash holes in the plastered walls. The “status” child was the one who could get the most staff members involved in the action. The child holding this honor at the time was a twelve-year- old girl weighing 220 pounds, and when she “blew a fit” all ward staff plus anyone else in the neighborhood got involved. A favorite trick of some of the girls, including this twelve-year- old, was to stick straight pins, head and all, under the skin, usually in the stomach. This was guaranteed to cause a stir, and successfully involved our pediatrician and sometimes trips to the local emergency room. New children admitted to the ward quickly learned: this was a place to raise hell; it was the staff versus the kids, and neither group expected to like the other. It was amazing how many kids admitted were aggressive, destructive, negatively oriented, and uncontrollable. Escape attempts were regular occurrences. The mood of the unit was generally one of anger, frustration, hatred, and despair. Although we

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carefully selected competent staff members for duty on this unit, they often reacted to the assignment with “Why me?” Clearly, something had to be done. In order to get some idea of what was happening between children and staff that created such chaos, we conducted a two-week study in which independent observers (students from nearby Wesleyan University) spent random periods on the ward throughout the day and evening simply recording whether or not an interaction took place between a child and staff, and rating the interactions that did occur, positive or negative. The results were startling: 80 percent of the observations indicated “no interaction”; of the interactions that occurred, 90 percent were rated negative. Clearly, staff generally retreated to their office when there was no trouble. So how do you get them out of their offices? You raise hell! We found it necessary to somehow develop a system that would encourage staff to interact more with the children, and thereby increase the percentage of positive interactions between children and staff. We needed to redefine the reward system active at the time, diminish the punitive nature of the environment, and generally make the unit a more pleasant place to be for both children and staff. About that time I read a book called A New Learning Environment by Harold Cohen. He analyzes a token economy program conducted with juvenile delinquents in Washington, DC.4 In discussing our own situation with our chief psychologist, Randolph Burnham, I challenged him to come up with a similar program. He accepted the task, and I relieved him of most of his other duties for a month. With the help of George Durham, our consultant in behavioral therapy who had been instrumental in developing our program for autistic children, one month later Randolph presented a ninety-five-page manual titled The Behavioral Learning Environment Unit: BLEU. We made Jeff Hewitt cottage coordinator for the new Bleu program, with Randy Burnham as clinical coordinator. A three- day training period ensued, and we presented the manual in an interactive manner complete with roleplaying, allowing the staff opportunities to make modifications. Then Bleu was presented to the kids, first as a practice schedule and finally

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as the real thing complete with our staff dressed as waiters and waitress, carrying breakfast rolls as they announced, “Time to get up for breakfast!” Thus began the new program.

Bleu: tHe BeHavioRal leaRning enviRonment unit While our use of learning theory to help modify behavior in a systematic way began on the Autistic Unit with individual children, Bleu was the first formal effort to develop a total milieu program based on solid psychological theory and with clearly stated consequences for appropriate and inappropriate behavior. It guided everyone at the hospital, including clinicians, food service workers, and maintenance people. It was the forerunner of many other program designs in the other living units, which we modified to meet their specific needs. Changes evolved in the natural course of events as staff learned and grew; and other major changes evolved as new administrators, philosophies, and mandates influenced the process. (See Appendix 1 for excerpts of the Bleu manual.) Bleu is basically a token economy program. Children earn credits (Bleu dollars) for clearly defined appropriate behaviors and spend their money for desired extras (food selections, recreation choices, bed times, etc.). They receive bonuses, which they put in their savings accounts, to be used for out- of-program activities. They are fined for specific inappropriate behaviors. Bleu Program, Key Tools: Liquid Bleu dollars are given for appropriate responses to requests. For example, “It’s time to get up and dressed for breakfast” earns 2 Bleu dollars. 100 Bleu dollars per day possible to spend during the day; a possible 60 Bleu dollars to be earned in school. Bonus dollars: 1 bonus dollar for each dollar earned. Extra bonus dollars are given by staff for “caught being good.” Bleu dollars are spent on such things as meal choices, seating choices, second desserts, etc. A child with zero dollars still receives a full meal—a poverty meal—one without the extras; but the same child is eligible to earn dollars for good behav-

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ior during the meal, for recreation participation, for hassle free behavior, etc. Bonus dollars go into a savings account. Hassle score: Daily measure of earnings minus fines divided by 100 (number of earnable dollars per day). Hassle Index: Weekly or monthly average. Used not only for individuals, but also for milieu measure. See Figure 7.2 for a three-year measure of the milieu. Finance and control sheet: Daily record of individual’s earnings. Fines, bonuses, and staff members involved. The latter is for staff supervisors to review for counseling purposes. (E.g., “Why do you give X more fines than other staff do?” Or, “Try to find more opportunities to bonus kids.” etc.) Financial Advisor: Assigned clinician reviews finance and control sheet to negotiate spending from Savings Account on activities outside of program options. This gives wide flexibility to clinician. An opening for children who are resistant to meeting with “shrink.” Fine system: Ten categories of fines ranging from one dollar per word for swearing—to 20 Bleu dollars for hitting or attempting awol. All fines to be given neutrally, with no further escalation. We chose to fine for swearing because in iCu, as part of the chaos, every other word was an expletive. Since the idea was to clean up the atmosphere, that included the language. To experience the system firsthand, I chose to be the “financial advisor” to the next child admitted to Bleu. Billy, a twelve-year- old, was a superficially rough-and-tumble kid who immediately managed to get into a few fights. I entered his room, introduced myself as his “financial advisor,” and asked if he wanted to go to my office so I could explain the program to him. “No shrink is getting me in his office,” he informed me. “Well, fine,” I responded. “When you decide that you’d like to spend some of your savings you let me know,” and I left. A few days later I received a call from a childcare worker who said that Billy wanted to see me in my office. I quickly explained the system

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to him, particularly covering the things he could spend his savings dollars on. Then, getting out his finance and control sheet (a form used to record savings, bonuses, and fines, as described above), I pointed out that he didn’t have enough in his savings to buy anything (a telephone call home cost 200 Bleu dollars, a visit 500 dollars, a weekend home 1,000 dollars), mainly because of his ten “hitting” fines (20 Bleu dollars each) along with very poor earnings. Since hitting or fighting was the most obvious and troublesome behavior he exhibited, I said to him, “I’ll tell you what I’m going to do. So that you can get some money in the bank, I’ll put 500 dollars in your savings account if by next week at this time you’ve cut your hitting fines in half.” “No sweat,” he replied enthusiastically. We wrote out a contract, signed it, and ended the session in less than ten minutes. A week later, Billy could hardly wait to see me, but with feigned nonchalance he announced, “You owe me five hundred bucks.” He had only four hitting fines. In addition, his daily earnings had improved so he now had a large enough account to negotiate spending his dollars. I had now become his ally. I could help him—in a very concrete way. It wasn’t long before our weekly sessions were lasting the full hour with only the first five or ten minutes spent in “financial advising” and the remainder taking on more and more characteristics of a typical psychotherapy session. Interestingly, Billy complained that he was getting too many fines from the staff. We decided that somehow we had to change the staff ’s behavior and talked about what we could do to stop that. He had some good ideas: not yelling, curtailing harsh language, being nicer, and so on. Not only were the kids and staff more relaxed and more accepting of each other, the physical environment improved too. The kids’ rooms began looking more welcoming, with curtains on the windows, hung with Velcro, easy chairs and lamps, donated by staff for as long as deserved. The atmosphere had changed from chaos to order. Figures 7.1 and 7.2 clearly illustrate the changing milieu over three years. We caught ourselves thinking new children weren’t as disturbed as they used to be. The reality was that a child entering the milieu immediately adapted to the norm, a norm very different from that at the iCu.

Figure 7.1 The client hassle index.

Figure 7.2 A three-year graph of the monthly milieu measure.

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In the meantime, we were updating the system to match new learning and experiences. A tiered system with higher privileges and expectations for sustained earnings kept the program fresh. We changed assessment terminology from “Hassel Index” to “Achievement Index” for a more positive note. As time went on the program evolved into a powerful treatment tool for pulling dead- ended children out of treatment ruts. It eventually became possible to mainstream the Bleu children into campus school and recreation programs. After several years, Bleu had stabilized to the point where it became more likely for us to admit new children directly to Bleu. These included younger children, and consequently the age range was broader. Therefore, we decided to create a second Bleu for younger children. Bleu staR was similar to Bleu except that it was geared to meet the needs of the younger children, featuring, for example, a program described in cartoons, shorter time consequences, and more concrete and immediate rewards. Mark Root, a childcare worker, accepted the cottage coordinator position for Bleu staR. Jeff Hewett, Mark Root, Margaret Stewart, and I presented the program at a national conference in San Francisco.5

Jake’s plaCe When we developed the Behavioral Learning Environment Unit, we emphasized a unique educational experience for the children consistent with the Bleu program. The staff named this educational program “Jake’s Place” to dissociate it from a “school,” which had a negative association for children the mainstream system referred to as failures. Steve Hodge accepted the new teaching position we created for the task. Within six months, one child improved one whole grade level. All of the children improved significantly, academically and behaviorally. As Steve Hodge explains, Jake’s Place wasn’t just any classroom: [Jake’s Place] was located on the ground floor of the Silvermine Building near the Bleu Unit; each child had his or her own curriculum and daily tasks geared to his or her ability. For each

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completed task the student earned a Bleu dollar. For example, in math, child A received a dollar for completing a problem correctly; child B received a dollar for simply attempting to solve the problem. Kids were involved in tracking data so they easily saw how they were doing. It was very reinforcing for the kids. In addition to academics, Jake’s Place offered arts and crafts, and so on. We did things like looking at job possibilities. One girl said she wanted to be a nurse. So we took her to Middlesex Hospital and showed her all the kinds of jobs there were. We had speakers come in. We explored relaxation techniques. We tried to give them a wide range of experiences.6

lessons eaRned Not everyone was entirely supportive of the Bleu program. Comments such as “It feels too much like bribery” and “It’s too mechanical, dehumanizing” were voiced by some of the clinicians or staff working in other areas. Nevertheless, clearly, the token economy structure of Bleu served a valuable purpose at the time. It brought some order out of chaos and made the ward a more pleasant place to be for both children and staff. We found, too, that it wasn’t necessarily the best solution for everybody. For some children, particularly those with psychotic symptoms, the time- out periods were often counterproductive. Also, for some staff, the mechanical aspects made it too easy to utilize the program as a crutch in a strict, unwavering manner and to fine a child too quickly. On the plus side, the system required a record of all fines and bonuses, including the names of both receiver and giver. Therefore, supervisors could help staff members use the system optimally. For example, if a particular staff person awarded relatively few bonuses to kids, he or she could be counseled in how to notice positive behaviors. Likewise, an excess of fines offered a good opportunity for coaching too, particularly if an individual was found to be out of sync with a particular child. Fining in the most neutral way offered a major learning experience for the staff. I remember entering the unit one day and seeing a staff member standing quietly with his hand open as a child, with a handful of Bleu dollars, placed them in the open hand, one Bleu dollar at

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a time, while expressing herself with *@&# after each deposit. When she ran out of dollars, she went off to her room pouting. No throwing a chair, no screaming or punching walls, just pouting. And it was over. Whether a highly structured milieu is a treatment program in itself or simply a behavioral management system, the environment in which the child spends a good part of the day must be defined with clear expectations and with clear consequences, both positive and negative. Responses to negative actions should be neutral and not arbitrary, and there should be built-in, consistent, and frequent opportunities for positive interactions. Bleu also taught us the importance of having a well-thought- out program with constant review and revision to meet changing needs and to prevent as much as possible the danger of becoming so routine that you forget the reason you are doing a certain activity. For example, the purpose of a time- out is to remove a person from factors in the environment that may be reinforcing inappropriate behavior. As the time- out becomes more and more routine, it can easily take the form of punishment, particularly as new staff members observe staff behavior and copy it without knowledge of the original rationale. The initial impressions of place and expectation are crucial to the child’s approach to the experience. We learned, too, the power of the staff ’s perception of the child. For example, saying, “This kid is inappropriate!” affects the kind of relationship that quickly develops. We learned to turn that around and say, “How can we make our program appropriate for the child?” I am reminded of a child early in our program who not only was an angry, aggressive, unattractive child but also had severe seizures that required that he wear a helmet. Staff constantly complained to me about him, saying, “He doesn’t belong here.” Finally, I met with the staff and said, “Bobby is here. I have tried to find a better place for him. There is no better place. He is ours. He is our responsibility.” It was like a miracle. Once the staff assumed ownership, their behavior toward him changed—and consequently Bobby’s behavior became significantly more appropriate. We learned that a milieu must constantly evolve and adapt to changing conditions, both internally and externally, and that we must be

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willing to give up old traditions and comfortable policies. The concept of “financial advisor” served its purpose but was given up as children became more receptive to, and often eager to talk with, their therapists. And possibly most of all, we learned that we could make a very positive change in a child’s life. We developed a sense of confidence, a sense that we could handle whatever difficulties arose and could find and adapt to new ideas and circumstances. We were getting a reputation in the community as a desirable place for both staff and children. We were developing an identity—a personality that we liked.

seagull and sunBuRst When we first moved from Merritt Hall to our new site, Cottage C housed the older boys and Cottage B housed the younger boys. Each was designed to accommodate sixteen boys, two per room. It soon became clear, however, that at least one room had to be a single, thus reducing the number of beds to fifteen. This number varied from time to time as the need for singles increased. Eventually, we divided the girls’ cottage and made each unit coed, with separate wings of the buildings for each gender. As both Cottage C (then named Seagull) and Cottage B (Sunburst) became coed, each developed their milieu program somewhat independently, guided by their supervisory team: the director of residential care, the medical director, and the superintendent. When we phased out the Autistic Unit (Alpha), the Sunburst team moved to the round cottage, Seagull moved to Cottage B, and the newly formed Bleu staR program for younger children moved into the vacated Cottage C. Each cottage team was required to develop a program manual for their children. Lessons from Bleu helped us learn the importance of a system of levels of achievement and expectations with clear guidelines for moving up to and maintaining the next level, while increasing benefits and privileges. Fred Miller, who started as a childcare worker on the Alpha Unit with our autistic kids, eventually became a cottage coordinator for Seagull Cottage, a position he held until the conversion to a medical model.

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Jane Klemba held a similar position at Sunburst Cottage, and since her children were the youngest, she helped to develop a manual that included cartoon descriptions of activities, levels, and consequences. Since the programs were reviewed regularly and changes made as needed, there was no absolute guide for the cottages. However, all program designs and changes were the result of group processes that involved the milieu staff and the clinical consultant (or co- coordinator). Any major changes had to be approved by the supervisory team, and no changes could be made that would have an impact on other cottages, the school, or clinical services without supervisory approval. Because the basic elements were similar among cottages, I will only highlight here some of the major characteristics, using the Sunburst Program Manual developed early in the planning process. (See Appendix 3 for excerpts.) The Sunburst Program Manual states a commitment to the knowledge that all children want and need to trust and be trustworthy, to be autonomous and industrious, to achieve and sustain self- control and self- esteem, to be competent, to combine with others to plan and engage in activities, and to enjoy accomplishments and mastery of their behavior. Sunburst Cottage was a fourteen-bed (seven bedrooms) coed unit for children ages six to twelve. Seagull also had fourteen beds and seven bedrooms, but housed eleven- to thirteen-year- old children, although ages varied depending on developmental factors. The cottage allowed freedom of movement with an underlying structure that communicated consistency and safety. Each bedroom provided space for roommate living, and closets, dressers, beds, and desks became each child’s responsibility. The cottage also contained a large dayroom, a kitchen, an office, laundry facilities, a toy closet, and two bathrooms. A “quiet room” was located near the entrance to the cottage. Quiet room use at Riverview Hospital for Children was covered by hospital policy, which was consistent for all programs.7 The milieu staff included seven childcare workers, two children’s services supervisors, two clinical nurses, a unit coordinator, and a

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clinical consultant. All milieu staff shared responsibility for developing, evaluating, and implementing the program. All manuals include an admission routine: an orientation to the program for each child provided by the child’s responsible person, with a review of the daily schedule, routines, and activities, and particularly the level system. Sunburst’s program consisted of four levels: Try Harder, Beginning, Moving Up, and Reaching. Children were given scores in three categories—Participation, Behavior, and Relating—and in three areas— Cottage Life, School, and Recreation. Each level had higher degrees of autonomy and privileges. Feedback was given continuously, as earned. At the evening meeting, staff reinforced areas of strength and explored problem-solving options. Children received feedback in the morning before school. Later, each child received formal individual attention through his or her responsible person. On Wednesday evening during the recreation period, a Cottage Night was held, a special activity either on grounds or off for all kids who had reached Beginning or higher that day. While the program was built on positive reinforcement, restrictions were also seen as necessary under certain circumstances. These included room restriction, ranging from one hour to forty- eight hours for extreme behaviors such as assaulting another person. In Sunburst, meals were served family style, with the children responsible for setting the table, serving, and cleaning the table. The Sunburst Program Manual includes a chapter on program development, which outlines staff participation in the evaluation and improvement of the program. Weekly team meetings, periodic workshops, and regular individual supervision were required. As the children grew to adolescence, we transferred them to the newly developed Adolescent Program at CvH. Throughout this reorganization, the basic philosophy remained the same. Each program operated using a milieu therapy approach with a behavior modification support system. Separate program elements, including education, recreation, and traditional therapies, all worked together to provide a healing and supportive experience, and all staff members contributed.

[ CHapteR 8 ]

CHildRen’s sCHool ... In 1969 our school was in full operation, with Irving Renn as principal, Alan Spaulding as assistant principal, and a full complement of teachers. The school operated like any public school, on a public school schedule, with a full range of courses and a full day of learning. It also operated almost completely independent of the rest of the Children’s Unit, with very little interaction between the two staffs, except the casual crossing of paths as the childcare workers delivered the children to the school. In many ways the school personnel did not see themselves as part of the hospital. They had their own union; they identified themselves with the Department of Education; they had different schedules, with summers off and public school vacations. They saw their primary and only purpose as education. In our distribution of duties as co- directors, Peter Marshall oversaw the school with a mandate to bring the school and the rest of the program together. There was much resistance to this, but gradually the school and the unit communicated cooperatively, with the principal becoming a member of the administrative staff and participating in facility-wide discussions and policy development. However, with the children now residing in Merritt Hall, on the other side of the hospital campus, the physical and psychological separation remained a significant issue. Even when we moved to our new home at the Silvermine Complex the separation remained, because now we had to transport the children by bus before and after school, as well as during the lunch hour. However, there was hope for the future because bonding was approved, appropriations awarded, and architects hired for the building of our own school on our own property.1 When Irving Renn retired, Ronald (Ron) Quinto, a teacher with our autistic children, became the new principal. Amy Wheaton replaced Peter Marshall, and Amy was designated director of educational services, although her official title was assistant director of the Children’s 82

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Unit. Amy’s primary responsibility was to plan for the construction of a school on the grounds of our new site. One teacher described that process as a chance to design her own space and to actually see a plan promising exactly what she had asked for. Construction was completed quickly and the opening ceremony took place.

evolving pedagogies Eventually, we addressed the education program itself and adapted a clearer educational philosophy, modeled after William Glasser’s Schools Without Failure and the basic principle that all children, even those considered too sick emotionally, or too disturbed, or too unmanageable, should be afforded the opportunity to learn. In 1981 Ron left to become director of the Child Guidance Clinic in Bridgeport. Steven Hodge, who eventually left to become program director of the Children’s Home of Cromwell, followed him. Louis Ando became the next principal and ultimately Riverview’s fourth superintendent. He was followed as principal, in short order, by David Regan from High Meadows, George Zitnay, and then Randy Adams, who remains the longest-standing principal of Riverview. Tom Allan, who started in 1972 as a student teacher, was also originally assigned to the Autistic Unit working under Ron. Three years later he was appointed cottage coordinator of Sunburst Cottage, which at the time was the open cottage for younger children. This was a huge crossing of lines, a teacher in a traditional nursing/childcare position. Not only did this cause resentment among the childcare staff, but the teachers union objected and eventually Tom had to decide whether he was going to be a teacher or a childcare worker. He chose the former and returned to the school, where he reactivated the Behavior Management Program, which he originally developed and childcare worker Anthony (Tony) Nalewajek refined. Instead of the vice-principal having to monitor the hall when kids were sent out of the classroom, the children would go to the Behavior Management Room and meet with Tom. The children were invited to carols,2 where they’d work quietly on their school tasks as well as process their behavioral issues.3 The concept of team teaching was introduced early in the history of the RiverView School. Two of the first teachers to work together as a

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team were Robert (Bob) Delvecchio and Edward (Ed) Shukis. Ed started in 1972 as a childcare worker on the Autistic Unit and left to obtain his teaching certificate. He returned in 1977 as a teacher and teamed up with Bob, a new teacher recruited by Amy Wheaton. The two teachers initially occupied neighboring classrooms and taught kids of similar ages. At first, they started bringing their classes together for outdoor activities, which was encouraged by the principal. Eventually, they started teaching together and co-taught until their retirement. As elsewhere, forces out of our control affected our work: such things as the Joint Commission on Accreditation of Hospitals ( JCaH) changing standards; changing cultural factors, both locally and nationally; new state and departmental changes and philosophies; and union-negotiated decisions. As always, it was essential to make these mandates opportunities for growth. Meanwhile, we continued to improve our reputation within the community and in the state. When Lou Ando accepted the position of principal at Riverview, he had just spent a few years working with young prisoners for the Department of Corrections. By coming to Riverview, Lou followed his inclination to work with kids before they got into the correctional system. Lou shares some of those ideas: Once I saw Riverview, I knew that was where I wanted to be. There were great staff, good facilities, and a good administration, but actual programming was a little stalled. At that point I thought that education in a psychiatric hospital was the place to do some things that could keep kids out of the justice system. I was interviewed by you [Dr. Wiseman], Carl Sundell, Marge Stahl, and Yvonne Johnson, and I began at Riverview as director of education on Friday the thirteenth, 1982. Believe it or not, at that time I thought I had taken a three-year job! I was at Riverview for a total of eighteen years.4 After getting an idea of how the school operated, Lou began making changes: We grouped teachers into teams and assigned them to units; we broke up traditional grade-level assignments; we used a modu-

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lar approach to the curriculum. We tried to take some of the ideas that were used with itinerant/transient populations working as migrant workers and use those same educational ideas at the hospital. Generally some of those kids would be there for six weeks and then they were gone, so instead of a fifth grade curriculum that was designed to take nine or ten months, we developed four- to six-week modules. We developed a learning center, computer lab, vocational education and vocational training programs, and work experience. Riverview was a great place to be. On paper we had sixty-four beds, but in reality because of the single/double room situation, we generally took no more than fifty-three or fifty-four kids. Despite the beginnings of a unionization process, the staff was very much like one big family. We had Christmas parties at your [the Wiseman] house; we went to Marge Stahl’s for picnics and cookouts (later pool parties). We took the kids on camping and canoe trips. Very few people actually watched the clock. Childcare workers would work an entire shift and then come back to enjoy a cookout with the kids on their unit on their own time. Teachers would come in on weekends and evenings to take kids to the Durham Fair or to work on their gardening projects or the crafts they were making for display. Slowly, however, that began to change. The staff was originally comprised of fairly young people either fresh out of school or in the process of earning their graduate degrees. They aged, developed families and responsibilities of their own. Simultaneously, the unions were looking at a less than adequate pay scale and, in trying to improve the conditions for workers, were effective in establishing a “them and us” mentality. It wasn’t long before by the mid-’80s, people at union meetings were talking about “staff ” and “administration.” Depending upon where you sat, one of those was a dirty word. One of the great things about working at Riverview Hospital is that the administration—Carl, you [Wiseman], and Marge— were always open to new ideas and trying things out. It was not uncommon to approach you with a novel idea and being told to

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go ahead or to rethink it but try it anyway. Your enthusiasm for anything that looked like a better idea was infectious. With little concern for chain of command or job descriptions, we were able to improve the quality of care by doing what needed to be done, as opposed to performing what job descriptions dictated. In one of these “new idea initiatives” I was made director of quality assurance. We revised the incident-reporting system, started to keep track of incidents, modified the risk management and utilization review functions. This was all assisted by the drive for accreditation by what was then JCAH.5 One of Lou’s favorite accomplishments was hiring Elizabeth (Betsy) Donlon, a very artistically inclined English and creative writing teacher. Recognizing her creativity, Lou basically gave her free reign to develop her own program. The result was the Learning Center. In a letter to me, Betsy writes about her experience in developing the center (also known as the tlC, for tender loving care): It is clear to me now that it took a great deal of vision for the Superintendent to recognize that my personal brand of creativity could somehow benefit the RiverView School and reinforce his experiential aims for the children there. At the same time it took trust for Principal Lou Ando to turn me loose in a wonderfully large, empty room, tell me to make a list of whatever I wanted to put together a working learning center, then walk out the door, never looking back, and leaving me alone to dream and build. . . . The operative words here are: permission, adventure, and accomplishment. I gave the tlC students permission to be themselves and while there to teach themselves a small bite of something they wanted to know. I came to think of myself as “Granny” and the students who came, singly or in groups, as visiting grandchildren who needed and thrived from Granny’s attention, her approval and, like all grandmothers, her hidden agenda of instruction. My goal was that each child experience a personal accomplishment on each visit; this was achieved in a number of ways, some extremely simple, some astonish-

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ing. Every individual and group activity was geared to a generally short and disrupted attention span, whether resulting from [the children’s] chronic anxiety, psychoactive medications, or appointments with counselors, therapists, families. I don’t remember seeing any children bored when they were in a constructive form of self- expression and, as they were not under usual constraints or pressure, there needed to be few rules. So, the kids came to identify the room and their time in it with a sense of freedom and whatever nonjudgmental approval of their efforts I could offer them. Many of the activities were set up for one- on- one interaction but even each child in a small group of up to five could reap the personal rewards of working independently. I asked teachers to request time for individual students or for activities designed for an entire class. These teachers accompanied their classes to the Learning Center and stayed with them during the activity period. Those of us fortunate enough to have enjoyed a fairly peaceful childhood will remember the eagerness to “do” things: the excitement of planting a garden; the fun of dressing up in costumes and putting on plays; the challenge of playing games; the serious plans for creating a neighborhood newspaper; the sense of adventure listening to an exciting story. Drawing on these simplest of activities, the Learning Center provided for the student’s participation in child-like programs designed to give their social skills a push forward, to nudge them toward a creative investment of themselves in some new skill, to make it possible for them to produce results that they themselves could easily recognize as enriching and take pleasure in. As with all experiences, underlying learning was the desirable by-product but not the goal. The students were given choices. On the first day, I let them naturally gravitate to what they liked. After I’d gotten to know them and their interests, I could direct them to further activities that were appropriate to their interest and personally exciting to them. For example, many of the children, without knowing it, learned computer basics at RiverView School. We had sta-

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tions of computers and provided graphics programs (e.g., Print Shop) and very good learning games (e.g., Where in the World Is Carmen San Diego?). With a word processor they created stories or wrote expressive letters. With Print Shop, they made greeting cards for precious parents or sisters and brothers. One class produced a regular newspaper which, due to short attentionspans of many students, would not have been an option without the motivation or availability to use a computer, the fun and the personal sense of accomplishment they felt when they did use one. With the video camera, one young class enthusiastically wrote, produced and taped a weekly news show in the Learning Center that they then watched and shared with other classes and other individuals. All the students relished performing, reading on- camera, taking turns being “camera person,” and looked forward to later proudly watching themselves. We also video-taped plays, songs, nursery rhymes, and interviews, making costumes, sets, and titles (with the word processor) usually with the help of their regular classroom teachers. The large, sunny room was equipped with pillows and blankets for sitting or lying on the floor to read books and magazines or to do puzzles. There were globes on the shelves as well as magnifying glasses and magnets and microscopes. There was a record player and records and earphones and slide projectors. On the wall there were large pull- down maps (among many items dragged out of storage) often used for videotaping as the students pointed out geographical locations on their news show. There were scissors and glue and construction paper with which to make things, funny pictures and signs on the wall to laugh at, and an easel at the door for welcoming announcements and displays. I gradually filled the Learning Center with anything that might catch the children’s interest, open a new door and broaden a perspective, or provide any kind of new and “normal” experience in exploring the world around them. Some of our

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teachers and friends would also bring in objects they felt would add to the attractions of being there. The Learning Center saw loving, eager, curious children who like all children had enormous energy and great curiosity. Dedicated teachers and staff and a child- oriented administration (as opposed to a bureaucratic one) continuously nurtured and protected all the unfortunate youngsters who came to and left Riverview with a regularity that could have made everyone there callous, but didn’t.6 Not everyone immediately lauded the Learning Center, however. In fact, at first there were some clear divisions among the teachers. Some saw it as an excuse for kids to get out of their regular classroom. Others, perhaps, were envious of the degree of freedom Betsy had to plan her own programs, and others simply ignored it and didn’t make it available to their students. On the other hand, some teachers adapted the tlC enthusiastically and created integrated curriculums. Eventually, many teachers and childcare workers came to appreciate the program. When Betsy Donlon left Riverview, the Learning Center gradually changed and eventually closed in 1985.

funding A major problem in our relationships with the local public school systems was the issue of funding. Who paid for a Riverview child’s educational expenses, especially if the child was to be at Riverview for an extended period of time? Typically, if the planning and placement team of a school system determined that a child needed outside placement in order to obtain an appropriate education, and the team made such a referral, that school system would be legally responsible for the child’s educational expenses. However, when a child entered a psychiatric hospital, the placement was deemed “other than educational reasons,” and therefore the town shirked responsibility for educational expenses. Eventually, in 1977, the state legislature passed Senate Bill 1441, which made the Department of Children and Youth Services a special school dis-

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trict. RiverView School would now be eligible for federal funding. With the funding came the requirement that all dCYs schools be in compliance with state and federal education laws and policies. High Meadows, the training school at Long Lane, the State Receiving Home school, and the Family Day School in Bridgeport all had to implement the new law. And a superintendent of schools for the new district had to be hired. The Department of Education assigned someone to act as superintendent of schools while the search for a permanent person proceeded. Unfortunately, very little discussion or planning was done as to the role of this person in relation to the facility, which was not a typical public school, but a treatment center with a school. Before long, the new school district’s acting superintendent called principals to meetings without any notification to the facility administrators. The facility superintendents for each treatment center decided to take action and attend, unannounced, one of the acting superintendent’s meetings. The meeting began with the predetermined agenda, without any acknowledgement that there were uninvited guests present. Finally, the facility superintendents rose as a group. I said, in effect, “You clearly choose to ignore us and we choose not to be part of your self- destruction.” We left the room. Not long after this and after an extensive search, Robert Suerken, former assistant superintendent for the Criminal Justice Department, accepted the school superintendent position, but not until after thorough discussions were held. Who had what responsibility? How could we obtain a working relationship with different mandates? Instead of jumping right in and instituting new procedures, Robert spent a good amount of time visiting each of the institutions, getting to know the staff, the facility programs, the administrative goals, and missions. Robert immediately met with the facility superintendents to discuss roles in relation to each other and to the teaching staff. It was clear that he had responsibility for ensuring that all federal and state Department of Education rules and procedures were compatible with those of the facilities. When he reviewed Riverview’s program, he told me that he would be spending more of his time at the other facilities.

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Apparently he liked the program Riverview had been working so hard to develop. One problem, however, that Robert needed to tackle immediately was that of residence. Children with deceased or missing parents had no legal residence, and no specific town claimed financial responsibility for their schooling. Robert set up a No Nexus Unit in the central office, staffed by a full-time educator whose job, basically, was to make arrangements to educate these children, who were now officially in the care of the Department of Children and Families.

[ CHapteR 9 ]

ReCReation in tHe CHildRen’s unit ... When children and adolescents sixteen and under were finally admitted to Connecticut Valley Hospital, and before the Children’s Unit was formed, recreation was the primary form of activity. Michael Kerwan, of the hospital’s Rehabilitation Department, directed this program. In 1964, when the Children’s Unit became a reality, Michael became the recreation director of the new program under the supervision of the director of nurses (or director of residential care). In addition to being the sole recreation person, he trained psychiatric aides in recreational skills and ensured that staff had the necessary materials and equipment. While the number of recreation aides was totally inadequate, a major breakthrough occurred when the Children’s Unit was given permission to hire eight part-time college students to provide recreational activities on the units on evenings and weekends. It was the first sustaining and structured program outside of school. The program’s success was gratefully tied to volunteers and parttime college students. Many of the local colleges participated in this effort: the University of Connecticut, Wesleyan University, Trinity College, Holy Apostles Seminary, Central Connecticut State University, and Albertus Magnus College. These were invaluable resources, particularly during the summer months. By 1965 the students, as volunteers, part-time college students, and summer workers, became the core of the recreation staff. Many stayed on as full-time employees or returned after graduating. Among them were many longtime employees, such as Carl Sundell, whose name comes up frequently in this history. When Mike Kerwan retired, Carl became the next director of recreation, with Dolores Randazzo as assistant director. Susan Reale returned after graduation with a social work degree; Bill Brown, as a teacher; and Al Stewart, childcare worker. Others, including Margaret Stewart and Andrea Spaulding, also returned. The volunteer program 92

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eventually became a formal program under the supervision of the recreation director. Carl Sundell began his career in 1965 on the Children’s Unit as a recreation worker, and Judy McCain became recreation aide. They worked hand-in-hand with the ward staff, often jointly participating in recreational activities and vice versa. Judy describes her first day on the job: I remember there was another kid. It was his first day too. . . . It was very confusing—a lot of things going on at one time. A lot of just management—large group things. Only two ward staff, one aide or nurse, and one recreation person responsible for the entire unit, so the group living staff got involved in activities, and they were usually large- group activities because you couldn’t break off four or five kids and leave thirty-five kids without anything to do. So it would be things like a bus trip or going outside and playing ball. On the girl’s unit there was just one part-time recreation person, and the group living staff felt they had absolutely no responsibility at all for any kind of recreation. They felt it was well within their rights to send their parttime recreation person out with twenty kids to do an activity.1 I will never forget the first Christmas party a month after Peter Marshall and I became co- directors of the Children’s Unit. The ward and recreation staff agreed to put on some Christmas skits. We invited Arafeh, CvH superintendent, to attend. As we sat in the auditorium and watched, I remember sinking lower and lower in my chair as the older boys put on a skit that gradually turned into an ad lib free-for-all. Clearly, we had a long way to go. I must say, Arafeh was very gracious and assured me that things would get better. In fact, things did get better. As the Recreation Department evolved, teaching the children specific skills in team activities was particularly exciting and rewarding. Many of the children had little experience being part of a team or working cooperatively to achieve a goal. Eventually, under the guidance of Carl Sundell and later Tom Prue, various athletic teams were organized. The teams actually competed against

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other institutions, such as the State Receiving Home (later called Connecticut Children’s Place), at Warehouse Point. This motivated staff members to form their own softball team, to which the children were invited to watch. Gradually, recreation became recognized as a vital part of the total treatment process. Developing group skills as well as individual skills was as important to the Children’s Unit/Riverview experience as any other aspect of a child’s stay with us. In fact, under the Bleu program, recreation originally was considered a privilege for “good” behavior, following the traditional model. However, once we defined recreation as part of the treatment and as important as school itself, equally valuable as seeing one’s therapist, kids could no longer be excluded from a recreation activity unless a safety issue was involved or the behavior during the activity required removal. In addition to the athletic teams that evolved, other group activities expanded: an annual carnival in which each cottage had responsibility for building and managing a booth, including one for “dunking the staff,” even the superintendent, in a pool of water. This was a joint venture between the unit staff and recreation staff. Likewise, the annual Christmas party, organized by the teachers and recreation staff, featured a Christmas play and a sing-along led by Willie Fuqua, the music teacher; and Santa Claus passed our gifts to the kids. The event included a banquet by the Food Service Department, with parents and family members invited. I have always thought of this event in relation to that first Christmas play described earlier as a metaphor of our progress and evolution. The tradition eventually changed, as did Riverview’s treatment philosophy. The Christmas party became much more generic and included professional performances from community groups. That was indicative of progress and good use of outside resources, but there is something to be said for having to rely on your own creative energies and joint programs that involve staff and kids working together. Speaking of Christmas, it was usually a joyful, exciting—and for some a sad—time when many staff members from all disciplines had some role to play: sorting out donated and purchased gifts, getting wish lists from the kids, arranging cottage parties, dealing with children’s and parents’ anxieties, enthusiasm, ambivalences, and sorrows,

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as well as making arrangements for home visits when possible or developing alternative plans for those not able to go home. One Christmas, the chief psychiatrist, Yvonne Johnson, suggested that giving a gift to someone is as important as receiving a gift and that the children should have an opportunity to share that part of the holiday season too. To try this out, each child picked the name of a childcare worker in the child’s cottage. Then the therapists took their children shopping, and together they would think about gifts to buy. This became a learning tool and an opportunity for the kids to participate in the experience of thinking of others. The whole holiday season brightened, with excitement beaming on the kids’ faces as their staff recipients opened their gifts. However, the staff reacted with mixed reviews. Some felt uncomfortable getting gifts from the children. For the clinicians, it was no easy task and quite time- consuming, especially taking their kids shopping. They eventually recruited some of the clerical staff to assist. The experiment lasted three or four years and finally faded out. Another experimental event was the summer tradition of an overnight canoe trip down the Connecticut River. Initiated by Don Dulio, continued with Rick Damata and then David Wells, this was an allsummer project constituting an overnight at Pin Oaks for honing camping skills; using the Riverview pool to learn canoe safety rules (like how to get back into an overturned canoe); an overnight trip to Harkness Memorial Park; and finally an overnight canoe trip down the Connecticut River. For those kids who qualified by completing the training, this was an exciting adventure. The use of the swimming pool proved to be a major recreational activity and learning experience. When the RiverView School was being designed, legislators insisted that the expense of a pool was not warranted and they decided to eliminate it from the budget. Fortunately I had the opportunity to meet with the legislative committee and was able to convince them of the therapeutic value of learning to swim. I specifically mentioned how well our autistic kids adapted to the water and how pool activities fostered responsiveness to physical learning experiences. For example, we found that when we threw an object in

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the water, our autistic children would quickly learn to jump in and get it. Sometimes we tossed alphabet blocks into the water. We’d say, “Bring me the letter ‘A’ ” or “Bring me the letter ‘Q,’ ” and they did! Following directions on land was not as readily elicited. Obviously I made a few generalizations, but we got the pool. Many children who came to the Children’s Unit had never been in a pool and were afraid of the water, but they left as skilled swimmers, an obvious boost to their selfimage. Some of the children joined a Boy Scout troop, a popular activity run by community volunteer Izzy Field. The troop would meet each week on the grounds and participate in traditional Boy Scout activities, as well as specialized projects for our kids. An initiative of the Recreation Department that continues today evolved from a weekly newsletter into a valuable periodic hospital publication—River Views—which offers everything from relevant, or reverent, cartoons to acknowledgment of exceptional staff accomplishments, interviews, and other newsworthy information. It is great reading for me even after forty years. Working together with children and staff, we also did things like build a ropes course at Pin Oaks, construct a bridge over the creek, and improve the picnic areas. One major project organized by Dave Wells and Chris Roccanello was the construction of a beautiful sailboat. The boat was displayed at Liberty Bank and then put up for auction to benefit the auxiliary. Mike Bartolotta, director of maintenance at Riverview, won it. In July 1975, Gary Nolan and Bob Delvecchio developed the Pin Oaks Project, a Project Adventure ropes course.2 Later, in 1985, Gary attended another Project Adventure workshop and in conjunction with the recreation director from Altobello, Ronnie Zera, developed the climbing wall in the gym at the RiverView School. Eventually, Gary obtained his special education degree and started full time as a teacher. The following comment from Gary nicely expresses the joys and sorrow of working at Riverview: It’s nice to see the kids’ progress. Kids are here for such a short time we don’t get to see the successes. But this one kid I have

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really turned on. He’s one of these kids who really used to put the wall up, would get very angry and into himself. He wouldn’t let anybody penetrate, and you watched as he began to open up and begin to trust a few people. He still has a long way to go, but you see him start to take pride. You saw the dejection when he didn’t get on the honor roll last semester. And this semester he got on it and he’s beaming and now he’s on the higher level. That’s the kind of kid that everybody is kind of saying they want to take a little credit for: “Look at the way this guy is acting now.” That gets us too. The other student sits there and says, “I don’t care. Give me a restriction. I don’t care.” That’s a hard kid to reach. I think we do see a lot of those.3 As noted, recreation enjoyed a long and evolving life, from an early shared activity by ward staff and whoever else was available, to a reliance on volunteers and part-time college students, to a one-man recreation department, to the Residential Care Department, to a Recreation Department with a full staff, and finally, with the merger and adoption of the medical model, to the change to a rehabilitation model. This latest incarnation required new definitions, different credentials, and, of course, stringent medical records accountability. Those recreation workers who didn’t possess the necessary credentials remained recreation workers rather than rehabilitation therapists.

[ CHapteR 10 ]

adolesCenCe ... Soon after the formation of the Children’s Unit at CvH (1962), which included children to age sixteen, administrators organized youth groups with age-appropriate recreational and educational programs at each of the three state hospitals. These programs eventually coalesced into adolescent units for children ages fourteen to eighteen, with their own identified staff.

HousatoniC adolesCent Hospital Fairfield Hills Hospital in Newtown, Connecticut, renamed their adolescent unit Housatonic Adolescent Hospital when all children’s services were transferred to the Department of Children and Families and Leonard Suchutliff was superintendent. The program structure was very much a residential treatment model for drug and alcohol, but a brief treatment area known as Adams House was added as a mental health component. When the program was unexpectedly included in the merger with Riverview, few of the staff transitioned. The commissioner considered moving the Brief Treatment Unit to Riverview but leaving the Adams House as Housatonic Adolescent Hospital’s residential treatment unit. After a review of the overall program, however, the commissioner closed Housatonic Hospital and moved the staff to Riverview. ConneCtiCut valleY adolesCent unit At CvH, volunteers working with social worker Bob Oates began organizing youth activities. At that time, the personnel office appointed as youth coordinator Bruce Copeland, a psychologist. They gave him a staff and a ward area in Merritt Hall. One volunteer to join the unit was Peter Brown, a psychiatric aide who describes the situation as follows: “It was a lot of fun. We had groups that got together, sometimes 98

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marathon groups that kept going. Someone would leave and come back again. The staff were all dedicated people who wanted to work with adolescents. The hospital generally didn’t want the adolescents, so everyone in our group wanted to be there and we got along great. With Bruce, we developed a pretty tight program using a lot of behavior modification techniques.”1 Joyce Jones, a Children’s Service Unit supervisor at Riverview in 2003, first began working with the adolescents in 1973. In a room on the first floor of CvH’s Merritt Hall, the team developed an educational program during the day shift and a recreational program in the afternoons. The adult recreation program, provided by the CvH Rehabilitation Department, was led by William Davis, a physical education teacher, and, in 1975, Ronnie Zera, a recreation worker who later became director of rehabilitation at Altobello and then at the new Riverview. The youth still lived on the adult wards, however. In 1977 the adolescents were brought together in Russell Hall, one of the older buildings at the hospital, and assigned three wards, one for boys, one for girls, and an autistic unit (graduates of the Children’s Unit’s autistic program). Art teacher Donna Nolan describes Russell Hall as something like the facility in One Flew Over the Cuckoo’s Nest. Her art classroom was a long corridor. “It was a large room, high ceilings. It was a very open, strange feeling when you were in this room. There were no boundaries, no bulletin boards, no place to hang your artwork.”2 According to Joyce Jones, “The physical environment was not conducive to treatment, but the staff was dedicated to make it work. They were skilled staff and maybe 95 percent of the time we had good treatment. We had a lot more freedom to do things. Staff was willing to do a lot of things with the kids.”3 Gary Zera, who later became director of nursing at Riverview and then superintendent of High Meadows, started as a psychiatric aide at Russell Hall in 1978. Gary commented about the high quality of some of the staff but felt that there were serious problems among many, who “showed no respect, no view of working with people who needed care and respect. It was the dark ages of custodial care. There were lots of

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good people, too, who had no vehicle to make change or turn the corner for a new climate.”4 Many of Gary’s co-workers did not transfer when the program was moved to Altobello.

altoBello adolesCent Hospital In 1975 Senate Bill 1446, An Act Concerning the Transfer of Children’s Mental Health Services to the Department of Children and Youth Services, mandated a plan to transfer both the CvH and Norwich adolescent programs to a vacated facility in Meriden. This facility, known as Undercliff Hospital, had gone through many transformations. Built in the early 1900s as a sanatorium to serve children with various childhood diseases, including tuberculosis and smallpox, it accepted adult patients in the 1940s and became a mental health center in the 1960s. Later, it was taken over by the Department of Mental Health as a halfway house for patients from the three state hospitals. Next it became a community mental health center serving the Meriden and Wallingford communities. When it was transferred from the Department of Mental Health to the dCYs, the facility was renamed Altobello Hospital in honor of Henry Altobello, a local political advocate for children and adolescents. However, major structural problems with the facility soon surfaced. As state law requires, once a facility is vacated and before new tenants can move in, the building must meet the latest fire regulations. Threequarters of the buildings were condemned, including the auditorium and all recreational and vocational/educational areas. After extensive renovations had been completed, inspectors granted use to only two wards on the first floor, a school on the third floor, and the kitchen and dining room on the fifth. The entire second and fourth floors were condemned. This made life in the new facility somewhat difficult. Art classes were set up in a separate building at the back of the property. This was perhaps a step up from the art room at Russell Hall of CvH, except for the fact that the art program was separated from the rest of the school and living units, which limited access for kids on any kind of restrictions. In addition to the main building, a separate building that had been the Adolescent Drug Rehabilitation Unit became Cliff House, a more or less step- down, “open” cottage. There were exposed

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pipes, and the configuration was not practical (e.g., the nurses’ station was illogically located away from the rooms). The dire state of the facilities really took a toll on morale. Gary Zera described the situation at the time as “an embarrassment. I was ready to leave. I didn’t want to work in a place with such poor morale and moral decay.”5 In addition to the facility problems, most recreation equipment and camping gear were lost in the move. Therefore, staff didn’t have some of our most effective tools for building self- esteem in a group of kids who desperately needed it. Despite disappointments with the unexpected space limitations, staff looked forward to having their own facility and hoped they could build something better. A new superintendent, Edward Perrin, had been appointed, and Peter Brown became director of residential services. Oliver Clark, who started working at the CvH adolescent program in 1977, was named director of nursing, and Earl Patterson, part-time psychiatrist, accepted the designation of medical/clinical director. Things went relatively smoothly for a time. JCaH (hospital) accreditation was awarded under the consolidated standards, but it soon became clear that the hospital standards were going to be adhered to eventually. During the next accreditation survey, Peter described what seemed to be happening: “I think the central office didn’t want us to pass, so they would have justification for a new building. We sent all our accreditation papers to central office and they never sent them in. So we didn’t get accredited.”6 David Frieze, assistant to the deputy commissioner for children in the central office responsible for the institutions, appointed a committee to conduct a study of Altobello. The report revealed serious problems in almost all areas: an organizational structure that contradicted all organizational theory and made it almost impossible for key people to do their jobs; very poor morale, with little support for leadership; a general sense of “moral decay”; and most important, poor patient care. The conclusion? A major overhaul. Deputy Commissioner Charles Launi asked that I chair a team that would include Judith Normandin, director of the Bridgeport Family Day School, and Ellen Ryder, who was then assistant to David Frieze of the central office. Ellen’s assignment was to oversee the project.

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The commissioner gave the team four months to develop a program and structure like that of Riverview. This clearly meant a residential treatment environment and philosophy rather than a strictly medical model. On an early morning in February 1982, at the changing of shifts from the night staff to the day staff, Launi called an all-staff meeting and introduced the new management team, which also included Everists Berzins, newly appointed facilities manager of the hospital. We presented our table of organization showing a clear line of authority and responsibility, and a plan for implementing the goals and objectives of our team. Launi’s remarks “ripped everyone apart,” according to one employee, who wishes to remain anonymous. However it did, the employee admitted, “mobilize people to turn things around.” Many who had worked so hard to make Altobello a high- quality program, despite what they perceived as a lousy campus—poor organization, inadequate staffing and funding, and overly critical involvement by central office—felt a mixture of anger, frustration, and hope. On the one hand, they felt unappreciated and unfairly criticized, but on the other hand, they felt optimistic about the possibility of better organization and management. Oliver Clark could see both sides: “Some staff felt threatened, like they were being analyzed, and that it was an abrasive change in management. Others felt it needed to be done.”7 In any case, it was not an easy time for anyone. The new table of organization had me as interim superintendent, Judith Normandin responsible for group living/nursing, Ellen Ryder for all clinical services, and Everists Berzins for all maintenance, food service, and business services. For the first few weeks our team spent time interviewing individual staff members, reviewing policies and procedures, and generally getting a sense of the morale and expectations of staff at all levels. Each evening, the team would convene to discuss the day’s happenings and develop strategies for the next. The first priority was to reorganize the group living structure, starting with the leadership. Following the Riverview philosophy, we held interviews for unit coordinators. All childcare and nursing staff members were eligible to apply. Eventually, we selected Bob Oates, a childcare worker,

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for the Hubbard (Evaluation) Unit, Joyce Jones for the Chamberlain (Treatment) Unit, and John Lynch for Cliff House, a separate building, presumably an open- door halfway house. It was clear to our team that the atmosphere was at first one of suspicion, fear, and concern about jobs, but soon staff recognized the need for change and joined us in trying to make improvements. I remember one day when they were conducting their usual “morning rounds.” Rounds consisted of the lead worker from each unit meeting with our team in my office to report the incidents of the previous night. These included restraints, seclusions, and any number of negative events. One morning I felt myself sinking lower and lower into my chair, so I said: “This is one hell of a way to start the day! Didn’t anything good happen with the kids? I can read the night report and we can work on solutions, but let’s start the day with what good we are doing.” That set off a string of happy comments from each of them. We all left the room feeling much better, and that became how we started each day thereafter. At the end of our four-month period we announced, “Mission accomplished!” at a dinner for department dignitaries held on the grounds of the facility, announcing the completion of the reorganization and the appointment of Judith Normandin as the new superintendent. I returned to Riverview. In short order, Judith hired a new full-time psychiatrist, Michael Lustick, and a new director of residential care, Anna Catchatera, and appointed Oliver Clark as director of nursing. Other key personnel were Nancy O’Neil, chief social worker; William Boylin, chief psychologist; John Lynch, chief social worker of the former adRu (Adolescent Drug Rehabilitation Unit—Cliff House); Everists Berzins, facilities manager; Bob Haxton, business manager; Janice Karpinski, purchasing chief; and Ronnie Zera, director of rehabilitation services. A former nun, Anna Catchatera brought warmth and caring and helped create a “new morality.” Michael Lustick and Judith Normandin provided strong management. As noted by many, Judith was very conscious of the poor, institutional look of the facility, and with the help of Janice Karpinski, Everett Berzins, and Bob Haxton, major improvements in

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the physical environment made it a much more pleasant place to live and work. The team moved ahead rapidly to bring Altobello back to life. Additionally, with the impetus of Michel Lustick, a gradual move toward the medical/hospital model began. When Judith left to become superintendent of the Community Mental Health Center in Hartford under the Department of Mental Health, Margery Stahl of Riverview replaced her. Margery, with her nursing orientation and the mandate from central office to develop further the move toward a medical model in hand, completed the conversion to the medical model at Altobello. She described it as “a time when there was a real movement away from the paraprofessional coming in and having a real responsibility. They wanted it to become more like a real hospital, which meant nurses and psychiatrists.”8 It was during this period, too, that serious discussions began about the adequacy of the Altobello facility. With much of the main building condemned and unusable, the cost of rehabilitating the structure was prohibitive. Additionally, the site itself was unsatisfactory. Built on the side of a hill (hence its former name, “Undercliff ”), with the only flat area occupied by the Department of Mental Retardation, there was little space for outdoor recreation. Hence, it became economically feasible to start all over again on a different site. Fortunately, or unfortunately, depending on how you look at it, there was more than adequate room on the grounds of the Riverview Hospital for Children in Middletown. I strongly resisted the idea of building an adolescent unit on the grounds of the children’s facility, arguing as I did at the beginning that it was better to keep a program for children small, and that mixing adolescents with young children was undesirable from a programmatic point of view. However, because of the powers that be, and the reality that the space at Riverview was more than adequate, and the fact that it was already property owned by the state, economics won out. However, after much discussion we firmly agreed that the two programs and their identities would be kept separate, with different staff and separate administrations. The only sharing would entail the grounds and maintenance as well as the Riverview pool. With these

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major decisions agreed upon, architects were appointed, the Public Works Department was ready to move, and plans were developed to build an adolescent hospital, as a friendly neighbor adjacent to, but separate from, Riverview Hospital for Children. Consequently, architectural drawings were completed, which included a separate school, a separate kitchen and dining room, as well as all other services. Also in the new plan was an upgrade of the kitchen and dining room in the Silvermine Building. This included a more open view of the river and bridge.9

[ CHapteR 11 ]

teamwoRk ... .

The program at Riverview Children’s Hospital really hit its stride during the 1980s. A clinical coordinator and a residential coordinator co-managed each residential unit with equal responsibility. Lead children’s services workers convened daily for inter-shift meetings to discuss child-related issues and to ensure continuity of care across the children’s day. Participants in these meetings included teachers, residential childcare staff, clinicians, psychiatrists, and rehabilitation/ recreation staff. The management held weekly unit meetings with the coordinators to discuss issues that may have cropped up and changes that might be needed. During these years the Connecticut Office of Policy and Management instituted a new management tool: a management incentive plan based all managers’ annual raises on the accomplishments of their specific objectives. This proved worthwhile, as it forced us to define and assess our personal and agency goals and objectives for each year. As the programs matured, cognitive behavioral therapies were introduced and the hospital became known and respected throughout the country. The following synopsis of life at Riverview in the 1980s is taken from my notes for quarterly and year- end reports.

1980 The year began with a restructuring of the administrative staff, or “management team,” as well as with a new philosophy of management. Our purpose was to give each team member more responsibility for the total operation of the hospital and to shortcut problem solving. While the team members reported directly to the superintendent and each had primary responsibility for his or her particular area, they were responsible to each other as well. This meant, for example, that should a conflict arise between the group living area and clinical ser106

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vices, the managers of the two would work out the differences between them, rather than each approaching the superintendent with his or her complaints. Only if the differences went unresolved at this level would the superintendent have to mediate. This approach was very successful and gave each member a greater sense of ownership for the total program.

1981 Along with Janice Gruendel, deputy commissioner of dCYs, and Walter Pawelkiewicz, director of research and planning for dCYs, I served on a committee to develop a “continuum of care” model for children’s mental health. (Despite the many hours spent on this project, it wasn’t until several commissioners later that it again became a focus in the central office of the Department of Children and Families. In fact, it wasn’t until after I retired that the idea was reactivated and I had the opportunity to implement it in the community.) 1982 Many of the staff volunteered to participate in a Pathfinder Workshop conducted by Earle Devlin, retired director of social services of Undercliff Hospital (the Department of Public Health facility, which was turned over to dCYs and became Altobello Adolescent Hospital). This workshop was designed to evaluate/diagnose organizational perceptions. The results of this led to many discussions and eventually a “project plan” that incorporated many of the ideas and suggestions. The dCYs developed a five-year plan with a goal of reallocating funds to lower levels of care. Consistent with this goal, meetings were held with community providers, dCYs personnel, and Riverview clinical staff to brainstorm about ways to provide various community services without increasing the cost of our operation. This led to several ideas, and many were implemented the following year. A basic philosophy was that the state should not be in a position to compete with community services, but instead assist in filling gaps.

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1983 Since my goal was to provide community services and to act as a catalyst, hospital staff went out into the community to provide services to child guidance clinics and schools. Clinical, educational, and recreation staff volunteered to work in community settings, providing staff training and direct service to kids. The local YmCa was allowed to use the hospital pool, and the Riverview kids’ basketball team played against teams from local groups. In short, relationships were forged that helped the community as well as the hospital. It had been my hope that Riverview would become a training as well as a treatment center, and that began to take shape too. The hospital became the placement of choice for Yale child psychiatry fellows who were completing their child psychiatry residency. Riverview clinical social workers supervised social work interns from the University of Connecticut, and student teachers from Southern Connecticut and Central Connecticut State Universities did their special education student teaching in the RiverView School. Also, as a result of an agreement with the rehabilitation therapy program at Southern Connecticut State University, students came to Riverview to assist in running groups in art, music, horticulture, and pet therapies. In the mid-1980s, when admissions slowed, I was able to address another of my goals, to make the hospital a contributing member of the community. We began a partial hospitalization program (pHp) that operated from 7:30 a.m. to 6:30 p.m. Children attended school and received therapy at the hospital but went home to sleep. As private hospitals began to adopt pHps, the Riverview pHp was phased out. It was not my intention to be in competition with other facilities, and my goal was to address a need. During the late 1980s and early 1990s, the child psychology environment began to change and Riverview changed with it. There seem to be four reasons for this change. First, the field of child mental health treatment was taking another big step. After addressing the conditions in hospitals for children, practitioners were now questioning the efficacy of extended periods of hospitalization. This philosophical change had an impact on the private hospitals. As they attempted to shorten

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hospital stays, children with the more resistant forms of mental illness were referred to Riverview. On the fly, our facility was developing programs for children with eating disorders, fire-setting tendencies, and behaviorally aggressive problems and children whose mental illness was comorbid with mental retardation. While Riverview had always treated kids with these issues, the pressure on hospitals to reduce length of stay forced many more children into our state hospital. The second reason for the environmental shift was the change taking place within the Joint Commission on Accreditation of Hospitals. JCaH was being converted to the Joint Commission on Accreditation of Healthcare Organizations ( JCaHo). It was changing its procedures, and pressure was placed on Riverview to meet hospital standards (as opposed to residential treatment standards). At this point, a slight diversion is necessary. Riverview had been established by the legislature as a hospital. Because of its unique programming and dedication to innovative children’s services, the medical model used in other primary and tertiary care facilities was not in place at Riverview. As an example, the Clinical Staff Organization oversaw clinical services. In the formal hospital environment, the Medical Staff Organization, 51 percent of its members physicians, would have directed these services. These modifications in operations prevented Riverview from being accredited as a hospital. (As mentioned earlier, Riverview had routinely been accredited using the Consolidated Care Standards, a compromise in the accreditation process that allowed for a kind of hybrid residential/hospital model.) JCaHo procedures now required that Riverview meet (strict) hospital accreditation standards. The third reason for change is related to the emergence of managed care. Managed care is a special program for children who may be in dead- end situations and need special attention in a hospital, a residential program, or even an out- of-state facility. An experienced social worker is assigned to the child and family to develop a comprehensive plan for behavioral health services. As the notion of managed care spread into the federal Medicaid reimbursement structure, different rates were established for “true” hospitals. Facilities that did not meet hospital Medicaid standards were reimbursed at a lower rate and considered to be “private, non-medical institutions” (pnmi). To maximize

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federal reimbursement, Department of Children and Families administrators pressured Riverview Hospital to meet the hospital standards and thus increase the amount of federal income to the state. The fourth reason relates to internal issues within dCf. As part of an administration change in 1988, all hospitals operated by dCf were reviewed. Housatonic Adolescent Hospital, located on the grounds of Fairfield Hills Adult Hospital, and Altobello Adolescent Hospital, located in the old tuberculosis hospital, were both experiencing reduced census. In addition, both facilities required significant infrastructure renovations and upgrades. The census needs, construction costs, and operational expenditures led the dCf administration to make some dramatic decisions concerning the organization of mental health services for children and adolescents. During a rare lull in admissions and with the census at its lowest point in years, we decided to officially branch out into the community and offer our services. The management team appointed Edward French to serve as coordinator and then, as our plan became a reality, director of community services. The accomplishments described in the following paragraphs were due largely to his efforts. Edward surveyed and individually interviewed staff members and eventually agreed upon a designated percentage of their time that could be devoted to community services. At the same time a variety of dCYs personnel and community service agents met to discuss needs, and matches were made with interested Riverview staff members. The staff provided the following services: 1. Partial hospitalization. After various revisions, the management team, dCYs central office, the Department of Central Collections, and Blue Cross approved a written proposal. The program officially began on 31 January 1983, and as of 4 April 1983 five children participated, the goal for the school year. (This involved approximately twenty hours of clinical staff time as well as time spent by teachers and recreation staff.) Edward French, Peter Briggs, and Denise Abbata led the program. When Elmcrest Hospital in Portland, Connecticut (bordering

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Middletown), opened an extended day or partial hospitalization program, Riverview closed their program in 1986, much to the dismay of the schools and parents of the children involved. 2. Outpatient care. Two social workers spent eight hours each week seeing children and their families at the Shoreline Clinic in conjunction with Middlesex Memorial Hospital Clinic. Occasionally, a patient originally referred for admission to Riverview Hospital could be diverted to outpatient care. Conversely, when the clinician recommended hospitalization, he or she continued the case during the patient’s stay, upping his or her community hours to sixteen. 3. Play groups. One social worker conducted a play therapy group with several “problem children” from the Middletown Head Start Program (two hours a week). 4. Weekly meetings with teachers of Middletown Head Start program. 5. Teaching basic parenting skills at Middletown Head Start (two hours a week). 6. Psychiatric consultations. Our chief psychiatrist, Yvonne Johnson, provided psychiatric consultation to the dCYs New Britain office treatment staff (one and a half hours a week). 7. Consultations to three Tri-RYC group homes (three hours a week average). 8. Consultations to the Young Parents Assistance Program (two hours a week). 9. Participation in four child protection teams (two hours a week). 10. Participation in a local juvenile review committee (one hour a month). 11. Consultations to regional office supervisors (one and a half hours a week). 12. Workshop. In conjunction with Middlesex Memorial Hospital, Riverview staff conducted a workshop called “Helping Children Deal with Loss,” attended by more than one hundred people in the children’s services field. 13. Teaching assistance. Lou Ando, school principal, consulted with special education teachers in Portland weekly.

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14. Children’s Task Force. After various meetings with Brenda McGavin, dCYs networking coordinator, Ruth Ettenberg, Region III networker, and Seymour Sarason, a leader in conceptualizing social service networks, Ed French and Ruth Ettenberg of the Region III Advisory Council developed a plan that included meetings with the Middlesex Interagency Council to present the notion of developing a forum to consider children’s issues. Shortly thereafter, the council, with Ed French’s leadership, organized the Children’s Task Force with tremendous support. In summary, Riverview staff, as a result of community services development, provided approximately fifty- one hours a week of services to children in the continuum- of- care model categorized as supplemental, supportive, and preventive. This contribution was in addition to the regular inpatient services hours, which had not been diminished. For many of the staff members participating, this was an exciting venture.

1984–1985 Major renovations were now completed in the residential units— kitchens, showers, and quiet areas. In the Silvermine Building, a space for medical records and a family therapy room were added, and the school received a computer room and a created a learning center. Most facility objectives for the year consisted of refining the work of various committees: Quality Assurance, Patient Review, Research and Staff Development. The school curriculum and the Behavior Management Program were revamped. Also, the Bridging the Gap Committee began reviewing policies and procedures in preparation for Altobello’s move to the grounds of Riverview. As mentioned earlier, Lou Ando assumed responsibility for quality assurance as Carl Sundell took on added responsibility consulting at High Meadows, which needed to revise their management data collection system and were looking for a new assistant superintendent. A further realignment of the management team included assistant superintendent Margery Stahl, Judy McCain as director of residential

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care, Louis Ando as school principal, Yvonne Johnson, clinical director, and Lyle Ressler, business manager with Jacqueline Reardon as executive secretary. Also reporting to the superintendent were Jacqueline O’Brien, director of clinical education, Tom Prue, director of recreation and activities, and Edward French, director of the partial hospitalization program.

1986 –1987 Extensive training of all staff on issues of sexual abuse as well as safe holding procedures was conducted while preparation for JCaH accreditation was again under way. All nurses were now included in the Clinical Staff Organization. Quality appropriateness studies focused on specific programs as a means to evaluate decisions. For example, the nutritionist performed a study on height and weight gains or losses in hospitalized children as compared with expected levels for their age group; the Social Service Department studied the frequency of sexual abuse among children as victims or perpetrators; the psychology staff reviewed admission notes and referral material to evaluate interview questions; the recreation staff looked at the appropriateness of their progress notes as they related to program and treatment goals. The nursing staff conducted several studies, including the use of locked time- out, turnaround times on laboratory work, and the use of antibiotics. While the results were not earth shaking, these studies show an effort to systematically look at all aspects of the hospital activities. A change from rotating shifts to straight shift requirements took effect. While the night shift was already a straight shift, the other two shifts, 8 a.m. to 3 p.m. and 3 p.m. to 11 a.m., rotated every other week. The union fought for all shifts to be straight, with choices made by seniority. This was probably the most contentious issue between management and the 1199 union. It was, in fact, their first major conflict and clearly put a wedge between the parties. It was the beginning of the we-against-them mentality, or good guys versus bad guys, depending on where you sat. Management contended that the rotating shifts made more sense programmatically, but clearly for many staff, alter-

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nating first and second shifts was an inconvenience and interfered with their family lives. The issue became a heated one that eventually was brought to arbitration. The management argued that rotating shifts made it possible for staff to know kids in all parts of their lives, getting up in the morning, going to bed, returning from school and recreation, and so on. Also, straight shifts meant that the most experienced personnel were likely to choose the day shift, with more support staff available and more opportunities for training (since consultants were available during the day shift only). Most new and less experienced staff would be assigned to the night staff. Nevertheless, staff preference informed their union’s position, which argued for straight shifts and a more consistent schedule. A major shift in management occurred when Marge Stahl applied for and accepted the superintendent’s position at Altobello Youth Center, replacing Judith Normandin. Riverview’s loss was Altobello’s gain, although we participated together on the management team. Lois Ando assumed the vacated assistant superintendent role, with quality assurance a primary responsibility. Judy McCain, who had been residential care, chose to return to her first love as clinical nurse, preferring working directly with children to serving as an administrator. A new hire, MaryAnn Diddario, became director of residential care, and Kenneth Towbin took the director of clinical services spot, replacing Yvonne Johnson, who returned to her beloved Colorado. These changes in personnel completely reshaped the dynamics of our management team. Kenneth’s enthusiasm, energy, and clinical and teaching skills brought a new dimension to our total milieu program. The humorous banter between him and Lou Ando kept our team lively and exciting, as well as very productive. One of the objectives this year was to explore with several colleges the possibility of offering courses at Riverview for the benefit of the staff. Some results of this exploration included an agreement by Southern Connecticut State University to offer credit courses at Riverview toward a master’s degree in the Psychoeducator Training Program; New Hampshire College (now Southern New Hampshire University) agreed to offer undergraduate credit for workshops attended and/or

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for nursing at Riverview. Continuing education credits were awarded through the Connecticut Nurses Association. Herb Schact, founder and director of the Waterford Country Day School, introduced me to William Walsh of Chicago. Walsh was known for his extensive work on nutrition and behavior. The outcome of this conversation was a departmental conference held at High Meadows. Walsh delivered the keynote address, and many staff members from the department’s various facilities attended. The hope was that with Walsh’s enthusiasm, we might get some research started in Connecticut. Due to controversy, however, we were unable to pursue this idea.

1989 Around the middle of this year, the governor announced that all eligible state employees would be offered a “golden handshake,” or an opportunity to retire early with a substantial bonus. Up to this point I had not even thought of retiring. I loved working at Riverview and thought I had the best job in the state. I counseled several people about the choices they had to make, but retirement didn’t occur to me until a colleague pointed out that I, too, was eligible under the criteria described. I decided to look into it. Neil Neilson, the superintendent of the Long Lane School, was in a similar situation, and the two of us attended personnel counseling classes and weighed our options together. Eventually we both decided to retire. For me it was a very difficult decision, but several factors led to the conclusion that it was time to turn over the reins. It was twenty years earlier that I had begun at the Children’s Unit. At that time I had made a five-year commitment to myself with the idea that I would then move on to something else. But I felt there was still work to be done, so I made another five-year commitment, then another, and now it was time to reconsider. I reminded myself of my philosophy as a recreation director: “Kill the game, don’t let it die,” or “Stop when you are on top.” I was at the top of my personal hill, and so I began some quiet introspection and found that my input in supervision was less than it used to be, I was dealing with the same personnel issues that I had dealt with a hundred times, and I just didn’t have the level of enthusiasm

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that had kept me going for twenty years. Finally, I realized that my relationship with the commissioner had begun to falter. We clearly held wide differences of opinion on the future of Riverview. She advocated a hospital setting, and I so strongly believed in a residential setting. It was time to move on to different arenas. So I did.

[ CHapteR 12 ]

identitY ... The 1990s represent a period of major changes. Like an adolescent becoming an adult, Riverview went through enormous modifications over a relatively short period of time. There were several changes in leadership, a changing philosophy, a merger with adolescents, a forced marriage, and a questioning: Who am I? And what will I become? Finally a new name ensued: Riverview Hospital for Children and Youth. Upon my retirement in 1989, Commissioner Amy Wheaton appointed Margery Stahl, interim superintendent of both Riverview and Altobello. Wheaton had previously been my assistant superintendent and a strong supporter of the residential model. For some reason she changed her opinion and her revised mandate was to put the medical model back into Riverview. Marge was a natural for this job, having grown with Riverview from its infancy. She was part of the evolution of each program. Spending part time at each facility, she managed to rewrite the policy and procedure manual of Riverview, realign the childcare staff, and, once again, put nurses in charge of the residential units while further preparing for the transition to a medical orientation, including recommending modifications of the design of the new addition. Marge was also charged with moving Altobello to the Riverview campus. At first everyone understood that there would be the two hospitals sharing the grounds, but on 14 September 1992 attendees at the regional director’s meeting found out there would be one hospital on the grounds of Riverview. It would now be called Riverview Hospital for Children and Youth (the uppercase “V” was dropped). This news came as quite a shock to all. And it was still not clear what was going to happen at Housatonic.

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tHe meRgeR: a foRCed maRRiage The merger was very much like three small rural towns—each with a different ethnic and cultural heritage, and each with its own mores, attitudes, community standards, and personalities—suddenly being brought together, against their wills, to form one city. One might expect a clash of emotions: anger, fear, frustration, loss of identity, betrayal, and general anxiety about the future. All of these responses emerged when the state ordered Altobello, Riverview, and Housatonic to amalgamate. Typically, the dominant culture would eventually prevail, but not until each group had given up its ways of life. This could be a long process and the final assimilation, in which a common language and behavior would develop, might not fully occur until all the old-timers had left. The end result would be a totally new personality. When Marge Stahl first assumed the responsibilities of acting superintendent and then superintendent, of both Riverview and Altobello, there was the unspoken assumption that they would be friendly, sharing neighbors, but separate hospitals. Marge spent her time between the two facilities, seventeen miles apart. Lou Ando, now chief operations officer, worked primarily at Riverview. Stahl spent most of her time at Altobello, and she had the unenviable task of closing that facility and moving staff to Middletown. Union and collective bargaining issues became a major concern. Meanwhile, construction of the new hospital buildings began. In these early days of managed care, there was pressure to make the hospital more of a medical facility. As noted earlier, the administration supported the medical model, and psychiatric nurses were hired at an unprecedented rate. The new plan called for a nurse on each unit for every shift—in contrast to the previous staffing pattern of having one head nurse in the hospital. Select Altobello staff members were encouraged to attend school to gain nursing degrees. In 1991 Carl Sundell, who was at the time serving as assistant superintendent of High Meadows, was asked to take a leave and oversee the process of merging the hospitals. This was to be a one-year commitment. Then in early 1992 Marge Stahl decided to retire after more than twenty-five years of service. After her long years of administra-

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tive excellence and commitment to the improvement of the lives of both children and staff of the Children’s Unit/Riverview, as well as Altobello, she would be sorely missed. Soon after, in August 1992, Carl Sundell became superintendent of the two merging hospitals. Also at this time, Lou Ando became assistant superintendent. This enabled Carl to continue the process of merging the hospitals while Lou provided the direct operation and management of Riverview and tried to maintain some degree of sanity in the confusion. These were obvious choices. Lou was well known and respected at Riverview, and for the past year Carl, integral to the evolution of the hospital almost from the beginning, had been very involved in putting together some staff development programs. Now, Carl began spending a lot of time at Altobello as well as Riverview Hospital, basically identifying best practices from each. These included everything from treatment planning to program philosophies, behavioral intervention procedures, emergency procedures, medical records, basic safety, and security issues entailed in opening a hospital. Union contracts that had been negotiated separately now had to be reconciled. When in December 1992 the commissioner brought Housatonic Adolescent Hospital into the merger—now conflating three hospitals—“there was a massive reaction.” Carl Sundell recalls: The people at Housatonic Adolescent Hospital were real angry about what had happened. They had anticipated that they were staying as a freestanding facility, and now they were closing. Door-to- door drive is an hour and five minutes from Housatonic to Riverview. Some of these people lived south and west of Housatonic, so they were facing a long commute. They were facing a loss of identity, and everything you could think of. At which point, the reaction among the staff at Riverview and Altobello also became very negative. People were extremely angry about what had happened. Virtually all the work we had done seemed to go to shambles.1 Certainly the people at Housatonic were extremely angry, but so were people at Riverview and Altobello. Sundell traveled to the three

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facilities on almost a daily basis trying to build credibility and attempting to help everyone understand what was happening. Every effort was made to be as considerate as possible to the staff. Since each hospital had functioned independently, there were numerous redundant positions, and administrators attempted to select the best person while considering union seniority rules to fill positions in the consolidated facility. Individuals were encouraged to apply for vacant positions elsewhere within the dCf, such as area offices and central office. Lou Ando took responsibility for merging policy and procedure manuals. Of particular concern was the development of a single medical record that would meet the revised Medicaid mandates. Grief counselors were made available to all Housatonic employees, since they were dealing with the death of their hospital as they knew it. It must be stressed that, while the combining of the hospitals was promoted as a merger, Housatonic and Altobello staff were not just changing locations. The names of their facilities were to be eliminated as the new facility officially became Riverview Hospital for Children and Youth. Sundell notes: Folks were very, very upset. This all occurred before Christmastime in December of 1992, and the anticipated opening date of the new hospital was April of 1993. We felt really under the gun to get things done and get training accomplished, to get to know the staff and let the staff know us, and to get the policies and procedures in place, but we found ourselves dealing with a great deal of anger and frustration. We found that the staff, particularly at Riverview and Housatonic, felt a great deal of loss around the closing, the loss of identity at their facilities. And the only ones who were somewhat optimistic about the whole process were the folks at Altobello.2 Slowly, Housatonic patients were moved into the Bleu ii unit in the Silvermine Building, and personnel were integrated into the daily functioning of the hospital. With the Housatonic Hospital merger with Riverview, at least in practice if not in the hearts of staff, attention now turned to the construction project and the Altobello staff.

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As it turned out there were several delays in the construction, with the Department of Public Works removing the contractors and assuming responsibility for part of the job. This led to various lawsuits and some subcontractors walking away from the project. The result delayed the opening until October 1993. The new building did not end the troubles, however. Various problems in the construction soon became obvious. In about a third of the rooms, the heating system malfunctioned and temperature would fluctuate. In many of the rooms the temperature was in the mid-50s. And this was during one of the third- or fourth- coldest winters on record in Connecticut. It snowed Christmas Eve and twice a week until May. The new facility opened with rooms that couldn’t be used, and virtually every skylight in the place leaked. The locks jammed and often didn’t work. Staff objected, too, because even when the deadlocks worked, staff had to unlock them to enter, then turn around and lock them again—just one more bit of frustration. This was not a very happy beginning to add to the anger and frustration that were already brewing. Outside of the building, other problems persisted. Without snow dams, drifts of snow frequently fell off the roofs, burying recently shoveled walkways and drenching staff and visitors. Falling icicles were a constant hazard. The most obvious change, of course, was physical appearance. The addition of several new buildings, the renovation of the Silvermine Building, additional parking spaces, and a new entrance way more than doubled the size of the facility. It no longer looked like a small residential center, but rather a large hospital. Remember, the plans were made and facility development was done when the expectation was that there would be two separate facilities, each with its own identity, kitchen/dining room, school, administration, and so on, and with only a few shared areas, like the pool and major maintenance duties. Concurrent with the new buildings was the complete renovation of the Silvermine Building. Plans for this renovation were developed in the early 1970s when the move from Connecticut Valley Hospital took place. At that time it was clear we needed an area for those children whose care necessitated housing more secure than cottages. The office wing of Silvermine was “temporarily” converted to a residential

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unit. With the merger, the Bleu program was eliminated and the wing that ten years earlier was “temporarily” utilized now reverted back to office space. For a time, two dining areas were operational, the West Campus space for the children and youth who resided in those units, and the Silvermine dining hall for the children and staff on the East Campus. Food was transported from the kitchen, which was located in the West Campus. This practice eventually ended, and the Silvermine dining room was converted to a staff training area. Also, a new residential area, specifically designed for younger children, was added to the building: the Pueblo Unit. With construction completed, the business group from Altobello moved in first. They virtually moved intact; among them were business manager Bob Haxton; fiscal officer Mark Harrington; and purchasing director Janice Karpinski, as well as various assistants. The Riverview business office consisted of only Lyle Ressler, manager, and his assistant, Helen Muno. Their counterparts at Housatonic chose not to transfer. Carl Sundell elaborates on the impact of cultural and philosophical differences coming together: [T]he more important thing, I think, was the philosophies at the three hospitals. There were three freestanding facilities, and it’s really difficult for me to characterize their history, but Housatonic and Altobello were both adolescent facilities. Housatonic worked primarily in what would be called a residential care mode. They basically developed what they hoped was a warm, supportive environment on a couple of units. They used a clinical component to help them, but they never moved towards a medical model. They basically really were, despite being called a hospital, a residential treatment facility. Altobello, which had been pulled together in a medical sense in the mid- eighties, was really the strongest medical model of the three. They also had, for better or worse, the best policies of the three. That made a great deal of pressure to accept the policies of Altobello virtually in total, which was understandably resisted by the staffs at Housatonic and Riverview. River-

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view was a mixture of the two but, since the early nineties, by the time I came, had been moving, for better or worse, towards the medical model. Mostly because of insurance regulations and some changes in JCaHo, the intent of the department was to create a medical model. My own preference would have been not to go in that direction. However, that was what was requested of me so that’s what we set out to do and, in fact, accomplished, for better or worse. In any case, this caused a lot of consternation. Each of the staff felt their way was best. This caused a lot of dividedness. It was something we spent an awful lot of time on and when we opened, some things had still not been able to be resolved.3 Three different work schedule philosophies also posed challenges. Sundell describes this process: There were meetings that went on at Altobello where we took the schedules and list of employees at each hospital and merged them into an enormous spreadsheet. People would come to me and say, “OK, if we try this schedule how much would it cost?” As people started to talk to each other you had a culture at Altobello where people had gone completely over to the medical model where if you didn’t have a license you couldn’t be in charge. The units were not [headed] by lead children’s services supervisors; they were led by nurse supervisors, and some of the people who were not particularly thrilled by that left. You came from a really—don’t want to say more rigid, well that’s not such a bad description—perhaps you would say less flexible model in Altobello meeting up with two more residential models from Housatonic and Riverview. The clashes started early and I don’t think they are entirely over.4 Each administrative and supervisory position was now occupied by three people: three superintendents, assistant superintendents, medical directors, directors of nursing, psychology, social work, recreation/rehabilitation, and maintenance, school principals, and

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so on. Seniority played a major role in the paring- down decisions. Some people left for administrative roles in either the central office or other dCf facilities. Others were integrated into the new hospital in other roles. Andrew Kass, for example, whose official title was assistant superintendent of Housatonic, became management information system director, responsible for health information systems, as well as internal statistics, patient roster, and joint commission data. A few, like Gary Zera, Mark Root, and Kevin Dowling, saw the writing on the wall and returned to school to get their nursing degrees. Both Gary and Mark eventually became directors of nursing, and Kevin became a nurse manager on one of the units. Oliver Clark, designated director of nursing, describes the merger as the “biggest upheaval.” Three different social groups with differing professional attitudes and procedures and different ways of interacting with children attempted to find common ground. Riverview, Clark says, showed more “social acceptance of children—by hugging and showing affection. Altobello, on the other hand, was the most rigid, with Housatonic very laid back.”5 Robert (Bob) Haxton who had become the business officer, describes the situation from his perspective: It turned out that the business office was all Altobello people— we came over virtually intact and also the bookkeeping from Altobello survived. That was my choice because it was easier for me to keep the same kind of books. Here they had to merge together three different activity funds, three petty cash funds, and so on. In the hospital at large, initially there were a lot of people who were not very happy with the whole arrangement and either felt like they were being taken over, invaded, put upon, or otherwise in distress. I can remember people standing out in the lobby screaming at each other because of some stupid little thing. Everybody was really on edge. Here in the business office, we get kind of a different picture than some others. We are probably the most removed from direct day-to- day care, even though what we do directly affects what happens. You know, if they want to go out and get a child

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some clothing they have to get a purchase order or petty cash and they have to come to us. But we take a different view— perhaps more dispassionately, so I see that sometimes people will get frustrated with what they are doing and fight the organization because they can’t change what’s going on in their area so they act out against the organization. The majority, however, really do enjoy working here. They enjoy working in a place that tries its best to care for these very, very sick children and to do their best for them. Also, while we do have to look out for how our money is spent, we’re not driven by a profit-making motivation—not concerned about a profit first. Treating the child came first.6 Mark Harrington, the fiscal officer, who had previously worked out of the central office in Hartford, had a very different perspective. Working directly in the institution was a whole new experience for him. His job was to merge three different budgets. He shares: It took about a year before we got our act together and got everything cleaned up. You are with people you are serving. They’re right here. It’s not like talking to a person on the telephone that you may see once a month or writes you a letter. Things are much more immediate. You have to drop what you are doing and take care of a situation. That was a bit of an adjustment. But I would never want to go back to an office. This is much livelier. You get more of a sense of accomplishment because you can see the results of what you are doing. There was a time that people said, “I’m not going up to the Altobello business office . . . we are Riverview.” There were a couple of people who really freaked out because their credit union deductions [their statements] would say: Altobello. Some people came down here and were bent out of shape because of that. “We’re not Altobello! We’re Riverview!” . . . There was “old Riverview” and there was “new Riverview” because they were getting all the new stuff in the new building and the people in the old buildings felt left out. That caused a problem for a while. Most of it was they were concerned about the kids.

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That’s what’s different in working in this kind of environment. I’ve stayed here for ten years, which is the longest I have stayed anywhere, so it can’t be all bad. We’re big enough so that we can make a difference to a lot of people but we’re small enough that you are not just a number. It’s worse now because I don’t know a lot of people. I don’t get out of the office as much. It’s different when you don’t know everybody. I probably couldn’t do what they have to do on the wards. But it gives me a better appreciation for what my own kids are like.7 Lewis Goldberg of Riverview became chief of psychology. Like many of the other clinical and childcare staff members, he expressed his dismay about the change to the medical model. When he came from West Virginia to Riverview for an interview, he was “very impressed. Riverview was one of a kind,” he said. “I came to a place that had a residential feel and [was] a very comfortable place. The structure of the units had senior childcare workers as the unit managers and things worked very well. And the big point of pride was that we had a small percentage of children on medication. We would get kids in on lots of meds and slowly take them off these meds.”8 John Lynch from Altobello, because of his seniority, became chief social worker, replacing Marcia Pease- Grant, who had been in that role for many years. Likewise, Ronnie Zera from Altobello became director of rehabilitation service, replacing Tom Prue, Riverview’s director of recreation. Notice the change in titles, which was necessary to conform to the medical orientation. MaryAnn Diddario had been promoted to the central office as chief of the Department of Nursing Services and her position as director of nursing at Riverview was filled by Oliver Clark of Altobello. The medical director position, too, became vacant when Kenneth Towbin left for a teaching and research position in Washington, DC. Leslie Segal and Dorothy Stubbe temporarily shared the position of medical director. Later, an outsider, Robert Lobis, filled this position but after a relatively brief stay left the agency. Carl Sundell appointed Lou Ando assistant superintendent. The evolution of the campus marriage into a happy one, however, was to take a while. Many internal changes, attitudes, cultural differ-

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ences, and identities were yet to be resolved. Collective bargaining agreements made as part of the mergers in 1994 persisted as contract requirements until 2008! Ellen Ryder tells about the ordeal from her prospective as someone who had played a wide range of roles, first as a social worker at the newly developed adolescent program at Norwich Hospital, then as its director. When that program closed and moved to the Adolescent Unit at CvH, Ellen became assistant to Dave Frieze in the central office. When the Altobello program struggled, Ellen became a member of the team that took over interim management. Upon completion of that project, she returned to the central office. From there she became interim superintendent of the State Receiving Home at Warehouse Point until the early 1990s, when she returned to Riverview. She describes her return as “a shock.” The most significant thing was the new supersized Riverview. Even more significant was the organizational structure. Each unit now had a chief psychiatrist, nurse supervisor, and clinical leader. Certain functions had a coordinator or director with administrative status and the required committee system. Ellen continues: I knew that the merger wasn’t complete—that there were still territory and identity issues among staff based upon where they worked before, but I guess I expected them to be fairly evenly distributed, with everyone feeling some displacement and wishing for the good old days but with good-natured camaraderie. To be sure, there are some great people who maintained positive attitudes and rolled with it all, but I was surprised at the degree and direction of the hostile/negative stuff I heard. I was surprised that Altobello seemed to be the dominant voice/force. . . . I had assumed old Riverview would be [predominant], due to location, name, and the fact that I associated Sundell and Ando with Riverview. Also, I had a notion of old Altobello having been “Riverviewized”—by you [Dick Wiseman] heading the reorganization there and later Stahl, Sundell, and Ando being superintendents. Obviously I was wrong about that. The most surprising thing for me was how negative some of the Altobello

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people were about Riverview—feeling they had lost their wonderful identity and reputation with the name and were now part of an inferior operation. Although I know how well Altobello did with their JCaHo accreditation surveys, first under Judith Normandin, and continued to do even better under Marge Stahl, my perspective was that their reputation never improved very much in the community. I continued to hear wide criticism of Altobello from community and private agencies while I was at State Receiving Home. At the same time, Riverview was widely praised and rarely criticized. So the sense of superiority coming from some of the Altobello staff was a jolt to me. Altobello also seemed to be the dominant “culture” due to their presence in so many administrative slots. I had a sense from some of the Riverview staff that they felt invaded, overrun, and insulted.9 Bob Sinkewicz was one of the clinicians to move over from Altobello: When we merged it was a blending of several cultures. The Riverview model was here—what I usually refer to as the classic Riverview with a lot of terrific staff and helpers. The Altobello model had to a large extent embraced the medical model, with the unit chief as the psychiatrist. The Housatonic model was a blending of those three cultures. It was difficult. I think it was different for those of us from Altobello because we had already made the change into the medical model, so we didn’t have that big of a change. I think it is a beautiful facility with a lot of services. One of the things I like best about the service here is [that] we really do function using a disciplinary team, with psychiatry, psychology, social work, nurses, childcare, education, and rehabilitation; and we have a great deal of mutual respect for the various contributions to that team. I like the fact that we do our independent observations and then we synthesize the evaluations and come up with a shared treatment plan for the child and family and their various helpers. So I think it is an excellent model for practice, and it really does give us a real opportunity to promote kids toward good health.10

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Krista Judson, a childcare worker who came from Housatonic, observes: I don’t think we really merged. The Riverview people felt like they were being invaded. Originally it was just Altobello that was to merge. Then we were told we had to go. It was devastating. I don’t think any of us wanted to merge. We felt we had a really good program and we didn’t want that disrupted. It was very hard—I still don’t think we ever melded together. It’s better than it was, but you had three different hospitals with three different cultures trying to come together. There were different shift schedules, different administrations who looked at childcare workers differently. I think the biggest thing was we couldn’t just take the kids out, which is what we were used to doing. I still have trouble with that. Kids had to earn the privileges. They had to put effort into their own treatment, their benefits. I think we lost that positive reinforcement. I think that was the hardest for the Housatonic people. All different rules. I had to go to third shift because I was offered a lead child service worker position. It was hard to change from being a lead children’s service worker in charge to come to a place where the nurses were in charge.11 Kevin Dowling, now a nurse manger, who took advantage of the extra training offered on moving from Housatonic, describes how devastating it was for the staff to be suddenly told they were moving. Those who did transfer to Riverview found themselves in a very different culture. Coming from a small program that was modeled after a residential treatment program to a large hospital that was in the process of developing a strong medical model leadership style was shocking. Joan Narad, the team leader for Pueblo Unit, described what it was like to come into the situation not having been part of any of the other hospitals: The merger was only a year old at the time that I arrived, and at first it was fairly confusing. I would hear things like “When I was at Altobello” or “Housatonic,” or “When it was just River-

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view . . .” you could always tell where people came from because they always wanted to do things the way they had before. People had different ways of doing things. There were certain arrangements that were made—preferential arrangements, giving preference to people they knew when making assignments, either to certain units or department hierarchies, which left some hard feelings. I wasn’t part of that so it was kind of baffling to me. It was only when the first JCaHo accreditation came up that people pulled together as one hospital.12 Obviously, the line staff or childcare workers were most deeply affected by the merger. The nurses were also significantly affected because it once again brought power and authority back to their positions. A by-product of this was the deprofessionalization of childcare staff. This was a movement that had started a few years back, led by some childcare workers, both at Riverview and at other childcare facilities, and supported by Riverview management. Lou Ando reflects on this: Because significant authority and responsibility had been taken from the children’s services workers, they began to retreat more into their defined role. They weren’t as creative as they had formerly been, and it soon became apparent that the medical model was in full swing. Kids started to be called “patients,” and one of the aspects that had made Riverview Hospital so successful seemed to be slipping away. Since its inception, the philosophy of the management and staff had always been that it was our mission to work with children who may have had a problem. They were all kids. And, underneath any diagnosis, aberrant behavior, or medical condition, there was, at its core, a child. It seemed so basic to staff at that time to treat these youngsters like children with basic needs, needs that were not eliminated by the presence of serious mental illness. As the facility became more of a hospital, embracing more of a medical model, it began to assume the characteristics of a hospital that treated the illness that just happened to be located

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in a child. In 1985 we would sit at treatment planning meetings and talk about behaviors. By 1995 we sat at meetings and started to talk about diagnostic categories. In 1997 Carl Sundell retired as superintendent and Linda Rossi made me acting superintendent. Later I was assigned to the position permanently. Not being mental health–oriented, she didn’t like the fact that Riverview had a lot of staff, was costing a lot of money, and, I even think, was a little jealous of the facility’s reputation in relation to the rest of the department. There were many things to do. At that point I really wanted to turn back the clock and change Riverview back to what it had been when I was first hired. I started to meet with personnel and talked about bringing back the lead children’s service worker positions that had been eliminated in favor of nurse supervisors, nurse unit managers, and staff nurses. After about one year there was a change in administration. Kristine Ragaglia succeeded Linda Rossi, and Ragaglia appointed Tom Gilman as deputy commissioner. I was directly responsible to Tom, and in our supervision meetings, I would stress upon him that Riverview needed options. I wanted him to let the hospital be the hub of a behavioral health system. I wanted to develop options prior to hospitalization and options post-hospitalization that would allow kids to move through faster, avoid hospitalizing kids unnecessarily, and to provide them with post- discharge support so that they could remain in their communities.13 For Adam Kaczmarek, one of the most highly respected childcare workers, the merger limited his leadership role and his chances of rising to a higher level in the organization. Adam started at Riverview in 1978. He described the situation at the time of the merger and how the chaotic management environment adversely affected the children: There was a total change in the character of the hospital with the merger. There’s always a power play for positions in any organization, but the merger was probably the most frustrating time. I seriously considered moving then. It was physically

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draining, emotionally draining. I don’t know how it got that bad. Part of it was the power plays. Part was people didn’t know what to do. It was just terrible—the amount of seclusions and physical restraints. I think the fourteen or fifteen years I was at Riverview I used a physical restraint just once. During the merger I had to use a physical restraint on a daily basis. To have someone get a serious injury was a rarity; now it happens regularly. I asked Adam if he felt that the increased use of physical restraints reflected the fact that there were now older kids on campus. He responded: “No, it’s happening on the units with the same age range as before. Obviously with the older kids there is more. Part of it was bringing the papoose [restraining board] on the units. We fought it because we knew if it was there we would end up using it. Right now we’re going through it again on Pueblo. Now we have it off the unit completely. We don’t use it. There’s a total change in philosophy on how we deal with kids.” I asked him what he attributed this to. Were fewer restraints being used now? No, we’re not using fewer restraints. It’s an ongoing battle. The leadership was told—a push from the central office and the Child Advocates Office to reduce the amount of mechanical restraints. Physical restraints are now seen as acceptable and are the least restrictive form of intervention, seclusion being the highest form. . . . When JCaHo comes to survey, their focus is on seclusion and restraints and they mean mechanical restraints—papoose. The problem is that it is dangerous to hold a kid for too long, and what happens is [staff] may hold for twenty-four minutes, because if you hold for twenty-five minutes you have to fill out other forms. It’s the same with mechanical restraints. You stop at fifty-nine minutes and you don’t have to fill out other forms or call the doctor. It’s very frustrating. Several people are out on permanent disability; that’s the major difference since the merger—an increase in mechani-

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cal restraints. Obviously that is because of the older kids, how more dangerous things have become. Asked whether kids are more difficult today than they used to be, Adam replied: We have talked a lot about that. I remember Lou Ando coming down a few months after the merger when things were in total chaos around here—things like leaving the fire alarm box unlocked with the doors open. We had fire alarms every single day. There were just a lot of transitional things. One of the good things about being left alone on the unit is the ability to adjust the program. For example, if a child slammed the door repeatedly there would be consequences. He would be put in his room for twenty-four hours. And that would be the end of it. Today that would be considered too severe. Even when a child assaults a staff member, he would be made to apologize but that’s all. It used to be that if a child assaulted a staff member he would be in his room. If he did it again he would be out of the loop. That was clear. There’s a concern here for doing that now. It’s seen as being too harsh. I asked whether that was a gradual change in philosophy: No, that was not a gradual evolution but happened very quickly, when Marge was here. You’ll get a lot of different opinions about why that happened. My opinion, which some others believe too, is that it was a struggle for power—who is going to be director of nursing—several people pushing for that position. At first it eliminated the coordinator’s position. Some of those people went on and got their nurse’s degree; the lead children’s workers continued to supervise for a while. Their positions weren’t really affected. Then a couple of years ago they decided to phase out the lead positions, and then they decided to give them their responsibilities back. So now the lead positions are back and [the lead workers] basically are in charge of

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each shift and do the supervision and all that. I do all the supervision, the scheduling, assignments, and all that. Also there’s a charge nurse on each shift as well who basically has the final word. And that depends on the culture on each unit. In some the nurse still takes responsibility for doing all the house stuff, like setting up the daily schedule, and so on. On others they may leave all that to the lead. The role of the psychiatrist is also very varied depending on the psychiatrist. Ours is very much involved. Others are hardly ever seen on the unit. The same is also true of the nurse managers. Some are very involved; others pass a lot down to the lead.14 In the midst of the retrofitting, the Joint Commission on Accreditation of Hospitals determined that, due to all the changes, they would be seeking reaccreditation. As Bob Haxton puts it, “There was a finite amount of time that you had to apply for reaccreditation. So while everyone was trying to settle into a new building and having the heebie-jeebies about having those three different cultures and not everybody was willing to change because they wanted to hang on to what they know, along comes a major, time- consuming task to deal with.”15 By 1993 all construction had been completed, all positions identified and redefined, new policies and procedures written, all new tenants moved in. The final touch for the new identity? All the residential units were renamed and given Native American names. Despite the merger anxiety that Riverview was experiencing internally, the hospital continued to provide the highest- quality care. The JCaHo recognized Riverview for three successive surveys, after having been accredited with commendation. The dCf commissioner routinely referred to the facility as “the jewel in the dCf crown.” Families and legislators alike vied to have children placed in Riverview rather than in private hospitals.

Pin Oaks Grove, Middletown, Connecticut. Photo: Frank Michael Winiski, 2012.

Pin Oaks Grove, Building 6. The wooded picnic area and cabin are adjacent to the area designated for the Children’s Unit development in 1966. Photo: Frank Michael Winiski, 2012.

A promise kept. In 1971, the school for Riverview’s children opened to serve seventy pupils up to age thirteen. Photo: Frank Michael Winiski, 2012.

RiverView School pool. The therapeutic value of a pool cannot be understated. All RiverView kids learned to swim, which gave an obvious boost to their self-esteem; and learning games, like finding alphabet blocks at the bottom of the pool, helped kids who had trouble following directions on land to excel poolside. Photo: Frank Michael Winiski, 2012.

Sailboat. Built by Chris Roccanello, David Wells, and Riverview children, it is shown here in the common room. Photo courtesy Connecticut Valley Hospital Archives, 2004.

The round cottage. I was opposed to this design, although it was beautiful in its own way. We originally decided it would be the girl’s cottage, but that didn’t work at all. Then we tried Sunburst, moving the younger boys in. That was better. Finally we moved the “autistic” kids to the round cottage. That worked well. They were able to handle the circular configuration best—even better than staff. Photo: Frank Michael Winiski, 2012.

Renovated Riverview, 1984–1985. Across the lawn is the main building of the complex. The taller structure is the dining room, which overlooks the river. Photo: Frank Michael Winiski, 2012.

“Pursuit of Happiness.” The name of a residential unit in Pueblo, part of the renovated Silvermine Building. Children were encouraged to personalize their rooms. Photo: Frank Michael Winiski, 2012.

“Dream Wish Relax.” The name of cottage nurses station. Photo: Frank Michael Winiski, 2012.

Corridor of new main building complex. On the right is the clinical wing and on the left is the school and gym. Toward the back are entries to the residential units. Photo: Frank Michael Winiski, 2012.

Renovated nurses station, Pueblo Cottage. Photo: Frank Michael Winiski, 2012.

Bench made from parts of the restraint bed. Staff and children constructed this bench memorializing the elimination of mechanical restraints. Photo: D. Wiseman, 2010.

Riverview Hospital. Photo: Richard Ribsyl, 2003.

[ CH a p t e R 13 ]

post- meRgeR A Total Personality Change? Riverview Enters the New Millennium

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The transition from Riverview Hospital for Children to Riverview Hospital for Children and Youth was clearly a major adjustment for everyone concerned. It no longer was a small “mom and pop” organization as described by that organizational consultant some years ago, but was now a large organization, with three times the number of staff members, restructured leadership roles, changes in the philosophy of treatment, and generally a redefined personality. It would be many years, with various leadership changes, both at the hospital level and within the Department of Children and Families for the new personality to develop. As the chief psychologist, Lewis Goldberg, puts it, “There used to be a driveway and there were azaleas planted [in memory of ] Sandy, a childcare worker who died; and with the merger, the driveway to Riverview was bulldozed, being eliminated. It was very symbolic, a great metaphor for the change in identity.”1 Lou Ando functioned in the capacity of acting superintendent from 1997 until late 1998, when his role became official. Shortly after assuming responsibility as superintendent, Lou recognized that much of the emotionality that accompanied the merger was exacerbated by the change in emphasis to the medical model. Not only was staff continuing to deal with feelings of displacement, the vectors of authority and responsibility were changing. Medical staff was now in charge. This left the direct care staff feeling disenfranchised. With the commissioner’s office paying most attention to the protective services mandate of the department, Lou saw an opening to continue to meet Medicaid requirements while retreating from those elements of the medical model that negatively affected the children’s services and general functioning of the facility. 135

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Lou met with the commissioner and central office managers and presented a model of hospital operation that restored some authority and responsibility to childcare workers. He also proposed a certification process for childcare staff that would increase their responsibility as they took advantage of voluntary training opportunities. Finally, he included that element that I had proposed for Riverview nearly twenty years earlier—making the hospital a hub of mental health services and training for the community. As luck would have it, a change in administration at the commissioner’s level presented an opportunity that would prove to be a blessing as well as a curse. Kristine Ragaglia, former child advocate, was appointed commissioner, and her first initiative was to address the behavioral health service deficits that had come to her attention in her advocacy role. In 1999 the bureau chief of behavioral health and medicine, Marie Cerino, left her position. A neonatologist by training, Marie had spent most of her time attempting to improve medical services for children in the care of the department. Recognizing that mental health and substance abuse were issues of primary concern for children and youth, Kristine Ragaglia began a crusade to improve these services in a program that later became known as KidCare, building on the community collaboratives that had begun blossoming in the state. Lou Ando was approached to function as bureau chief in an acting capacity until a replacement for Marie Cerino was identified. The search for a medical doctor with a behavioral health background and interest was expected to last three to six months. In the interim, Lou acted as both—superintendent and bureau chief. After a yearlong search, a suitable bureau chief had still not been found. Lou was offered the position permanently but at first declined. Eager to get back to the hospital, he felt an obligation to attempt to return Riverview to the status it had achieved before the merger. And then, according to Lou, the commissioner issued a challenge: “You’ve complained about what needs to change and you can do more in central office than you can at the hospital. Are you serious about this or not?” With that, Lou accepted the bureau chief position and the search began for a replacement superintendent. He reminisces about what it was like for him:

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In August 1999 Tom [Deputy Commissioner Tom Gilman] asked me to come to central office to work on a systems of care project for a three- to six-month assignment as acting bureau chief of behavioral health. At that time we had developed a job description and interview protocol. We advertised and conducted interviews, but it was nearly a full year and a half and a suitable candidate was not found. I wanted to go back to the hospital. For that year and a half, I was basically doing two jobs and, in my opinion, not doing a good job of either of them. Central office staff felt they did not have a bureau chief who was fully committed to what they were doing, and the Riverview Hospital folks felt abandoned and betrayed. At one point it was even said to me that I had used the superintendent’s position of the hospital as a stepping-stone, and I really didn’t care about them. I realized that hospital staff were modeling the feelings of abandonment that so many of our kids are subjected to when they’re moved from place to place or taken from their homes. I knew that this couldn’t continue and accepted permanent assignment to central office in 2000. That was when we began looking for a new superintendent for Riverview. Robert Plant applied for the position and was selected over a number of other candidates. I was confident that we had a good replacement in Bert, as he preferred to be called. As clinical director of the Child and Family Agency of South Central Connecticut, he ran their child guidance clinic in Essex. When he began, this was a very small clinic, but through grant writing and other expansion efforts, Bert expanded the program to include such things as intensive in-home services, Early Head Start, and intensive family practices. It was there that he became a member of the Middlesex Community Child and Adolescent Service System, the first community collaborative in the state. Bert knew the community, knew residential care, was aware of hospitals, was a psychologist—which didn’t hurt—and in the interview he really seemed to appreciate the staff and the children. While this is more of a personal observation than a professional one, Bert also had three young children, and in

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his talking about his relationship with them, I believed we had identified a person who would move the hospital in a direction of what was best for kids.2 Plant quickly assumed the responsibility of his leadership of Riverview.3 In a personal interview with me he recounts the early days of his tenure including his implementation of the aBCd program, which focused on (A)utonomy, (B)elonging, (C)ompetence, and (D)oing for others: There was a lot of concern from a lot of people, including the commissioner at the time, who coined this little slogan: “Restraint free by ’03,” and when I arrived, there was already a committee in place and several attempts previously to reduce seclusion and restraints. The first thing they did was to try to improve the training around the seclusion and restraint program (referred to as the Case program) and particularly improve the verbal de- escalation component and additional training related to that. What I found was that people were better trained in the verbal as well as the physical aspects of that. In fact, following their training, rates of physical restraining and seclusion went up, and what they found was that people knew how to do it better. So rather than discouraging them from using the techniques, it actually encouraged it. So then I think the decision had already been made that they had to really take a look at what was happening in the milieu. They had a committee and I joined it in the middle of it. That’s when we developed the aBCd milieu program and really focused on the notion that if you better met the children’s needs and did so while you supported their autonomy and encouraged the formation of healthy relationships, strengthened their sense of competence, and also focused on doing for others and getting outside of themselves, there would be fewer power struggles, fewer regressions, fewer frustrations and there would be less of a need to use restraint or seclusion. So, really, between the spring of 2000 and into the beginning of 2001, we rolled out the aBCd Program. We didn’t do it all at one time but sequentially.

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Around the same time we realized that in addition to this training we had to do other things that impacted on the restraints and seclusion. So we did a number of things. We set goals for units. We changed policies and procedures, like who could authorize and initiate restraint and seclusion. Another thing we realized was that before the aBCd Program could be supported and initiated, we needed to address two things: first we needed to have consultants to help each unit maintain fidelity to the program because it could drift pretty quickly soon after the training; also, we wanted all the childcare staff, the nurses, clinicians to be working differently, with a different focus and they had to be well supervised, so we changed the supervisory structure and added—or actually reinstituted— lead children’s service workers, which had been red- circled as a category of the past. We selected the leads based on their ability, knowledge, and commitment to the aBCd Program so that they could carry that message into the front line through supervision. I think the whole impetus around the milieu revision was that the milieu had become very control oriented, there were level drops and points being charged for some kinds of behaviors and restrictions that would keep kids out of the milieu as a means of trying to, quote, control behavior. And it was backfiring; and it was creating more conflict and tension between staff and children and not addressing what kids really needed. So the whole milieu that we designed was to recognize that kids need autonomy but also recognizing that there were other ways to deal with negative values by teaching a model that incorporates a largely relationship base. Along with all of this we also received a grant from the Mental Health Services Administration to extend our training to staff, giving staff the tools they needed in order to effectively carry out the aBCd Program. There were basically building blocks that we thought were necessary for staff to understand in order to work effectively with kids. They needed to understand the nature of the diagnoses, the symptoms, the experiences of kids. There was training on trauma and its impact on

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children and how they react following traumatic events. In a way, [they were informed] about how it’s easy to misinterpret certain behaviors such as oppositional or defiant behavior when really they may be motivated by fear or trauma. So it was really a kind of a general training, trying to tie everything back to the core principle of autonomy, belonging, competence, and doing for others. So there was a real attempt to link the training to the concepts so that the coaching role included giving advice, teaching skills on how to plan activities with kids so that the activities are supportive, and engaging them in such a way that you’re not always directing but helping the kids do some directing in an appropriate way. One of the unique things about the training was that in order to include all staff, we offered the same training about ten times in order to accommodate staff on different shifts and schedules. Interestingly enough, in the first two years we had a huge reduction, almost 80 percent, in the use of mechanical restraints, also a 50 to 60 percent in reduction of seclusion. One of the things we initially weren’t tracking in the database was the use of other kinds of physical restraint. Eventually we did track that and there was also a reduction, though not as significant. But one of the things that was sort of an artifact that during this time we also eliminated was the use of mechanical restraints for the entire East Campus (the original Riverview with younger children). Part of what that meant was that without the use of mechanical restraints there was going to be some increase in the use of physical restraint. Generally, there were ups and downs, but overall we have sustained a 60 percent reduction in mechanical restraints, and around 50 to 50 percent with seclusion. I think another issue that came up during my tenure as superintendent was the length of stay issue. It came up pretty early on, and initially it was the hospital bringing it to central office and saying: We are having a great deal of difficulty in discharging children. We feel there are systemic issues preventing children from leaving here in a timely fashion, many of which

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we don’t control and that we need assistance if we are really going to best serve children and families. We presented data showing that from 1995 or 1996 the increase in length of stay was pretty linear up through 2001. From 2001 to 2003 we were able to decrease the length of stay by a factor of 15 to 20 percent. But between 1995 and 2001 it had gone up so much that we were nowhere near what it had been in 1995. It hovered between 180 and 140 days. That was a very significant issue. One of the first things we tried to get in place had to do with how referrals to residential care were made. If Riverview wanted to refer a child to residential care, the region had to initiate the paperwork. Then it would have to go from the worker to the supervisor, to the program director, the area director, and then to the central placement team, and then sometimes to the community collaboratives. What you can imagine is, if it sat for a few weeks on someone’s desk it could be months before even the application is sent to a residential center. And we’re saying this is a hospital for acute care; we can’t wait six weeks before something gets processed. So we did get that changed. Although we weren’t making a direct referral ourselves, we were able to initiate the referral package. So there were fewer steps and that helped. And we were able to decrease the los [length of stay] for a couple of years. . . . We had problems when kids aged out [exceeded the age limit of the facility, seventeen years old], and some of them needed to go to the Department of Mental Health and Addiction Service (the adult mental health system). The whole process there required that the regional staff had to make the referral to dmHas and [the referrals] were often getting done too late. Meanwhile the kid would turn eighteen and was still here. Sometimes it took six months and even a year before transitioning to an adult hospital. So we started identifying any kid at age sixteen that would potentially need adult services. We met with them on a monthly basis to review all potential cases and what the planning was. So we did some planning up front and that really made it very unlikely for a kid to be here after age eighteen. In some cases,

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the transitioning could have been earlier except for the statutes that prevented them from taking any youth under eighteen. There were a lot of other issues that went on. For instance, staffing . . . particularly with nursing recruitment. Probably within the last year it has been better than in the past four years as far as the number of vacancies—through a combination of periodic freezes. Sometimes in the middle of a major recruitment effort where we had a lot of ready-to-be-hired comes a freeze and you can’t hire them. By the time the freeze is over, the people have left for other jobs and you have to start all over again. Then there was an early retirement about a year ago and we had accumulated thirty-five to forty vacancies prior to that and around thirty-five people took the early retirement and all left at once. We had over seventy vacancies at one point and we had really a hard time and worked hard to bring it back to our present level.4

RiveRview Hospital In 2005 Riverview officially became a hospital, although under Lou Ando’s leadership they were able to keep some aspects of the milieu treatment philosophy. The identity crisis was over, at least officially. While ever since the merger, as described earlier, the facility had adopted many of the formal characteristics of a hospital setting, 2004 and 2005 were marked by a long and tedious struggle to comply with the requirements of the Joint Commission on Accreditation of Health Organizations. In that year a survey was completed and a score of 99 out of 100 was awarded. After being surveyed for forty years under the Consolidated or Mental Health Facilities Standards, the commission announced that since Riverview was a hospital, they had to be surveyed under the hospital standards. As mentioned earlier, third-party payers (insurance companies) reimburse the facility on the basis of its accreditation status, paying almost twice as much for a “hospital” stay as they would for treatment in a “mental health facility.” It’s interesting, however, that reimbursement has always been at the hospital level because JCaHo and the insurance companies accepted the “lower” standards as appropriate for a children’s program. Thus, for

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many years JCaHo has consistently given full accreditation, often with commendation. While some aspects of the identity crisis still exist, many of Riverview’s old-timers retired when the state offered another golden handshake. Thus, many of the people who were interviewed for this book and are an integral part of its history have moved on to other careers: as teachers, nurses, childcare workers, clinicians, and so on. Along with them have gone their memories of what used to be. Certainly, from its beginnings back in 1962, when children were first brought together at CvH, and its evolution from a custodial placement facility where children were sent, without warning, and “dumped at the door,” to a hospital that families can feel good about, Riverview’s history has been a positive one. An official description of Riverview was published in the New England Psychologist Directory of Psychiatric Hospital and Units, May 2004: Riverview Hospital for Children and Youth, its name since 2001, is the only state operated psychiatric hospital for children and youth in Connecticut. It stands on a hill overlooking the Connecticut River just outside the center of Middletown, CT. It can be reached on Silver Street which runs through Connecticut Valley Hospital, the adult psychiatric hospital which was its former parent, passes by the Connecticut Juvenile Training Center on the right, Rushford Center, a private drug rehabilitation facility on the left, and just past a local radio station. As you go through its entrance the road divides and to the right is the “old Riverview” or “East campus” which consists of the Silvermine building, the original building on the site which at one time housed the patients from CvH who worked on the dairy farm in ages past. It is now used for staff offices, conferences and training purposes. A new addition now includes Pueblo, a residential unit for younger children. Also, there are three other residential units: Quinipiac, Kiwani, and Lakota, each housing 11 to 12 children. Also, a separate building, the Riverview School for the younger children, is located here. As one continues on to the left at the intersection is the “New

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Riverview” or “West campus” which was added in the early 1990’s to accommodate adolescents, includes all the administrative offices, the main dining hall, library, conference rooms, maintenance shops, a separate school, and four residential units, Passaic, Acadia, Manhasset, and Sachem, housing 12 to 15 youth each.5

tHe new Residential units Each of the eight separate residential units (four on each campus) are coed, and all follow the same milieu program, the aBCd Program, somewhat modified to meet the specific needs of the other programs. The units all have their own dedicated staff, making up a team. A typical team structure, with some variations depending on the unit, its population, or mission, looks like this: Team leader: a child psychiatrist Assistant team leader: a psychologist or psychiatric social worker Nurse manager Nurse coordinator or supervisor Nurses Lead children’s services worker for each of three shifts Children’s services workers for each shift A rehabilitation therapist Typically, teachers are teamed up and assigned to work with a specific living unit. The units include the following.

Pueblo A ten-bed unit for the youngest children, ages five to ten—although occasionally a four-year- old has been admitted—this addition to the Silvermine Building was originally designed in 1970 to replace the so- called temporary ward for those children needing a more secure setting (Bleu program). With one delay after another, it wasn’t constructed until 1997, long after Bleu had been phased out and the ado-

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lescent buildings completed. Since this was also to be the most secure unit of the Riverview setting, the dining room/kitchen was also updated but not used as such, since the new dining room in the West Campus was built for the merger. Joan Narad, team leader of this group, started at Riverview in 1994. Her previous experience included a private practice and work in a private hospital. She also consulted at the Yale Child Study Center, where she supervised some of the child fellows who had been at Riverview. “They always said such good things about the program,” she remembers, so when the medical director at Riverview, Robert Lobis, urged her to come, she accepted. “For me it was a good change and I haven’t regretted it all this time, ” she says. In addition to her ward duties she is also designated as the medical director of the East Campus, “which gives me supervisory responsibility for some of the other docs and I have a child fellow or two on my unit and that makes it a lot of fun.” She adds, “One of the nice things about being a doctor here is that the other doctors are very supportive, share recent psychiatric information, and really help each other out, and it makes it a nicer working environment.”6 Working with the youngest children in the hospital raises many questions about the suitability of a hospital setting for such children and how a failed mental health system has made it necessary. Joan talks about working with very young children: You know, on our unit it takes a special kind of people to work with very young children and you really have to like kids, particularly younger children. They are more primitive. They don’t have many verbal skills. They don’t have as many vocational interests that older kids would have. They all have special needs that are demanding. Our kids will always ask for their appointments. They insist on it. They will tell me if a clinician doesn’t give them an appointment or if I don’t see them. They are good consumers. If one of the clinicians is not available, they will see someone else. Sometimes the adolescent will say, “Nah, I don’t want to see you today. I want to be with my friends.” The

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younger kids won’t do that; they will drop everything and come with you. They have a real need for people, which I think is very positive, and if they shut off I really worry.7 The length of stay on this unit is often longer than on other units. While Riverview always looks for the family first as the primary caretaker, this is not always possible, and the lack of sufficient community services usually means that further residential care is needed. This presents a serious dilemma because, as Joan points out, [p]robably the younger the child is, the more important it is to get the child back into the community. It is really important for the younger child to be with their primary caretaker and have continuity with them and have help for the family. Now, many families we see here could use primary caretakers themselves. We often had the wish (on my unit) where there was an abusive relationship or domestic violence to have the mother and child together in a residential setting and treat them together. We’ve seen kids who have been here for a long time that, even though they threaten to run away, when they do go out, say to the beach or the mall, they hang very close to the staff. They’re really quite fearful. They don’t have the normal child experience of going with the parent to the supermarket, and so on, all those things, which really help. Many of our families are isolated too. They distrust the outside world. They distrust the governmental agencies and it’s difficult to get over that. We want to provide treatment but we also want to provide the normal age-appropriate child development experiences. That’s hard to do now. It was probably easier to do when you had your residential model. . . . In the past you had childcare workers in charge. Then you added nurses, then doctors, and the equilibrium changed significantly and their social structure changed significantly. Now I think there are efforts to bring out the best in all the disciplines, everybody. Like returning the lead children’s service workers to collaborate with a team. . . . It is wonderful that they can take the kids out and do the things they like to do. But I see more importantly that every day when someone comes to work they

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are really therapeutic agents on the milieu. Its almost like the psychiatrist, psychologist, social worker—the clinical people— are consultants and can facilitate some changes in the child but the real work gets done on the milieu so that childcare workers shouldn’t think that the treatment just gets done in the office. It really is the day-to- day interaction, the role modeling, seeing how adults talk to each other, how other kids are treated—the nitty- gritty stuff. When I was a resident in Philadelphia, I was on an adult unit and there was a ward chief and resident, and I thought, “Oh, there is a doc running it,” and it was very humbling to realize a few months later that the ward staff were actually there twenty-four hours.8 Joan spoke further about the need for earlier interventions in order to catch problems before they get out of control: If I had my druthers we would adapt something they have in the Netherlands where not only are mothers treated prenatally, but after birth they are followed every two weeks for a period of time and really are proactive in parenting training and assuring the safety of children because many of these children could be identified earlier. I think there should be a public health effort along these lines. When asked if there was a more comprehensive community service system available that could have prevented many of these kids from coming here, Joan told me: That’s a tough question. Of course, every depression, every psychosis has to come to the hospital if they are identified early enough and if you have a cooperative and understanding family that you can work with. You have to have people who can identify these disorders and not just think of it as a social issue. I think you need people who can identify: Is this pneumonia or is it a cold? We’re going to watch it and see what develops and not just think it is a superficial thing. Also, with the schools there should be more collaboration all around—between the school, the behavioral health system, the pediatrician. A lot of informa-

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tion is there. Schools are reluctant to be explicit with parents. Pediatricians are focusing on health and are often reluctant to label a child. I think we often recognize a symptom but someone has to keep an eye on it.9

Quinipiac This twelve-bed unit is primarily for the latency-age kids, ages ten to fourteen, and is coed. Like most of the units, it had gone through various transitions prior to the merger, from Cottage B, to Sunburst for the youngest children, to Seagull for the older children. Nurse manager Pat Colanghi started at Riverview in October 2003. She offers a fresh perspective, not having gone through the various identity issues or having dealt with the impact of the merger. She came to the Department of Children and Families because “it really felt good, working with kids.” As far as coming to Riverview, she adds, “I’m kind of mixed right now because I’m still trying to learn all about Riverview Hospital.” She describes what it was like coming in with a leadership position at Quinipiac, not having “grown up” with the system: It’s really interesting, coming in at this stage and at this point in my career because I’m coming in as a nurse manager where my understanding is that a lot of the staff come in here at a lower level and they work their way up with promotions. I think they have an advantage because they really get to know the program well and what’s going on with the kids in their treatment—their ideas behind the program and how they developed—and why they are where they are. I’m coming in and managing a unit and trying to learn the foundation as well as supervising the unit. I feel I don’t have a really good handle on things right now, but— what I can say—I’m really impressed at the unit level with the time they spend with the kids. I’m really impressed with the patience and the tolerance. It’s refreshing. Kids can act out in some pretty serious ways, and staff can transition having to be very supportive or structured and maybe have to restrain a

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child—not in a mechanical restraint, but just holding him— and they really seem to process it quickly for themselves and get back to a therapeutic kind of forgiving. It’s a new page for you and you can start fresh. And I’m very impressed with that behavior on the part of the staff on Quinipiac. . . . [T]hat’s really my only knowledge of the hospital because that’s the only place I’ve worked so far. I don’t really have the bigger picture of the older or younger children. The most striking thing for me is how the staff deals with the kids. Also, our psychiatrist, Alton Allan, has been here for a while. I like his style of medication with kids. He uses enough but not too much. He uses what’s necessary, and I like working with a psychiatrist with that kind of policy. He’s very involved with the children and the unit. . . . That’s been a pleasant experience for me.10

Kiwani Kiwani—Cottage C in the former Riverview—is an eleven-bed unit for ten- to thirteen-year- olds. Kiwani is an African name meaning “an awakening,” according to nurse manager Wilson Tirado. Kiwani’s teams are individualized for each child and generally consist of a team leader, an individual therapist, a first- and second-shift person, a teacher, and a rehabilitation therapist. The team meets every two weeks for review. Team leader Charles Rich was the first full-time child psychiatrist we hired, in 1974. After leaving for a position with the Institute of Living in Hartford, he returned to dCf part time at Altobello and came back to Riverview with the merger. When Charles Rich retired in 2003, Jeffrey Landau became team leader. At his request I met with him along with Peter Briggs, the assistant team leader, and Wilson Tirado. Landau, like many of the psychiatric staff, did his child psychiatry training in the joint Riverview/ Yale Child Study program in 1997and 1998, which required a rotation around the different units at Riverview: “I really liked the model. . . . I also remembered thinking that [staff] stay here forever. It’s really a stable place, with a multidisciplinary approach. I learned a lot about

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psychology and psychological testing, and social work and collecting family histories, and really enjoyed the experience and wanted to stay on.”11 There happened to be an opening so Jeffrey was able to start right away, assigned first to Kiwani for a year, then to Acadia for five more, and then back to Kiwani in 2003 as team leader. Wilson Tirado had been a nurse in the private sector for ten years, at Hartford Hospital and the Institute of Living before he came to Altobello. As plans for Housatonic to become part of the Riverview merger unfolded, he was assigned to Housatonic to help with the transition. “They were pretty upset that they were merging,” he said, referring to the Housatonic nursing staff. “They thought they had a good program, with a very tight-knit staff and they were going to be leaders on Kiwani.”12 Assistant team leader Peter Briggs also had a long history with Riverview, starting in 1975 right out of graduate school. He began as a caseworker and then became the intake worker, probably one of the most stressful roles. The intake worker deals with urgent phone calls from anxious clinicians and administrators. In addition to being assistant team leader on Kiwani, with a caseload of three or four, he served as assistant chief of the Social Work Department, a role formerly held by Marcia Pease- Grant. After the merger, he was first assigned to the Adama Unit (later renamed Passaic) and then on to Kiwani. As assistant team leader he would be expected to attend all team meetings and fill in when the psychiatrist was not there. Briggs describes his role: As assistant team leader I go to all of the evaluations. When the psychiatrist isn’t there, they are going to call me and I’m going to know a little bit about every kid on the unit, what the treatment plan is and what had been going on. I’m going to be working with the intake office with new admissions. I’m going to figure out how we will accommodate him—are we going to put these two kids together? Who needs a single room? Who doesn’t? It’s sort of a clinical/administrative role. There may be some program issues, adapting the aBCd Program to an everchanging population.13

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Passaic The Passaic Unit is specifically for “developmentally challenged” kids. It is located in the new building off to the far left of the common room. The team leader is psychiatrist Richard (Rich) Pugliesi, with a psychologist, Lisa Hayden, as assistant team leader and Kevin Dowling as the nurse manager. Originally the unit was called Adama, staffed by many who transferred from Housatonic. There was a lot of moving around of units during this time, and Adama was closed down, renamed, and reopened a1s a program for the developmentally disabled. Despite the disruption, especially for some of the cognitively and developmentally impaired children, Rich noted that with the opening of this new unit they were able to recruit staff who had skills and experience and who had an observed ability to function with the developmentally disabled and cognitively impaired. Rich explains: “It’s not just hiring a person who had been there for fifteen years. We need specialized people. . . . We try to create an environment that is soft, warm, and friendly and not restrictive or offensive. For a lot of limited kids that is something they don’t get because of chronic stress.”14 During our interview, Rich also talked a little about his philosophy of treatment, which is reflected in the day-to- day activities: “Any intervention we give to the child, if the family should be there watching it they would feel safe and secure. If we were doing things that would make me feel uncomfortable in front of the family, it wasn’t the right thing to do.” One of Pugliesi’s original goals was to screen kids before admission, go out and see them and see their families, come up with whatever they needed, and establish a hard staff contract about what the discharge plan would be. Nevertheless, this plan was not approved for implementation. He goes on to say: “I think there is a bias forming for me at the moment. I think we do a pretty good job of taking care of kids and we really try to get them out a lot. I think these kids feel well cared for, but I can tell you the few of them that have been here and are really ready to move on, they complain. They say that there is little activity and so it’s a lot of helping them deal with their frustration.”15

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Kevin Dowling originally was a childcare worker in the Adams House program at the Housatonic Adolescent Unit of Fairfield Hills Hospital. At the time of the merger with Riverview in 1993 he, along with others, were offered the opportunity to go back to school for a nursing degree. He accepted. At the time of the merger he was still a childcare worker and was assigned to the Bleu program in Silvermine. After receiving his degree in nursing, he worked on various other units and eventually accepted his present position as nurse manager. According to Kevin: The Passaic Unit has a very unique population. They are kids who are not only psychiatrically challenged but are challenged in other ways as well. Most have developmental delays, which makes it very tough. A lot of the kids have very little impulse control. Originally Passaic was a regular psychiatric adolescent unit, but there were several kids who really didn’t fit in with the others. They couldn’t fit in with the structure of the program or even deal with the regular consequences to their behavior—like a three- day processing procedure. So we developed the present unit. We do use the aBCd Program, but the biggest difference [between] what we and the other units do is that our interventions are very short term. They are immediate, quick. A kid throwing a chair on any other unit might end up on precaution and have to do several tasks related to it. On our unit we would remove the chair but not put him on precaution. Most of our interventions are very time limited. If something happens at ten in the morning the intervention could be done by two—or at least by the next day.16 There are fewer beds on the unit, and as could be expected, the average length of stay is much above the average of the rest of the hospital. Typically, these are kids who fall between the Department of Retardation and dCf.

Manhasset and Acadia Manhasset and Acadia are fifteen-bed units for youth from fourteen to eighteen, although occasionally a younger child may be admitted because of his or her size and/or behavior that may require mechani-

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cal restraints, which are not used in the younger children’s units. Also, according to Chris Malinowski, a nurse clinical practitioner assigned to Manhasset, they receive several youths ordered by the court for a thirty- day evaluation and therefore tend to have a shorter overall length of stay than some of the other units. Craig Allen, the team leader for Manhasset, chose to work at Riverview over many other options: There were a great number of positions available both in hospital settings as well as outpatient programs in community child psychiatry as well as consulting. Many of my friends in Connecticut suggested I go into a private practice. So I looked into all of my possibilities and found a lot of places that looked interesting but . . . I was sort of bowled over by the services that were available to the children here. I worked in a lot of different hospitals but Riverview had programming seven days a week, into the evening hours. They had the staff—dedicated teachers, the children service worker, the staffing ratios—the ability to, when kids are stable enough, get out into the community and try to normalize the experience of these kids who have significant psychiatric illness. It’s really the kind of experience that other places kind of dream about. I think, it is, in part . . . the financial backing that the state provides in Connecticut, because it takes money to be able to do those kinds of things. But I’ve learned over the years that the history of Riverview is also the history of Connecticut’s involvement with children with psychiatric illness, going back to Dr. Solnit and his involvement with dCf and wanting to integrate different departments that serve children, the protective child services with children with mental illness. The environment here was very attractive because of the resources, and the ability to work with kids long enough to see them get better (which you don’t get in a shortterm length- of-stay hospitals) and the intensive involvement (which you don’t get in an outpatient setting). The collegiality of the different specialties here is something that struck me right away. I didn’t want to go to a place where there was divi-

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siveness, and what I saw here was people who wanted to work together for the interest of the kid. I think all of those things pulled me in this direction. On top of that, the affiliation with Yale was attractive to me. I like teaching with the medical students rotating through here for their child psychiatry training. I worked with psychiatric students from Harvard and wanted to continue to do that. So I made the right decision. I do miss the outpatient part of it, but I am able to get involved with some of the programs, which dovetail with Riverview—programs which are designed to get children back into the community. For instance, the iCp [Intensive Care Program] in the Child Guidance Clinic in Essex and sometimes our kids will transition from the hospital with that support and service and put other services into place and help them transition back into their home or foster home, but also try to keep kids out of the hospital. The potential for having a seamless system is there in the state—Riverview could be more an integral part of that system. When kids get stuck here it is because there aren’t enough of the community services available.17 Robert (Bob) Sinkewicz, assistant team leader, has been at Riverview since he came over from Altobello. He has had a long history in state service, and particularly with the Department of Children and Families. In 1983 he was in the regional office in New Britain; he went from there to the State Receiving Home and from there to the former Long Lane School. Originally he started with what was then the Department of Health at Blue Hills Hospital in Hartford: I always wanted to be a clinician or primary therapist, and when I came to dCf, Riverview Hospital had such an outstanding reputation that I always wanted to work here. That was my goal. That was years ago when it was just a children’s hospital and there was very little turnover among clinicians who had been here—like Marcia Pease- Grant and Frank Rusczek. They had been here forever, and I really thought as I looked around that if I could get to Riverview, that if I could ever be a clinician at Riverview, I would have made it somehow. Now I can

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tell you, twelve years later, it is still what I always want to do. I still think it is an honor to work with the kids here, that the staff is outstanding at all levels of disciplines. So I’m very fortunate to have this job. This is what I’ve been trained to do and what I want to do. Given my earlier experience with dCf, I had a strong foundation about how the system works. When you’re in the regional office you really don’t get to participate in the lives of the children and their families when the kids go from placement to placement or from service to service. When I went to my first institution at the Children’s Place I was stationary. I would watch the kids with the family all through their treatment. It was a different perspective, but you have a really good opportunity with the places, which are more long term—a feeling that you’re participating in the lives of the children. . . . In a private psychiatric setting the turnover is so great you don’t have the opportunity or, what I always say, the luxury to do the meaningful work. We have here the real opportunity to join with the kids and the families—and their outside helpers— towards this effort to help them get back on track, back in the world, and back to the community. The Manhasset Unit came from Altobello. There were two primary units at Altobello, the Chamberlain Unit and the Hubbard Unit, and we came over to this unit as an entity. Manhasset means “sheltered place.” My entire career has been on the Manhasset Unit and I have a very strong commitment to the unit. I feel an obligation to make it the best treatment unit it can be to help every kid we have. We really do use every aspect of the therapeutic community. It is unique in that, rather than an attending model where the nursing and childcare staff monitor and supervise the patients while they are waiting for their so- called treatment, the treatment is actually blended into the therapeutic milieu, and so I feel very strongly about that sense of community, with shared values, developing norms for the kids, as opposed to just rules, norms where we embrace them as a community. We use a lot of aspects of values. It’s

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not just “you can’t do this” or you get diminished credit, like a strict behavioral program. You do certain things because it is the right thing to do. Those are the aspects of the program we implement it on Manhassett, and I think those are the things you are more likely to generalize. Now one of the things that has changed on Manhasset is that we are part of the aBCd Program, which the hospital adapted some years back. My perception is that it was an intention to deemphasize some of the behavioral management structure system and to emphasize some of the psychoeducational components and learning experiences. Personally I believe that you need both: a strong behavioral program for any inpatient for joint collaborative living, and the level systems and things like that give the kids a sense of growth and movement and progress. I think the aBCd Program was viewed as being quite rigid in its structure and we certainly don’t implement it that way. We have always had an individualized treatment. The aBCd is one framework and we use it, philosophically, to get away from what could become a punitive to a more psycho- educational approach. Can you learn from this experience, with learning tasks, for example? We’re trying to emphasize more of the learning and relearning processes, the cognitive-behavioral approach—those kinds of tools that kids will generalize into the community. [Another] big change I’ve seen over the years: the stressors that have impacted upon juvenile justice and influenced our hospital. We do a considerable amount of court referrals and so we do have an awful lot of court- ordered kids. It became for a while a lot of the more behaviorally disordered kids as compared to the psychiatrically impaired kids. I know that’s an oversimplification but that affected how we operate a therapeutic milieu. If we have a certain number of kids who basically say, not as pleasantly as I’m going to say, “Thanks, but no thanks” to whatever you have to offer—a more passive-aggressive, defiant approach—it’s hard to operate a therapeutic milieu where the help is really in a mutual aid kind of model, where there is a unique opportunity for kids to learn from each other. I run

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a group twice a week in a community meeting and really have kids interact with each other. It’s a unique model where kids help each other to give and receive help. What’s different in the mutual aid model is that it’s an additional thing as compared to “this is the place where kids stay while the other help is scheduled in.” So we had a larger number of delinquent kids admitted that affected us, and when you have kids suffering from serious depression or kids with a psychiatric impairment, that became, in my view, a dichotomy. The kids with a conduct disorder or substance abuse look at the other kids and say, “I’m not like that kid. That kid’s crazy,” and they tend to intimidate the more psychiatrically impaired kids. There was a time when the more psychiatrically impaired kids would respond to psycho-pharmacology or respond quicker, so while we may agree that there are more impaired and sicker kids, they would respond to medicine and could progress. The kids with behavioral problems? There are no good medicines for kids who don’t like to do what they are told to do and don’t accept authority, so they would actually see themselves as being arrested and maybe appropriately so; and they didn’t respond as quickly. They need longer-term models. In addition to the court- ordered kids, Riverview Hospital is seen more and more as a distillation of kids in Connecticut, of kids with mental illnesses. By the time a patient arrives at Riverview, much has already been tried at the community level, including brief hospitalizations elsewhere. It’s not unusual to have a patient come in with multiple hospitalizations and be on several medications. We don’t have kids who are introduced to the mental health system here. In many ways we have the kids who are not responding to treatment. I remember a time when a kid would come in with positive psychotic symptoms. We had a kid at Altobello who seriously thought he was the medical director (and he wasn’t the medical director). I think they were hiring the medical director at the time, but he wasn’t an applicant or a candidate. In those days you gave the kid Mellaril and three or four days later you started to see that kid clear and

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those kids got better quickly and they responded well to medicine. Even here it doesn’t seem that long ago. If a kid was on three medicines you would have a meeting with the parents, doctor, and others. Now, [a kid] can’t get in the door unless [they’ve tried] three medicines. . . . There has been a change that way. So I do think we have, I don’t want to say “sicker,” but a more challenging patient who has not responded to many efforts prior to their admission. [We have] more complicated cases. We have a kid who not only has a mental illness but also medical complications such that they can’t tolerate the side effects of medicine. They need a really specialized care. So we have kids who really can’t succeed outside the hospital care. We try to get them up and running. I think many of the clinicians, especially newer clinicians, want to do more of the luxury work. They want to talk about trauma, and sexual abuse, and so on. One of the things we learn here is, first and foremost, we want to get those kids safe and stable, because if those kids aren’t safe and not in control, they can’t do anything else. If we don’t get them up and running, they can never live outside the hospital. It’s less glamorous work to have kids who work with the clinician behaviorally get up every day and go to school. The kids in our age group who don’t do that can’t really live outside a hospital setting or even in a residential setting. So there is a combination of work that you have to do almost simultaneously. So it’s quite painful! How do you do the nuts and bolts, the mechanics, of getting the kids up and running, following directions, taking care of the self- care things, and also working on their complex families and their sense of abandonment? I would guess like 75 percent of our kids have had that kind of experience—sexual abuse, physical abuse, chronic neglect. When you think about it, what needed to be in place to grow a healthy child was in large part absent from many of the childhoods of our kids. And as I work on a unit it kind of comes back to haunt me that when you start this separation and indi-

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viduation process in adolescence, the past is “Who am I? Who am I like? Who am I culturally? What is my sexual identity?” So these early traumas that disrupted the early development impact that. So I just get very excited in working with the kids. Most of the kids stay three to four months. A smaller group of kids stay two, three weeks to a month. Kids stay longer because they have no other option of where to go; they languish here. Others stay as long as a year. Many of the kids who come here have already been to much less restrictive places but have been unable to manage themselves. We are much more active today in using the community collaboratives when we are planning discharge. It used to be that kids would routinely go from Riverview to residential care, but most weren’t geared up to it so it was a big drop. Today, KidCare and other efforts to bring the community into the picture sooner use care coordinators, important respite programs, as well as good after-school programs.18 Chris Malinowski was assigned to the Social Work Department, but has the additional duty of prescribing psychiatric overview for her caseload, which means she can sign for mobility status, medication, and other medical laboratory reports. Although relatively new, she spoke enthusiastically of her experience at Riverview: Leslie Siegel is the head of the decision making. It really amazes me how she seems to pretty much know everything that goes on and pretty much makes all the decisions about who goes where and is aware of any problems. Everyone has a different role. Manhasset is unique. I come from a facility that had a tremendous turnover. There are staff here that have been here a long time and provide a stability that you need. When I think of Riverview as a facility for kids, it is a very supportive, comprehensive facility. One of the reasons I left where I was (a private hospital) was that managed care ran the facility, pretty much told you what you had to do with the kids, what the next step was, when they were to be discharged. That really impacted on what happened on the unit. I don’t feel that

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that happens here. Riverview is a setting where I can really feel that I can do the most positive intervention. I know we are the medical model, but the feel is more like a residential. I came here just as we were getting ready for accreditation as a medical model and we have gotten accredited as a hospital, so I wonder how that’s going to impact on things. I know that on Manhasset we probably have more frequent turnover because we have court- ordered evaluation, which is for thirty days, and that makes it feel more like a short-term hospital.19

Sachem Sachem is considered a specialty unit, a fourteen-bed unit for youth ages thirteen to seventeen who are sent to the hospital as volunteer patients. They are not court ordered. All are, in one way or another, involved in the juvenile justice system. The youth here are prescreened for admission, and they have to come in voluntarily and be willing to buy into the program. They also must have a predetermined discharge destination. Sometimes they are first court ordered into Riverview, and later they may choose to stay in Sachem. A lot of work is done with the families to get the youth back home in about three months. Sangeeta Peschuri is relatively new on Sachem, but not new to Riverview. After completing her medical training in Burma and India and her general psychiatric training in Baltimore, she joined the Yale Child Psychiatry Training Program and signed up with the joint program with Riverview, completing her training in 2001. Our interview touches on her connection with Riverview. “I liked working in places where I can get to know everybody,” she says. “It was very collegial. It felt so much saner and safer [than other places I had worked] and I think that’s where my love affair with Riverview started—as a fellow. I always thought I would want to work here.” However, Sangeeta decided that she had to push herself to experience the outside world. “I didn’t want to get so comfortable with the place and not experience whether professionally there might be something else I wanted to do, like work in the community with families.”

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Peschuri worked at a private facility for the next few years but was concerned about the constraints imposed by the managed- care system. She felt she could not give as much to the patients as she wanted. “I thought I could do much more meaningful work back at Riverview, and have been happy ever since over here.” On returning to Riverview Peschuri chose the Sachem Unit because of the nature of the program and the opportunity to work with families and community organizations, with the goal of returning the child home. Talking further about her experience at Riverview she adds: I feel like I’ve been here a lifetime. It’s only two years, but you look at the many changes that we have gone through in such a short time. When I came to Sachem, a psychologist was team leader, a Dr. Bricker. He was the only psychologist as team leader and he was doing a superlative job. Jean Hagen was also on the unit, a part-time psychiatrist, but she wasn’t team leader. That was the culture here at the time: that psychiatrists were the team leaders as compared to persons from other faculties. I enjoy the people I work with, which would make it hard to leave here. I think what binds us is the difficult children we have. Our kids come with such incredible histories, and it just binds us with a common thread, and we all try to do the best in the child’s case. It’s sometimes very hard work but again that’s part of the bonding process. We kind of rave and rant about the system together and try to do the best we can under the circumstances. I think what makes Riverview very unique compared to other hospitals is the staff know they get some of the worst cases and kind of go into this kind of work because they are almost the only family these kids have. It brings up many transference issues and at times staff [members argue] really passionately with me about the decisions I have to make to send kids off to certain places because they feel so close [to the kids]. They feel absolutely horrendous and “Maybe we could keep the kid a little longer so we can work with them so we can send them to independent living or a group home.” I think that’s what triggers us

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to work together and I think that is why certain people are here. But it really doesn’t prepare you for the real world.20 The foregoing descriptions of the residential units and the comments of the staff members who manage them clearly provide snapshots of the moment. But as the story of Riverview reveals, there is flux. Not only do some staff members move on and newcomers replace them, but philosophies change. Hospital status requires a different mixture of staff and ward hierarchy. Theoretically, children should not be sent to Riverview until all possible community resources have been exhausted. It is the community’s safety net. However, in the early days of the Children’s Unit, children were forced to be admitted because of a lack of services in the community. Fifty years later, that is still the case despite recent efforts to build community services. There will always be children and youth for whom extraordinary services, such as a hospital, will be needed, and Riverview, as the last resort, should be available only for those children for whom no appropriate service is available. Jane Klemba isn’t attached to any particular unit, but she is, and was, a vital part of the development of the nurses’ roles in residential units, including the cottage coordinator of Sunburst Cottage described earlier. She rapidly assumed other administrative positions after the merger. Jane wore many hats at Riverview, all at various levels of her beloved nursing profession. She is highly respected by her fellow coworkers as well as management, and I asked her to reminisce about her years at Riverview with a basic question: “You have been here for a long time. You have seen kids come and go. Some did better than others. Are we better off with all this? Are kids better off?” Jane replied: The kids are more difficult today. I remember we used to take kids to our homes to dinner. Today, staff cover their badges because they don’t want the kids to know where they live, afraid they will retaliate when they leave here. Families have broken down so much. Now that I’m in the intake office I see all the psychosocial interviews and family histories. Probably 25 percent of kids referred to Riverview don’t have a father named on their birth certificate. The families are struggling. dCf is

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involved. The kids are sicker, the families are sicker. We went through a period of never using restraints at the old Riverview. We are trying to get away from it now, but of course we had younger kids; and it was also the philosophy that we wouldn’t need these things. It’s very hard to go back once you cross that line and the kids see that they are there. That’s what we’re trying to do now. I think a lot of the things we did back then were good—like the old Sunburst Program. Even Winchester I at Yale [Yale New Haven Children’s Hospital] has asked to borrow our Sunburst Program. They used the names like Try Harder, the basic level, Beginning, Reaching Up, and Independent. They were motivating and not punitive, like the old Bleu ii program, where you had to earn your meal level. But you can be respectful and have kids learn to expect that limits can be set without making the kids feel you don’t respect them. Help that limits doesn’t mean “I don’t respect you,” but rather “I think you are capable of respect for others.” I worry about the safety of the hospital. People get hurt a lot.21 The school/education program at Riverview, like the rest of the hospital, went through many changes and has felt the impact of all the external influences of the merger: the changing hospital philosophies; the several administrative changes in the school; the enormous impact of the state and federal mandates, which often were developed without thought of those children in institutional care; the coordination of those mandates with the various hospital milieu treatment programs; individual educational plans and individual treatment plans. Despite these challenges, most of the children have found the school to be a safe haven from their troubled lives. It has always amazed visitors as they toured the school how quiet and orderly things seemed, particularly when they are reminded that these kids were considered to be some of the most troubled in the state. Additionally, there were now three schools instead of one, roughly speaking: a high school, a middle school, and an elementary school, all functioning under one administrative staff. The new buildings,

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originally planned for Altobello only, include a school and gym located within the nexus of the hospital and connected by wide corridors to the rest of the complex components—the residential units, the dining room, the clinical wing, and the administration section. The original RiverView School remained intact and continued to serve the middleage children residing in the cottages of the East Campus (old Riverview). The younger children residing in Pueblo, the new wing of the Silvermine Building, occupy their own school on the lower floor of that building, downstairs from their residential unit.

tHe pRinCipal’s offiCe Randy Adams served as school principal when the three programs merged, a position he still held in 2014. As the person with the longest tenure of any full-time principal, Randy clearly brings continuity to the educational system of Riverview. Randy started as a childcare worker at High Meadows in 1977. While there he continued his education and obtained his school psychology degree. In 1981 he was asked if he wanted to work in the school. Later he earned his administrator’s degree so he could fill in at planning and placement team meetings and provide other administrative tasks. In 1991 he became principal at High Meadows, and in 1992 Dolores Woodward (who at that time was superintendent of schools for dCf) asked Randy if he would consider the school principal position at Riverview after the merger. In preparation for the proposed merger he spent time first at Housatonic and then at Altobello and finally arrived at Riverview in 1993. When I asked Randy if I could meet with him he suggested that it might be a good idea for Sarah Newkirk, his vice principal, to join us for the interview. It seemed quite appropriate, for they are a real team and have remained in their respective positions longer than any other RiverView School administrators. At the beginning of his tenure, there was still uncertainty because originally there were to be two schools with two principals. George Zitnay, who was at the time principal of the RiverView School, was to be principal of the elementary school and Randy was to be principal of the secondary school. Before the merger, however, came the an-

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nouncement from central office that there was to be a unified school and facility to include Riverview, Altobello, and Housatonic Hospitals. According to Randy: That was a very uneasy time for people. The people from Altobello were thrilled that there would be a brand new facility after years of teaching in a building that was falling apart. The Housatonic people were outraged because their place was going to be closed down, which was miles and miles from here. Only two or three teachers actually came here. The Riverview people really didn’t care while all of this was going on because they had assumed all along that they would pretty much stay the same. And then a monkey wrench was put in the system, and I came along from High Meadows, a fourth facility. And [I was] a relatively new school principal. Then George Zitnay accepted a job with another department. So I was appointed principal of the unified school. When George Zitnay left, the department immediately began looking for an assistant principal to help with this huge undertaking, which involved many different personalities and many ways of doing things. Randy continued, “We found a fantastic person in Sarah Newkirk, who had a wealth of experience.”22 After receiving her special education degree at Southern Connecticut State College, one of the few colleges at that time that offered a special education degree, Sarah worked in a sport shop selling shoes. That’s where Chuck Houser, principal of High Meadows, “discovered” her. Chuck invited Sarah to visit the school at High Meadows. The visit proved to be very fruitful, and it wasn’t long before she began teaching. She was assigned a self- contained class with twelve young children, a position she held for nine years. By that time Randy had become the school principal and Sarah went back to school to work on her master’s degree in learning disabilities. She was then assigned to head the Learning Center. Sarah remembers: At that time we had expos [fairs] and the kids would put on performances. They would [prepare during] social studies classes and we would have a big fair and parents would come. [The chil-

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dren] would write reports and go into a little booth and dictate it and it would get typed up. That was the beginning of documentation of treatment and education being merged together and team meetings where the teacher would attend, like they do here at Riverview. It was really the beginning of a real merger between the two. Sarah once again returned to school, this time to get her administrative degree, and her job as assistant principal at the Housatonic Adolescent Hospital followed. “Now that was a very different experience,” Sarah says. “I was coming from a residential facility and this was an on- grounds psychiatric facility. They had a locked unit and an unlocked unit. So students were separated according to their needs. We started to see kids with drug abuse, [did] some counseling, and held a lot of meetings with the administration and the teachers.” From there Sarah went, as principal, to the Bridgeport Family Day School, where Ron Quinto was director at the time. According to Sarah, “That was a very different program in the sense that it was very much in the community and with a lot of contact with the parents. So each of the programs I worked in was a different experience, doing something different—testing, grant writing, working with parents, and so on.” The Bridgeport Family Day School, however, was in the process of closing, so Sarah went to central office and worked with the No Nexus Unit. From there she went to Riverview as assistant school principal. She recalls: With the merger taking place, and a new school administration on board, the task began of trying to bring together the three groups. [On the first day,] everyone was milling around. We had the task of deciding who was going to teach with whom, where, what building, what level, and they all had different feelings— some were excited that it was a new building, but a lot of them had their hearts tied to the type of students they had worked with and the type of program they worked with. Altobello people wanted some of their programs to be part of the new program. Housatonic wanted some of theirs to be part of it. And nothing was said before everybody was thrown into the pot with all the

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vegetables. Nobody at Riverview said, “OK, this is the program. We are going to take some from Riverview, some from Altobello, and some from Housatonic.” So it’s like everybody gets dressed up to come to your house for dinner and having no plate. Riverview people were at home. This was their place. So the Riverview teachers went to their rooms. They had their nooks. They knew the program. They knew when you said Bleu 2 or referred to a particular cottage or building—and nobody else had that so there was this battle. It had to be Riverview’s way or it had to be Housatonic’s way, and nothing from Altobello.23 For a while the teachers from Altobello and Housatonic were teaching out of boxes. And although the basic structure of the school was already there, teachers did have some input into the design of their classrooms and program changes. Randy Adams lamented that several good people had retired: “People like Bob Delvecchio and Tom Allan. There’s a wealth of experience of being able to work with kids that nobody else can. The amount of expertise that we’re losing! You just don’t find it every day, being able to work with very special kids.”24 Sarah Newkirk remarked that retirees would probably miss their jobs too. “Bob Delvecchio really said it all: “Where would a fifty-sixyear- old man go up to the gym and play basketball with a twelve-yearold Hispanic girl and both of us have a ball? That, I know, I’m going to miss. No other job would give me that.’ ”25

ComplianCe witH state and fedeRal eduCational guidelines A major aspect of the school principal’s role is keeping up with all the state and federal guidelines, most of which were designed for the public school system. This was one of the first tasks of the dCf superintendent of schools, Bob Suerken, and Dolores Woodward upon Bob’s retirement. Principal Randy Adams attributed a great deal of help to Donna Cambria, who was the assistant to Dolores Woodward. Donna worked very closely with the Department of Education when legal issues came up. One of her tasks—not an easy one—entailed adapting many forms and decisions made by the Department of Education

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to fit the hospital’s protocol. She was also instrumental in developing contracts for specialized educational services that were required for individuals, such as evaluations for foreign-language-speaking children and parents and neuropsychological evaluations. Being a teacher in a school that is part of a residential treatment center or hospital has its own challenges, beyond the struggle to comply with public school standards. In addition to trying to integrate and coordinate behavioral guidelines utilized in the cottage settings and dealing with children who may be heavily medicated, teachers and principals understand that their children deal with complicated personal issues unique to their situation. Obviously there are similar issues in any school, but when the child is living away from home, has serious emotional issues, has probably been significantly abused, either by a family member or by an inadequate community children’s mental health system, problems multiply. As Sarah Newkirk adds: A child may say that his father may come this month, and the father has promised to come. And then you hear “Daddy’s going to come, Daddy’s going to come, and he’s going to bring me X.” And Daddy doesn’t show. So where is the division line? Sure, he needs to learn the multiplication tables, but that day the student needs something different. So it becomes a fine line of how you educate and how you can work with the student so he remains in the school and doesn’t blow and have to go back to the unit. There are those days where things just go smoothly and everybody follows. And we have a behavior management system that is extremely extensive. But there are so many components to this job that, when you say “teacher,” I would like the book to show that it’s much more than a teacher that’s standing in that classroom.26 Bob Delvecchio expands on the challenges of teaching, mentoring, and nurturing: A kid comes in here at thirteen or fourteen and we’re expected to bring him up to grade level in one year. First of all he prob-

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ably won’t be here for a year and, secondly, he has not been up to grade level in ten years, and how do they expect us to do it in one year? I feel if we can just get him to enjoy school while he is here, we’ll keep him from losing. You can’t treat kids on the run. Kids come and go so fast. I could turn our class over in two weeks sometimes. I have to teach short, quick lessons. Everything I give is, almost, for the day.27 Jay Resnick, also a teacher with the adolescent children, suggests: It’s very difficult and unrealistic, especially when you don’t have many kids who stay a year. They can do some things but can’t do other things, and they find school a very big stressor in their lives. Some who have very difficult times in school do very good in the unit, and some kids who find living on the unit difficult enjoy school very much. But, again, these are kids who have had multiple problems with their peers and are embarrassed by their low reading skills, and these kids have all different reasons for why they haven’t been going to school.28 Randy Adams points out, however, that despite all the confusion, the kids learn: “We hold the pupil services to a very high standard in terms of our records, our forms,” he says. “We’ve been commended many times by the Department of Education, by our own supervisors and superintendent of schools for the quality of our records that we have in our files.”29 Randy attributes this to the dedication of the school staff, emphasizing the value of the team approach, which is implemented throughout the school system. The fact is that many children do learn at the school and there are many happy stories of children’s successes during their relatively short stay at Riverview. “I just got a report,” one anonymous teacher enthusiastically commented, “on a kid who was here four or five months who gained five years’ reading growth, so the teachers were elated with that because she went from a fifth grade to a tenth grade!” Karen Kovall, the teacher at the Pueblo school for younger children, talked about the No Child Left Behind federal standard. This standard,

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introduced during the George W. Bush administration, was an attempt to raise the educational standards of the country. It mandated that all children be tested periodically using standardized tests and that those schools that did not achieve a certain level for all students be penalized. The effort was indeed a noble one and, in fact, forced some schools to do better. It was not without great controversy, however, partly because of the lack of sufficient funding for the required testing process. But for children in residential or hospital settings, such as Riverview, it obviously presented serious problems. Additionally, in a school district that includes other dCf specialized residential settings, such as the State Juvenile Training School for Delinquent Children, failure to meet federal standards in one area affects the others. Since the Riverview census is smaller than that of other facilities, the school’s scores may go nowhere and basically all the scores are derived from the State Juvenile Training Center. According to Karen, “If they do well, fine. If they don’t do well, which is what happened last time— our kids did well but their kids didn’t—their scores got reported but ours didn’t. So we feel our kids didn’t get the credit they deserved. If Riverview fails in the Capt [Connecticut Aptitude Performance Test] there is no other psychiatric hospital with a school program like Riverview. There is no alternative school to send him to. Riverview is the alternative school.”30 Superintendent of schools for the dCf district, Ismael Carrera, at one point thought about refusing the federal funds, but he was told that whether he refused the funds or not Riverview still had to meet the standards. As Carrera tells it: Now we are stuck trying to figure out standards that don’t exist for our school district, how we fit in, or where we can send kids. They have taken away all the specialness for all of the special ed. kids, and so you got a kid who may be able to answer the questions but may need someone to read for him or write for him, or a kid who can only remain attentive for thirty minutes at a time and needs a break. That’s no longer possible. It’s against the rules. So special education is no longer education.

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You do whatever everybody else does or your teacher stinks. That’s not our kind of kid. If a teenager comes in here in a psychotic rage and that morning the Capt is being given, that teenager has to take the test, whether they are amenable or not. It seems ridiculous, but that’s how it is. And we’re being told to increase the academics, increase the academics to the exclusion of all the social skills that we are supposed to do here. Our kids in general don’t know how to fit into society. They don’t get along. All they do is fight. They have been abused. Where’s the time to teach getting along so that they hopefully can have some kind of a life? They want us to teach twelve months of academics when academics are the least of their worries. This kid is going home. Is he going to be beaten? Is he going to be sexually abused? That’s what he is worried about. He could care less if seven plus seven is fourteen and that’s the reality of this setting. Even the older kids fall into one of two categories: school is a safe haven for them and they go all the time; they may not be alert all the time, but they go because they feel safe, or they move around so often that they don’t have any stable schooling. So we punish the kids who do come all the time but are slightly behind because of an emotional crisis and need some support. We had a child who was five and had been in twelve foster homes and that means twelve different school settings. He had to be comfortable in one spot before he could think of starting to learn.31 Anyway, we always try to make it better. Look for better solutions. We are always fighting. We have a big range to cover. I think there is never going to be a perfect solution. We are always going to be in some stage of flux, trying to adapt the program with the kids. We have had Randy [as principal] for the past ten years. His support has been crucial. If it wasn’t for him being so involved with the students, meeting them after school, going the extra mile. . . . His whole philosophy spills over to all of us. He leads by example. We don’t have an absentee principal and that

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makes our school run that much better. He is a hands- on person—always engaging the children, which goes to the new philosophy of always being involved. Randy, every day, interacts with students, unlike many who are in management positions. He does this because he really, really believes in it, which is why we nominated him for manager of the year for the state and he won! Research has shown that teachers of emotionally disturbed adolescents only stay in the field for three to four years, after which they find other things to do. So for us to be around for seventeen years with the same population, that’s significant.32

CommunitY and paRent Relations The majority of children who come to Riverview are already designated as special education students and therefore require an individual education plan (iep). A large number of the students, particularly those in the older range, have a long history of school problems and probably have been in and out of several school settings, either in an alternative school program, a special education classroom, other residential settings, or many different public schools. Similarly, they may have had several different adult role models: their parent(s), their dCf worker(s), their foster parent(s). Thus, gathering data from these sources and developing an iep and integrating it into the individual treatment plan (itp) become an interesting ordeal. Nevertheless, such a plan is required. This is primarily the job of the pupil services staff. Planning requires setting a date and notifying all relevant individuals, who at the very least include the dCf case manager, if appropriate, the school of nexus, and the parents. The child is also invited to attend. The teacher’s role is to gather all information from the other teachers and compile a report for the meeting and, when possible, personally attend. Usually, because of the team teaching model, one teacher is able to attend. When the child is ready for discharge, a discharge meeting is held and again the relevant persons are invited. The teacher’s input/report is essential. While teachers from the receiving school are invited, they

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are frequently unable to attend and a three-way telephone discussion may happen instead. For the most part, the responses from the community schools have been very positive, and teachers seem to feel that the children have received a more than adequate educational experience given the difficulty that so many have had in their previous educational programs.

adapting to tHe mediCal model While the personnel structure of the school is relatively unaffected by the changing treatment philosophy, the medical model affects the educational system in a variety of ways. Those teachers who have been part of the merger generally feel that there is greater separation between the school and the rest of the hospital. As teacher Jay Resnick puts it, “There seems to be a separation from the school and the medical people who run the program.”33 While previously the teachers were more involved with the children in recreational or off- campus activities, particularly in the summer months, most of those kinds of activities are programmed through the Rehabilitation Department. As might be expected in a medical model, the variety and use of medication significantly increase. One effect of this is that some children come to school appearing very lethargic, and changes in medication may take a few days. Also, the increase in the use of medication often has the side effect of weight gain, compounding the cultural phenomena of obesity and diabetes. This in turn effects how already fragile children feel about themselves. tHe HigH sCHool The high school, or secondary school, is located in the new complex and serves adolescents from the four living units. Except in the case of special programs, such as physical education and art, the teachers are primarily assigned to work with the students from a particular unit and become members of the unit team. They attend team meetings and provide input into itps as well as participate in ieps. For the most part, the teachers at the high school were those who

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transferred from the adolescent programs of Altobello and Housatonic. One of the teachers from Housatonic who made the transfer was Jay Resnick. In 1979 Jay started at Housatonic, where he taught for fourteen years before coming to Riverview in 1993. For Jay and the other teachers who accepted the transfer from Housatonic, it was a relatively smooth transition, once they got over the trauma of being uprooted. This was primarily because, as previously noted, the Riverview principal, Randy Adams, spent a great deal of time at Housatonic assisting in the closing of the hospital. Additionally, many of the teachers knew each other from past joint meetings between the schools. Nevertheless, the change from a small unit to the larger facility was a huge cultural shock. As Jay points out, “Housatonic was much more like a homey feeling. The relationship with other staff I considered to be much closer.” He also describes the kids at Riverview as “more severely behaviorally disoriented or medically problematic—tougher.” He jokes, “Some people tell me it’s just because I’m older and it seems tougher.”34 Interestingly, Jay’s first assignment was not in a classroom. For the first fourteen months he worked one- on- one with a severely disturbed seventeen-year- old autistic girl, heavily medicated and a head banger, with an IQ of 45. His job was to help her with basic life skills. When this student was discharged, Randy started his regular classroom, teaching language arts as well as family and consumer sciences, a life skills course. He also designed and taught a course called “ssR,” or “Sustained Silent Reading.” Jay describes this course as follows: “We usually take a teenage novel and we either read orally or silently and we do a lot of discussion with it. We found out that when you assign a book, especially from here, most of it doesn’t get read. But if you read it out loud you can have some good communication with the patients here.”35 In describing what it is like to work at Riverview, Randy says, “We have all different levels and all different types of behaviors we see every day. We get kids who have not been in school for a long time. We have kids with drug problems, behavioral problems.”36 The class size can vary from day to day. Given that the school is in

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a hospital setting where children may arrive on any day, the class size ranges from three students to eight, the average being six. Jay works with kids on both the Manhasset Unit (where the kids might stay 191 days) and with the Sachem kids (where most of the kids are courtordered and may stay only three to four months). Like so many of the older staff who were involved in the merger and what they perceived as an uprooting, Jay needed to make comparisons of then and now. He describes Housatonic as an “old dirty building with tunnels that you used to see in movies.”37 For recreation there was a bowling alley where the staff had to set up the pins themselves, but they frequently took kids on trips in the community. Jay says, “Even taking kids home or babysitting for your kids—it was very different than it is today. We had a very close relationship with the kids back there. It was more like a family. I spent more time with parents who came to visit their kids.”38 While the procedures for responding to kids who are having difficulty in school vary somewhat, there is still a behavior management specialist who meets with the child. According to Jay: Here we try to get the kids to stay in class if possible. We give them every possible chance to stay in the room, where at the other facility they would be forced to leave the room. . . . If you have to leave the classroom, you take a mandatory time- out in the time- out room and you have to work with the behavior specialist on the behavior that brought you there, and the child should be returned to the classroom within five minutes. If the child is still acting out in the time- out room, he/she usually would have to go back to the living unit. But they should be back for the next class. There are a lot of things that go on with the kids that I’m not privy to. Being in the school I get reports every morning—from the Childcare or Nursing Department, Psychology Department or Social Work Department—about what happened to the kids the night before. I get just the basics of what happened. Sometimes it’s very limited. Sometimes I come in and I don’t know a lot about the kids until the next day.

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I have a team teacher and I go [to team meetings] on Mondays and she goes on Wednesdays and we go as often as the schedule dictates. Sometimes if the team has already completed their task we’ll give them written reports. So there is communication that way. The most communication is when the kids have their ieps and we go over their education to determine if they are eligible to receive special services, or if they already are eligible, we set up another meeting. The majority are [special education students] for past problems that they had in school.39 Another pair of teachers, Anthony (Tony) Ventrelli and Nachi Bhatt, both started at Altobello and remained team teachers for adolescents when they came to Riverview. Tony landed at Altobello in 1987 as a student teacher from Central Connecticut State University. Almost immediately after beginning his student teaching, a social studies teaching position opened up and he has been teaching social studies ever since. Nachi also started at Altobello in 1987. He had previously worked at Grove School in Durham. “I always wanted to work with youth with significant behavioral problems,” he says, “so when a position at Altobello opened up I saw this as an opportunity to work with this population—and have been working here ever since.”40 The two talked with me about the school’s changes over the years. Tony told me: Altobello at that time [1987]: The two living units were on the first floor, the school on the third, and the kitchen/dining room on the fifth. The second and fourth floors were condemned; so all the kids came to school through the elevator. We taught out of boxes for a while. The date [for the move to new facilities] kept changing and it was very stressful, for both the patients and the staff. We weren’t sure what we were coming to. We heard it was beautiful, and we were all excited about the move, but it was a very stressful time. We had some input into the design—talked about the time- out room, where certain things should go, but the basic structure was already here. We were able to make some changes but the school district had needs, as did the hospital. My classroom, for example, is pretty

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small. It was designed for five kids, but we now have eight kids in the class. At Altobello, we had one long hallway with classes off the corridor. Here we have this box formation. We have had several different superintendents and five different principals, each with their own vision of how to operate. We have gone through a variety of educational models, depending on who believed in what. The latest incarnation is trying to be in line with school reform models that are trying to come about, like accelerated schools, whereby teachers, staff members get to know students in small teams so there is time invested in kids. Each model has its own permutations and what it meant to us.41 Nachi added: The school day was shorter, that is, the academic time. At the time, our school district had less time for instruction. We had more time for clinical intervention whereby Tony and I were involved in community meetings on the units with kids as well as running groups along with clinicians and nurses and unit staff. We ran various groups, like Impulse Control or Aggression Replacement. . . . We were also involved in the everyday functioning in the sense that we were present when the kids would be going over issues during the community meetings. That was part of the school day per se.42 Tony continued: We had short- and long-term school. Kids who were just admitted were put into the short-term program for evaluation to see what their strengths were, what their weaknesses were, as well as finding out information from their home schools as to what they had to work on. After anywhere from two weeks to two months they were transferred to the long-term programs. We had six long-term groups and two short-term groups. We had math, social studies, career education, science, language arts, art, music, gym, and industrial arts. Some of that was off

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grounds. The principal at the time was Matt Delomo, who was replaced by Ken Valentine. Marge Stahl was superintendent. The hospital had changes. It went from a residential model to a hospital model. The school, too, had changes, changes in the federal law and state law, the unified school district, which increased the number of hours of instruction to come in line with the public school and also the Federal Children with Disabilities Act. The impact for us was more time for formal education, assessments, understanding our role with respect to the public system and how to help kids get back into the mainstream school by providing them with adequate hours of instruction as well as with more major subject areas. There was also a big shift in terms of the whole behavior management system. When kids violated certain cardinal rules, there would be certain consequences—things like shutdowns or community work. Students could actually acquire community work to the point where they would have forty or fifty hours that they had to complete before they could come to school. This changed because of the program changing. . . . As the school district came into alignment with what was going on nationally, some of those things changed. For example, if a child assaulted someone the night before, they might be shut down for twenty-four hours. Now we’ve seen a big shift away from that in terms of getting the student to the school quicker. I go back and forth as to whether I see it as more effective or not. Now there is a dichotomy between hospital and school (there has been a shift from individual disabilities) protecting them. Now the national guidelines are: yes, the individual with disabilities needs protection, but this school is responsible for the protection of all children within its walls. So now what that means to us is that if a child assaults someone in the school, school rules apply. A person could be suspended for three, five, ten days. Right now, we go with a two- day suspension when someone gets assaulted in school, because if a person is that unsafe in school he has to go through a process to commit to

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safety before he can come back in school so no one else will be harmed. No other student should be jeopardized because of one student’s problem. However, there had been a step in between. . . . There was a time where the patient would be removed from programming for twenty-four hours for an assault. That was a hospital policy. The school really didn’t get involved in that. . . . Our policy has gone back so that if an assault happens today in the school building, we have the option of keeping kids out of school for longer periods of time. On the other hand, if the assault happens at home, in the living unit, then that would go to civil issues—that being the hospital; and the hospital could ascertain when the kid is eligible to reopen programming. The school might know about it, but unless the assault happened within our walls it would not be in our jurisdiction. On a lighter note, going back to Altobello, it seems we were a lot more involved with rehab and doing a lot more fun things with the kids, as in summertime: playing kickball with the kids, softball, swimming, rocket-launching stuff—so many activities where we were involved with the rec staff. Today we’re totally cut off from that, which is kind of unfortunate because you get to see a different side of the child when they’re not in the classroom being forced into something that is very difficult for them in many cases when they’re learning- disabled or emotionally disturbed. It was fun doing this in the community, going to the beach, singing in the van and talking to them about things other than academics. It really pays dividends back in the classroom because now you’ve got a little more leverage to stand on with this kid. You can say, “Hey, you know what a great time I had with you at the beach. I hope your discharge goes well.” That sort of thing is sorely missed here. I would much rather do more recreational things with the kids during summers. But that’s changed too. Our whole summer philosophy has changed since we’ve come over here. Summer really mirrors the school year now.43

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tHe old RiveRview sCHool The original school continues to serve the younger children, who reside in the cottages of the original hospital, or “East Campus” as it is presently called. At the time of the merger, these kids still had their regular classrooms and many of the staff remained committed to staying with the younger ones—the changing identity, the changing treatment philosophy, the change in age range from fourteen up to eighteen, and the new regulations and restrictions had an impact on the personality of the facility, not unlike a small rural town that suddenly grows to a large city. I caught up again with the original team of Ed Shukis and Bob Delvecchio. Generally, as far as academic changes were concerned, they didn’t feel much had changed. There have always been shifts in curricula, different teaching methods, evolving behavioral strategies. However, they described what they perceived as increasing restrictions on what can or can’t be done. For example, in the past, they frequently took kids to Pin Oaks. Since new buildings now divided the Pin Oaks area from the school, it was no longer practical to walk there. Also, with the hospital model, clearance to leave the building has to be obtained for each child and is dependent on “mobility status.”44 Shukis and Delvecchio also felt the increasing restrictions in terms of their relationships with the children. Once discharged, staff members are not allowed to continue any relationships, including answering cards or letters sent to them from discharged children. “Sometimes you make a real connection with kids,” they pointed out. Bob shares: I sum up my days and all that has gone on and put it all on Elmo the dog. Elmo was allowed to go freely and so were the kids. All the kids used to play with him. It was nothing formal. He showed up one day and became a pet to sixty kids. He would sleep in one of the cottages, and sometimes come to school with one of the kids. Today you can’t even have goldfish or gerbils in the classroom. In fact, you can’t have any animals on grounds—except something formal. They call it pet therapy.

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[Elmo] was the kids’ dog. They didn’t have to worry about him being taken away. There were no questions about whether he could stay.45 Indeed, Elmo entered the grounds one day seemingly out of nowhere. He was a scraggly mutt—frail and hungry for food and affection. Under the dirt and mud, his tan and white coat was soft, and soon his tail wagged regularly. With love, loads of attention, and plenty of food, he eventually regained his health and became an active friend of the kids as well as the staff. It was a little fairytale-like, in retrospect. After taking turns sleeping in various cottages, he’d walk the kids to school and wait outside the door. One day a child exclaimed, “We did a good job with Elmo! He’s ready for discharge!” But Elmo stayed. Eventually, of course, he died, but not before living a long and happy life with the Riverview kids. Elmo was exceptional in that he tolerated just about everything, but the issue of liability became a hot topic in the hospital setting, and we could not adopt another dog. Bob continues: I think the kids in the hospital today don’t experience society outside the hospital as much as we did. The hospital is more sterile, a hospital experience rather than a community experience. I know they go out for recreation, but we used to go out on a lot of field trips and now it’s actually more difficult to go on a field trip. There’s more paperwork, more medication. The safety factor has compounded it. I think years ago we ran a program, which was a little more social. I can’t remember when I’ve taken a field trip with the children. It’s gotten really difficult for us. I still enjoy my job very much. I like working with the kids but do feel the restrictions with the hospital/medical model. Sometimes you feel like a referee—trying to get these kids, six or seven in the class—to interact with each other without actually going at each other, either verbally or physically. If you get some teaching in there you feel good. A lot of it is just dealing with the behavior. A lot of these kids—maybe it’s the meds—they’re good and bad. I’ve had kids come in and sleep for two hours, their heads on the tables, drool all over the desk.

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We’d make notes and report it, but it could take weeks for the meds to wear off or [for the child to] react to new meds. It’s really hard for these kids to come into an environment that is new where they don’t know anyone—coming in with all the baggage they have. It’s difficult, not only for the teacher, but the kids too. Through all of that you still have some successes each day. Some days you go home frustrated but then some days you feel pretty good. Looking at kids over the twenty-five years I’ve been teaching, I don’t know whether the behaviors are that much different but they are more intense. When I first started, we had about 50 to 60 kids and 90 employees; now we have 80 kids and 450 employees. You have a committee for everything. We have more committees then we’ve ever had. I’m not criticizing Riverview; I understand every place is like that. I think everyone should have something to do directly with the kids, spend part of their day with the children, like [Chris], who is helping the kids build a boat. For the record, it was back in 1978 that Margaret Stewart and I tried to develop an auxiliary. Then we started it up again it 1998. Today the auxiliary is a very active program, running various fund-raising programs.46

tHe pueBlo sCHool In 1994, after many years of delays, architectural changes, and internal modifications, the renovation of the Silvermine Building, which originally housed the Behavioral Learning Environment Unit, was finally completed. It included the addition of the Pueblo Unit to house the youngest children—ages five through ten. It also included the renovation of the ground floor to provide a suite of rooms for schooling these children. The fact that an entire residential unit and separate school are needed for children five to ten years of age (and occasionally younger) is a story in itself, considering the fact that Riverview is classified as the “most restrictive” facility. Two experienced teachers, Karen Kovall and Linda Adams, along with a student teacher and some volunteers, were assigned to this

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school program. I met with these two amazing teachers on 10 December 2004, following the annual holiday luncheon held in the Riverview School gym/auditorium. This has always been a festive occasion in which staff, children, and their parents are invited for a fantastic buffet and entertainment. I continued to play Santa Claus for several years after my retirement. This, of course, was when doing so wasn’t considered to be culturally or politically incorrect. The Riverview Food Service Department, which Al Bricker and later Ronald Arboscello and crews led, provided the elegant and plentiful buffet luncheons. The Food Service Department has always been of the highest quality and often commented upon by visitors. Karen began her career at Altobello in 1979 and was transferred to Riverview as part of the merger in 1994. Linda started at High Meadows as a student teacher in 1987, and she arrived at Riverview in 1994. The Pueblo School started when management decided to remove the classroom from the West Campus to make it easier for the students to return to their unit. Originally, all ten to twelve children were in one large room, and they were pulled out for specials such as reading instruction. At first there was a lot of flexibility but gradually the kids changed. “We used to have mostly conduct- disordered kids,” Karen told me, but now they are more schizophrenic, psychotic. There are a lot of really abused kids—a lot of fighting—so we separated into two groups.”47 There is now a suite of three rooms. Karen has the older kids—upper elementary—and Linda has the kindergarten through third graders. The third room is referred to as an occupational therapy room and contains a desk for small motor activities. Speaking as a sort of tag team, Karen and Linda describe how the Pueblo School differs somewhat from the other Riverview schools: Our classes are different here because we do a lot of juggling with the behavior system (aBCd) to fit our younger kids. For example, if a child has to be removed from the class and return to the unit, he can come back when he is feeling better, whereas the older kids may be out for the rest of the day. We have found that when the child goes out, say the first thing in the morning, by 9:30 he may be ready to come back and we would rather him

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come back and do a good job than stay out the whole morning. That’s one thing we can do very different from the other schools. A childcare worker can be seen sitting in the hallway, ready to jump in or help deal with a child who is having difficulty. The fact that the worker is also the same person working on the Pueblo Unit [means that] she is more tuned into the child’s experiences [outside of school] so she knows that if a child is having trouble first thing in the morning, he may have had a telephone call from his mother or whatever and [the teacher is] better able to deal with the situation. The teachers feel, too, that the flexibility with the program helps academically as well, because the younger children are not working for credits for graduation. Because they have a bigger room than the other classes in the other schools and because of their uniqueness, they have more flexibility. In fact, training guides often include the phrase “except for Pueblo.” While they do try to work within the general framework for Riverview schools, Pueblo teachers and administrators frequently create their own programs; they generally have to readjust for the younger age level. For discipline, in extreme cases, such as breaking a window, teachers are permitted, with the principal’s approval, to suspend a child for up to three days. The child would be expected to do some kind of community work, either on the unit or at school, and he may have to turn in his “caught being good” things that he had earned. For the most part, if the child is acting out in school the childcare staff can take him out for a while, or if necessary return him to the unit for a brief time. If the misbehavior is while at an activity in one of the other buildings, he may be restricted from there for a period of time.48 Most of the children on this unit are dCf kids whose parents are relatively uninvolved, so there is not a lot of interaction with families. Despite the horrendous life situations many of these young children have been through, these teachers hold high expectations for their stu-

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dents. As Linda relates: “Sometimes I think people just don’t have high enough expectations. They think that maybe [the child] can do it and maybe he can’t. They may not give the child a chance. We may be told, ‘Well, you may expect too much,’ but you come down here and you see all the kids sitting quietly, doing their own work. That’s the expectation. Not every day. But if you don’t expect that they’re never going to do it.” Karen adds, “It’s not necessarily being strict, it is: ‘You can do this; I know you can do it. Let’s try.’ It’s really hard to make people stick with a kid and not baby the kids. We’re not rigid. We’re just structured. Our personal goal is the kids have to be productive members of society. We tell them, ‘If you are going to go to public school and you start hitting kids, that’s not going to work.’ ”49

[ CHapteR 14 ]

a BRoadeR view of CHange ... In the years between 1994 and 2005, Riverview underwent massive change. The merging of three hospitals, settling into new buildings, fully adopting the medical model, and frequent changes of administration posed challenges for staff and administrators. However, these changes did not happen in a vacuum. Numerous cultural changes arose that required Riverview to adjust. While Riverview was wrestling with the enormous process of adapting to a new identity, changes were happening in the community that not only affected Riverview, but also would completely modify the face of the children’s mental health system. One of these was the recognition of the need for improving community-based children’s mental health programs. In part these changes were spurred by a national awakening. In the late 1970s and early 1980s, two reports exposed the status of children’s mental health in the country. One was written by the President’s Commission on Mental Health’s Select Panel for the Promotion of Child Health (1978) and the other by the Children’s Defense Fund (1982). The findings, famously presented by Jane Knitzer and Lynn Olson book, Unclaimed Children: The Failure of Public Responsibility to Children and Adolescents in Need of Mental Health Services, reveal the children’s system to be a national disaster. Children with serious emotional issues in most cases received no services or were “treated” in the most restrictive settings, such as hospitals.1 In response, the national children’s mental health scene began to change. The National Institute of Mental Health (nimH) launched the Child and Adolescent Service System Program (Cassp) in 1984. In 1986 Beth A. Stroul and Robert Friedman published A System of Care for Severely Emotionally Disturbed Children and Youth and put forward the principles and values essential for a service system that would allow 186

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children with emotional disturbance to remain in their homes. This program offers a brand-new approach to serving children. It is based on two criteria: that it be community based and family driven.2 Connecticut adopted the approach and promoted the following values: Case management should be provided to ensure that services are coordinated and delivered in a therapeutic manner. There should be early identification and intervention for children with emotional problems. The system should protect the rights of children and should promote effective advocacy for them. Children should receive services without regard to race, religion, national origin, gender, or physical disability. Services should be sensitive and responsive to cultural differences and special needs. Family advocacy and family involvement are critical. In 1991 Connecticut, through the Department of Children and Families, received a grant from nimH to develop a pilot project for such a system. Later, Commissioner Ragaglia attempted to make the Cassp model the centerpiece of the KidCare project. The Cassp name was eventually eliminated and the initiative became known as the System of Care. dCf Region III, which at that time included Middlesex and New London Counties, was chosen to implement the grant, and although retired since 1989, I was selected to direct it. Connecticut was the fortythird state to apply for such a grant, so we had many states to learn from, most notably Alaska and Vermont. The basic idea was to develop community-based systems of care. One of the frustrating aspects of my years as superintendent of Riverview was the fact that we often had to admit kids who had nowhere else to go because of their severe acting- out behavior. They did not necessarily have psychiatric conditions, nor were they in need of a hospital. For the same reason, once they were admitted it was very dif-

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ficult to find a sufficiently structured program that would accept their return to the community.3 So I jumped at the opportunity to do something about building a system of care in the community. When a team led by Laureen Sheehan, who was to be the supervisor of the program, interviewed me, we agreed that my task would be to set up two “local systems of care,” one for New London County and one for Middlesex County. We called two meetings, one for each county, in which all community providers of mental health services were invited. After a presentation of the Cassp (Child and Adolescent Service System Program) concept, people were invited to sign up to begin meeting to discuss the possibility of developing a system of care for our counties. Approximately twenty agency representatives signed up for each group, and we began meeting, at first every two weeks and then monthly, getting to know each other and the various services provided by each. It is remarkable how little each agency knew about the others. Comments would be made such as “I have a kid who needs that. Could I call you tomorrow?” It was instant networking—and this among agencies that hadn’t communicated with each other except in oftennegative terms. We agreed that the priority need in each county was a twenty-fourhour mobile emergency program. Our Middlesex System of Care group, now called the Middlesex Community Collaborative, decided to produce something instead of just talking. After we did some interesting brainstorming and idealistic planning, our discussion with dCf resulted in a request for proposal (Rfp) developed specifically for Middlesex County. Since the group had already decided that the Middlesex Hospital Family Advocacy Program was in the best position to operate such a program and would be the fiduciary, only one proposal was submitted for the entire county with the support of each agency involved. Although the Rfp offered only $68,000 (our ideal plan would have cost several hundred thousand), the hospital won the award and the Psychiatric Emergency Response System for Children and Youth (peRsY) was formed, the first of its kind in Connecticut. A need was identified, notice was given of the need, an Rfp was initiated, and the group decided on the appropriate agency to apply.

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In this way, Middlesex obtained the first case manager, now called care coordinator, and the first respite program, operated out of the Greater Middlesex YmCa. By 2005, the program was serving 197 children throughout the state. That number has increased over the years, and the program has become a model for the state. The group’s second initiative was to appoint a nurse intern whose task was to write a grant for a case manager. Again, dCf came through with funding to support such a position. Once we identified the case manager, a local family advocacy agency assigned a family advocate to serve as the first responder to requests for assistance. This advocate initiated a service review team (sRt) model of the care coordinator, Willard McRae, retired chief social worker for Middlesex Hospital Mental Health Clinic; myself, serving as clinical psychologist; and a representative of the referring agency and the family. The child or youth attended whenever appropriate. Our goal was for every family to leave that meeting with a plan of action. There was no charge to families for the service, and services were provided by community agencies. More than 250 families have made use of this service over the years. This community-initiated program was not consistent with the dCf-approved model; however, dCf recognized the benefits to be gained from allowing a community to structure its own service delivery system, and the program thrived. After the two-year grant came through, the dCf hired full-time system- of- care coordinators for each region. Since I was a state retiree, I was not eligible for one of the positions. Jorge Martinez, a social worker, became the coordinator for the Middletown/New London areas. By this time the Middlesex group had coalesced, with exciting results, while the New London County group had been floundering. I offered to stay with the Middlesex group while Jorge focused on the New London County group. By 2004, there were twenty-seven community collaboratives serving more than seven hundred children each year. Twenty-five collaboratives still exist. In order to fund the wraparound services that were required for the community collaboratives to address the needs of children, dCf initiated a “flexible funding” model that provided access to flexible, non-

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categorical funding. This funding allowed for the acquisition of services that might be unique to an individual child or family. There was a downside to the community collaborative initiative, however. At first, each of the collaboratives was allowed to function in ways that were best for their respective geographic area and the population served. With its expansion of the program, the administration felt it necessary to centralize many of the activities and require that the separate collaboratives function in a more uniform manner. The advantage of local flexibility having been lost, what occurred is what a statistician would call “regression to the mean.” Certainly the projects that were not doing well improved significantly; however, the programs that were doing well were hampered in their ability to grow and expand. Also, as the KidCare initiative became more widely publicized, the state legislature took a more active role, allocating more funds but requiring more oversight. To this end, dCf created the Children’s Behavioral Health Advisory Committee (CBHaC).

CHildRen ’ s BeHavioRal HealtH advisoRY Committee Around 1993, Joseph Woolston and Jean Adnopoz, co- chairs of a dCf state advisory children’s mental health subcommittee, decided to open up their committee to community members. As a recent community representative and founder of the Middlesex Cassp program, I was invited to join, along with several local providers and parents. The meetings were very informal, participants openly discussing issues brought to the table by the chairs. The informality was purposeful. There was no specific agenda, voting, or rules of operation, and attendance was open. We discussed issues until there was agreement, or simply continued at the next meeting if necessary. It wasn’t long before the majority of attendees consisted of parents. It was a very lively, spontaneous group. Representatives brought key issues and recommendations to the State Advisory Committee. Soon the legislature formalized our group as the Children’s Behavioral Health Advisory Committee. Forming a committee required establishing bylaws, rules of order, membership, terms of service, and the like. The new committee was

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very slow in gaining momentum. The first half hour of every meeting was devoted to reviewing minutes and other formal activities, often without a vote of a quorum because appointed officials failed to attend. Ultimately the group began to function, committees were formed, and a united voice brought recommendations to the dCf advisory committees. We defined priorities, giving stakeholders more decision-making authority for developing their local systems.

administRative seRviCe oRganization With the increased attention to children’s mental health issues, the state agencies responsible for providing services met regularly to ensure that duplication did not occur and that funds were spent in the most efficient means possible. These agencies included the Department of Social Services (dss), the Department of Mental Health and Addiction Services (dmHas), the Department of Mental Retardation, now the Department of Developmental Services, and the Department of Children and Families. Funding for children’s mental health came from a variety of state departments’ pockets: the dss, which processed all state- operated insurance (Husky), and dCf were most prominent. Of concern was the need to reduce the duplication of services and ensure that the best services were provided based on the needs of the children and families. All resources were funneled into a single private agency that would be responsible for monitoring all children’s mental health services that received funding from the state, including residential programs. This agency was to maintain a comprehensive data set, complete regular reports, and manage the approvals for care. Eventually, the state selected a company called Value Options to function as the administrative services organization.4 managed CaRe During this same period, managed care burst on the national scene, and significant attention was paid to ensuring that children received the services they needed—but only for the period of time that care was “required.” Certainly the managed- care philosophy had an impact on all aspects of medical care, but its impact on children’s psy-

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chiatric hospitalization in Connecticut was major. Specifically, managed care affected hospital admission criteria and lengths of stay. Was the change detrimental? That is a matter of perspective. On the one hand, the initiative fueled the development of community-based, less restrictive therapeutic settings and prevented hospital overstays. On the other hand, it sometimes forced the discharge of children who were not clinically ready to leave. Once the reasons for admission to a hospital were addressed, managed- care organizations required that children be discharged to a lower level of care. This was an absolutely appropriate requirement; however, sometimes there were extenuating circumstances. Children who were difficult to treat, those who did not respond to traditional treatments, those for whom lower levels of care were not available, and/or those whose families might not be ready for them to return sometimes had no place to go. Private hospitals could keep children longer, but there was no payment for these “overstays.” Frequently private hospitals lobbied for the admission of the child to the state psychiatric hospital, Riverview. Since Riverview was funded by the state it was less dependent on other third-party insurance payments. This created a public relations nightmare for Riverview, since costs went up, a greater percentage of the children admitted required intensive care, and many more had no appropriate discharge options. Finally, the KidCare program began to develop less restrictive alternatives for children who were to be discharged and to provide treatment options to avoid hospitalization in the first place. The community collaboratives were an important part of this plan, developing treatment alternatives that did not require children to enter the system at all. In addition, KidCare developed group homes and increased bed capacity in residential treatment facilities. As usual, Riverview Hospital weathered these growing pains. The pressure for hospital beds was managed, the Administrative Service Organization (aso) helped to ensure that appropriate levels of care were provided; length of stay came under control. In order to assist with the development of community-based treatment options, Bert Plant moved to central office to assume responsibility for this initiative. Once again a new superintendent was sought.

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It deserves mentioning that in the first twenty years of Riverview’s existence, there had been one superintendent. There was consistency of leadership and vision. In the next ten years, the facility had four superintendents. One can’t help wondering if these frequent transitions affected the mission of the facility.

[ CH a p t e R 15 ]

addRessing tHe mood in tHe milieu ... In 2004 a change in administration again occurred. Darlene Dunbar, a dCf area director and active member of the Middlesex Community Collaborative, was selected to be commissioner. Lou Ando was reassigned from the Bureau of Behavioral Health to serve as bureau chief of the Bureau of Continuous Quality Improvement, and Peter Mendelson became bureau chief of Behavioral Health Department. When Bert Plant was reassigned to central office as director of community programs, Melodie Peet took over as superintendent of Riverview. Melodie stepped onto the grounds of Riverview Hospital in the early 1970s as the first intern from the Yale University School of Public Health Administration. I interviewed Melodie for this book thirty-four years later, soon after her 2004 superintendent appointment to Riverview. Our exchange was more conversational than formal. We agreed there was still much tension, and people were still talking about the merger and its effect on them personally. Melodie knew that her top priority had to be morale. It seemed as if a mood virus had crept through the milieu, first through the frustrations of the staff, then the acting out of kids through awol attempts, followed by an attempted takeover by the kids and the union using the opportunity to petition for its concerns. Then the Office of the Child Advocate voiced its issues in the newspaper, and finally legislators suggested closing Riverview because they considered it too costly. This last matter culminated in Substitute Bill 198, An Act Concerning Riverview Hospital, which required dCf to develop a plan for alternatives for children at Riverview. Melodie began: It’s a complicated organization, and I remind myself every day that I don’t know enough about Riverview and its culture to make major decisions about a lot of it. I still see myself as 194

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being very much in a learning mode, and I think it will continue to be like that for a long time. It’s easy to see the first layer of an organization, but it’s only over time that you can see all the nuances; the complexity of the culture becomes more and more apparent. I think as I began I was going to have an open door policy with staff and I really didn’t know what to expect, but people have been coming with good numbers and a lot of people who have been here a long time have been very generous in really explaining to me what the hospital is all about. One of the things they talk about a lot is the merger of the three organizations, and it feels like there is still grieving going on in the hospital for the old culture of the three organizations. It’s one of the issues that I have spent a lot of time thinking about. How can we help people come to a better resolution about that and engage them more fully with the new hospital? I don’t quite know what to make of it. Which people keep holding on so strongly to their old identities with Altobello, Riverview, and Housatonic? But it’s clearly an issue in the culture—still at this point. Somehow it speaks to the new hospital never capturing the imagination and hearts of the old one, and I think that’s a challenge for me. How can we get people to connect in the way that they did with the three earlier facilities? But still a lot of people felt really, really close to the old values. In talking with Margaret Stewart [assistant superintendent at the time], she mentioned your thoughts about getting more community involvement. I think that is a must. You’ve got to get people out of here. . . . I think we have to get back to that. Now that there are better structures in the regional office it should make things easier to connect—whether it’s to the collaboratives or managed [care] services. There are many ways to do that, but the important thing is that the clinical staff is out doing something meaningful. We’re also trying to get more people in. We just hired a parttime chaplain that we are going to share with CJts [Connecticut Juvenile Training School] and she’s terrific. She’s aligned with various local churches and has volunteers who come and

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do worship services and get a choir going; and one of our staff is trying to get the Girl Scouts to come in. I know you had this many years ago but somehow this seemed to drop off. I think in some ways things are trying to get back to the way Riverview used to be and, you know, it takes a little negotiating given the fact that we are JaCHo accredited. So the structure of the hospital doesn’t lend itself quite as well as it used to. But I think you can figure out how to not make those things an impediment. It’s hard sometimes to stay focused because there are so many things thrown at you, whether it’s from the department or other regulatory agencies. Everyone has some idea of what you are supposed to be. Sometimes I think the kids get lost in all of that. I think my job is helping staff constantly focus on the kids, and connecting to the community. I think the morale is starting to turn around. It’s been very low for a long time, and I think people here were feeling sort of detached from the department, not appreciated by the department. That’s another thing that I think is my role, to make the distance less and simultaneously serve as sort of a buffer between some of the bureaucratic stuff. I’m feeling like we haven’t made any major changes and I don’t envision any earth shattering events. I want to protect the quality of the treatment. We have a lot of gifted clinicians here. I want them to be in closer connection with the community, more family involvement. I have talked about being able to take more control of our discharge process. Over the years its been sort of usurped by the Cpt [central placement team] up in Hartford. I see that as a certain loss of control. My perspective has always been that the best insurance you have of protecting the good work done in the hospital is to ensure a good discharge plan. . . . It’s foolish, I think, having the centralized system in Hartford where they determine what happens to kids when they leave here. I was talking to the deputy commissioner the other day to see if there was some way that we could refer directly to the collabo-

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ratives or to the managed [care] services people or whoever is going to do the placement planning. It would be a much more straightforward and direct communication. We could send the primary clinician to work on the treatment plan and the transition. I think they like the idea but they’ve got so much bureaucratic apparatus now that I think they can’t quite figure out what to do about it. There’s another fact now that’s confounding things. Under the exit plan, I think appropriately, they have come up with the goal of reducing the utilization of residential beds, out- of-state particularly, by 11 percent. So that’s where all the focus is now. It’s harder than ever to get their attention on our kids; and all the community resources are being devoted to those kids. It’s hard, because all kids are needy and you can’t place a value on any one group, but it’s frustrating sometimes. You try to get a kid out of here who has been here for a year or so and it’s not good for him or her to continue to be here, but trying to get any takers is a slow process. I’m trying to figure out some pace, like attending to things like that without getting in the way of good care.1 Peet went on record early saying she opposed psychiatric hospitalization for young children and attempted to raise the age of admission to ten. However, Riverview had been created by the legislature to serve children and youth from the ages of six to seventeen. A number of administrative decisions led to a rocky start, and several union grievances were brought to the attention of dCf’s bureau chief, Peter Mendelson. In an effort to get the hospital back on track, he formed a consultative committee through a contract with the University of Connecticut. Psychiatry, psychology, and social work consultants reviewed policies, talked with staff, and met with Peet and Mendelson on a regular basis. Approximately six months into this process, Commissioner Dunbar asked Lou Ando to conduct a program review of the hospital. Arnold Trasente, the psychologist who directed the Program Review and

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Evaluation Unit at dCf, led the review. Because of potential conflict of interest, Lou Ando directed the review but was not an active participant. After an exhaustive process, Trasente presented a comprehensive evaluation document that praised the dedication of the Riverview staff but identified areas needing improvement. The committee presented recommendations for improvement in more than thirty areas. Riverview was required to develop a response to the evaluation and address the identified deficiencies.

CultuRal ConCeRns When in 2008 Melodie Peet decided to step down as superintendent of Riverview, the question, of course, was who could replace her, at least until a permanent superintendent could be recruited. When Melodie was asked who she thought should come to Riverview, she replied, “Joyce Welch, nobody else.” At that time, Joyce was superintendent of the Children’s Place, formerly known as the State Receiving Home at Warehouse Point, a dCf facility that began as an orphanage and then operated as a safe place for children awaiting placement at mental health facilities, and more recently functioned as a treatmentoriented program. Joyce already enjoyed a highly respected career with the dCf, starting in high school when she joined a youth group organized by Gene Marchand, a dCf employee. One of their activities was to do volunteer work at the orphanage, which became the State Receiving Home. They would play games and do various activities with the children. “I found that I really liked working with children,” she said. After high school she went to the University of Connecticut on a work-study program. Upon graduation she got a job as a rehabilitation worker at the receiving home. Her plan was to work there for a year, but she decided to stay. Eventually, she found that she particularly liked working with adolescent girls. Cy Davis, who was superintendent at the time, brought in some people from South Carolina to teach his staff how to work with girls who were difficult to treat. Joyce remembered Sister Eunice, who reinforced Joyce’s interest and validated her skills in working with adolescents. “I remember a particular a bunch of girls that nobody else seemed to like, but I found that I liked working with

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them,” she told me.2 During the next several years, Joyce moved from childcare worker, to supervisor, to director of residential care. One day, Joyce was approached by Peter Mendelson and told that the commissioner wanted her to be the new superintendent of Riverview. Joyce was very hesitant, what with all the rumors about closing Riverview and the growing negative press coverage, and besides, she was happy where she was and wanted to stay at the Connecticut Children’s Place (tCp). So she declined. Joyce described what happened next: Then one Sunday morning I get a call from Melodie saying I was going to get a call from the commissioner. “She’s going to come and see you. I’ll be honest with you; she asked me who I thought should come to Riverview. I told her nobody but you.” I told her, “No. I have no interest in doing that. I’m pretty confidant of the work we are doing at the Children’s Place. It has a lot to do with my relationship with the staff.” I was pretty adamant about it. I was going to say no. Monday came along and nothing happened, so I relaxed. Tuesday, Commissioner Dunbar walks in my office and says, “Joyce, I have a big favor to ask of you.” And I said, “I know what it is but my answer is no.” She then replied, “But I’m the commissioner; you can’t tell me no, but you’re a nice person and I wouldn’t say that to you.” Basically she told me, “We just need you as an interim.” “Ok, what would that entail?” I asked. She replied that I would be the interim superintendent and could keep my job as superintendent of tCp. “You would go to Riverview Thursday with Melodie for a transition period and report to the administration there and keep the facility on track. We will get someone in asap.” I said, “OK, but I need to talk to Melodie first and I want to notify my staff first before they hear it from anyone else, so please call me before you tell anyone.” She said, “OK.”

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So I called Melodie, told her I notified my administration and would like to meet with her Wednesday morning. So then when I was approaching her Wednesday morning, Melodie had already left. There must have been some mix-up. Leslie Siegel had already gone to central office, so I agreed to stay, for security at least. Then there were all kinds of meetings. And finally, I said, “OK, I’ll stay to help get over this hump and facilitate a transition, but no commitment.” I’ve said all along that I wasn’t going to stay but I would help facilitate things. I spent a lot of time just going around talking to people. So many felt disenfranchised, marginalized. Like the psychiatrists would meet and ask me to come but they didn’t want anyone to know that they were meeting with me. It was the same with the psychologists, social workers, and others. We would meet in the back library. It seemed they just wanted to talk with somebody and express their anger. I had to keep in mind, and told them so, that I wasn’t staying here and they needed to talk it out with Joan Narad, who was acting medical director. It was interesting that a lot of people wanted to talk about the merger and about what it was like before the merger. I felt confidant that once they stopped talking about the merger, then we could talk about . . . what their concerns were and what we could learn from the past, and we could develop a retroactive plan and present it to the central office. Recruitment for a new superintendent had begun, but there were only four applicants. I figured that with all the negative publicity and the Advocate talking about closing Riverview, no one wanted to give up their career. I think it was a tribute to Dr. Williams and Dr. Azeem to be willing to come when they did. Around February, Darlene Dunbar was asked to meet with the Select Committee for Children, and of course they were going to ask about Riverview, so Dunbar asked her to sit at the big table, the area in the hearing room at the Legislative Office Building where individuals sit to present testimony. Joyce agreed to come but not sit at the big table. She recalls:

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While I was there, Darlene came back to me and said they were “going to ask about Riverview, and I want to be able to say that I am appointing you as interim superintendent at least until the fall.” “OK, but I am going to need help at the Children’s Place,” I said. This led to a series of acting superintendents, so I got on the phone and called tCp and told them I had agreed to stay at Riverview until September, and I anticipated returning to tCp and they would be appointing an interim superintendent at tCp. While I was at Riverview, however, I had learned a lot. I was impressed with how highly skilled the staff were. . . . I found it very validating—very beneficial for me. The staff were all buying in to the various changes, so I decided to stay.3 Once Joyce decided to stay at Riverview, help from central office came with the assignment of Fernando Munez, assistant to the commissioner, and Janet Williams to assist in the transition. Joyce continued telling me her story: “We talked about the Child Advocate’s Office. Could they assign someone specifically to Riverview? That was done, and Marcie was assigned and agreed that if she saw anything to be concerned about, tell her first so she could do something about it rather than read about it in the paper. This worked out well.”4 Meanwhile, High Meadows closed. Debra Anderson went to CCp as acting superintendent but chose to return to Riverview as both quality assurance director and assistant superintendent. Central office assigned Janet Williams and Fernando Munez to assist in the transition. These two proved invaluable, not only in providing emotional support but aiding in developing a strategic plan to be presented to the central office and to the legislative committee overseeing the transition. Eventually, tCp merged with Riverview. While basically a fresh start was needed to turn around the poor morale, negative press, and many concerns noted by the review committee, four other challenges confronted the new regime. (1) To reduce the use of mechanical restraints (2) To reduce the waiting time in emergency rooms, detention cen-

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ters, and other holding areas for children needing to be admitted to Riverview (3) To broaden the training capacity and education of all staff, including other departments of dCf (4) To expand and improve clinical skills of all staff, bringing them all up to “best practice” standards Joyce described how she felt things were developing: “We were managing pretty well actually. The staff was all buying into the various changes. The executive team [consisted] of Mark Root, Debra Anderson, Dr. Azeem, Michelle Sarofin and all the managers. . . . I was fortunate to be the superintendent but it was that group of people that did all the work so that we could move forward.”5 The four challenges gave specific focus to the enormous task of the newly structured team. Regarding challenge (1), the use of restraints of any kind has always troubled administrators and staff of psychiatric facilities. The task of elimination was a major issue that would require everyone’s concerted effort. When I entered Azeem’s office, I was struck by a large graph on his wall charting the use of mechanical restraints (as described later). Soon after my visit, he updated the graph to zero, reflecting the success of the project. A huge celebration by staff and kids ensued. Dismantling the large wooden beds used in the mechanical restraint procedure memorialized the event, and the staff and kids used the materials to build the “healing bench” with a plaque honoring Joyce Welch for spearheading this amazing accomplishment. In 2011 Azeem and colleagues published this project’s story the Journal of Child and Adolescent Psychiatric Nursing. It’s called “Effectiveness of Six Core Strategies Based on Trauma Informed Care in Reducing Seclusions and Restraints at a Child and Adolescent Psychiatric Hospital.” The article concludes: In summary the study has shown that over a long period of time, restraint and seclusion reduction can be possibly maintained and safely implemented in an inpatient setting through collaborative and concerted effort of staff by utilizing the six core strategies based on trauma informed care advocated by the

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Tracking Restraint Use. Dr. Azeem’s chart of diminishing restraints, 2005–2010. Copied from original; courtesy M. Waqar Azeem, 2010.

nasmHpd. It is also encouraging to note that despite the multiple efforts, the positive results of the techniques were achieved relatively quickly and sustained over a period of time. We continue to emphasize the clinical need for the eventual elimination of restraints and seclusion as best practice in the field of child and adolescent mental health.6 The second challenge was to reduce the waiting time for children to be admitted to Riverview. Lengthy waiting times are a major problem for the whole children’s mental health system and are a clear indication of the need for a more comprehensive continuum of care. Imagine a child in crisis who must wait in an emergency room or detention center for as many as thirty days because the facility is full and

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no other suitable treatment service is available. This situation was not unusual. The stress is widespread: it affects the referring agency, which may be spending hours trying to find more help for the child; the intake worker forced to turn away a very troubled child; the clinician at the hospital pressured to discharge a child who may not be ready; and most of all, the child helplessly caught in the middle. Obviously being able to reduce the length of time in the hospital would be like opening a valve in a dam, making the service available to another child. According to Azeem, the new administration was able to reduce the wait time. The third challenge was to broaden the teaching/education role of Riverview. As Azeem points out, Riverview has been a training area for child psychiatry and psychology for thirty-five years (since beginning the program with the Yale Child Study Center). “We wanted to further that training and become a national model, particularly for serving the under-served children not only for dCf but statewide.”7 Additionally, staff was encouraged to publish in professional journals and to present papers internally, locally, nationally, and internationally. (See bibliography for a list of selected publications and presentations.) The fourth challenge was to ensure that clinical services were functioning at the highest level, utilizing the most up-to- date outcomerelated data. Michelle Sarofin coordinated this effort. With regard to the bad press, it seemed the Child Advocate Office fed the press stories long after the problem had been resolved, and this was very disconcerting. Joyce met with the Child Advocate Office and requested that someone be assigned specifically to the Riverview office. Marcie Neff took the assignment. “This worked out extremely well,” according to Joyce Welch.8 After accomplishing her goal of not only healing the malaise of the previous few years, Joyce and her powerful team brought Riverview to an even higher level of maturity. She decided in 2011 it was time to retire. “When I thought of leaving Riverview, I didn’t want to be the superintendent who left everyone in the dust.”9

[ CHapteR 16 ]

tHe next geneRation ... In 2010 the Department of Children and Families experienced yet another change of administration. Once again, newspaper articles deemed Riverview too costly and urged that it be closed. This set off a number of meetings and discussions, and some controversy. An ensuing review of Riverview Hospital for Children resulted in a significant reorganization with administrative changes. Finally, a legislative proposal mandated that the dCf develop a plan to find alternative solutions to the treatment of children and youth presently hospitalized at Riverview. Following this plan, a public announcement celebrated the creation of a new entity named after a longtime leader in Connecticut’s effort to build a children’s mental health system: the Albert J. Solnit Children’s Center.

tHe alBeRt J. solnit CHildRen’s CenteR The name is significant in several ways. Not only is the new organization named after one of the state’s most notable and powerful advocates for children, but it answers the question “Is it a hospital or a residential treatment center?” The new entity is both. It broadens the mission of Riverview by consolidating all the department’s mental health services. A new superintendent, Michelle Sarofin, led the way. Riverview and Connecticut Children’s Place united, both administratively and programmatically. In its new incarnation, the consolidated facility is part of a revised approach to the treatment of children with mental health needs. It provides hospital care for those who need it and residential care for those who don’t. Six inpatient psychiatric hospital units at the South Campus (formerly Riverview) and six specialized treatment units, two at the South Campus and four at the North Campus (formerly the Connecticut Children’s Place), are in operation. In its role as a training center, the facility serves as a teaching hospital for residents in child psychiatry from Yale and the Univer205

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sity of Connecticut—psychologists, social workers, teachers, special education teachers, and rehabilitation interns. This new organization serves as the perfect ending to this history and offers a solid start to the development of a truly coordinated system of care from early childhood to hospitalization. Eric H. Erikson, in Childhood and Society and in his numerous other publications, describes his conceptualization of the eight stages of life and points out that maturity evolves from crisis to crisis, each followed by a higher level of maturity. This has been the story of Riverview.

a dReam oR a nigHtmaRe? The new plans seem to be the fulfillment of the dream of a truly comprehensive, coordinated, community-based children’s mental health system, building on the many initiatives described earlier. However, a question remains as to whether the momentum of the reorganization can be maintained. Is this a dream or a potential nightmare? Today, something exists that was not part of the plan in 1962: the growing grassroots emphasis on the development of more adequate community services supports the dream. The legislature has been reluctant to provide the necessary support and encouragement to the development of community initiatives; nevertheless, the communities have evolved, and with largely volunteer support from parents, community and local children’s services providers have become powerful assets in improving the local systems of care. There are now twentyfive community collaboratives in the state. With the possible exception of Yale University, Riverview employs the state’s largest concentration of experts in children’s mental health. As the communities improve their capacities to serve more and more children in their own communities and as more and more expertise is needed to support these programs and services, the Solnit Center is poised to take the lead in the development of a statewide, coordinated system of care. The nightmare in the story of Riverview is the fear that history will repeat itself and that the mission of the new Solnit Center will not be adequately funded or supported because of political agendas that lower the priority of innovative children’s programs. Those with River-

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view experience fear that funding for a comprehensive statewide continuum of mental health care will go to adult services because it will be forgotten that children grow into adults. If children’s needs are not met, there will only be a greater need for adult services. To paraphrase an old saying, it is better (and less costly) to raise a healthy child than it is to treat a disturbed adult.

appendixes The staff handbooks and manuals excerpted in this book are available in full in the ebook Riverview Hospital Staff Manuals.

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appendix 1 Excerpts from The Behavioral Learning Environment Unit: BLEU—A Handbook and Training Manual Prepared for the Staff at Connecticut Valley Hospital Children’s Unit

fiN OVERVIEW M

THE BEHAVIORAL

EEARNXNG

ENVIRONMENT UNIT (BLEU)

Here a t t h e Childruunis Unit during t h e paat year it has becane c l e a r e r and clearer t h a t t h e f i a d i t i o n a l methods of t r e a t i n g acteut, hostile-aggreesive belw is designed t o youngsters ham not been working. The pograin -sent& halp vary d i s t u ~ b e daating out, h o s t i l e , aggressive youngsters l e a m new, more s o c i a l l y - a h p t i v e mod- of functioning. With t h i s god i n mind, we have attempted t o s e t up t h e ecology of the ward such t h a t it w i l l not m l y incoqmrate t h e hst t r a d i t i o n a l methods a s well a s lemming priaciples, but a l s o m i f i o r a s al world. closely as passible and feasible, t h e n Society a t w e is set up such t h a t certain behaviors such a s jobs, work and learning are valued and reinfomed. Society is a l s o s e t up such t h a t other b e h a v i m have negative consequences. i3LEJO is an at-tempt t o spell. out c l e a r l y and consistently both positive and negative consequences to our ohildre!nvs behador. In a l l cases our focus w i l l be on new leapning f o r t h e chUd. We will attempt t o tsach youngstczzrs t h a t they and they alone 81% responeible for t h e i r actions and t h e consequences of those actions. BLEU is s e t up with an aye t o w d teaching children how t o manage t h e i r Lives.

W e must keep c l e m l y 5.n mind t h a t it is only through making choices and u t i l f z i n g t h e feeclback from these choices t h a t people learn. In this l i g h t B E U is s e t up so t h a t the choices a r e f r e e and t h e faedback c l e w .

In an attempt t o m&or t h e environment i n t o which these chlXclren w i l l eventually go, B W has adopted a number of economic contingencies. Children w i l l receive payment far acccroplishing c e r t a i n tasks. ks i n society these payments can be used t o purchase those th%ngs that t h e chiX&en need and want. SimiLarly, t h e r i c h children w i l l be able t o buy mwe and b e t t e r things than w i l l t h e non-rich. Unlike society a t w e , however, each ch.ild w i l l have t h e opportunity to becowe r i c h solely by h i s own behaviop. S t i l l another aspect of 8LZN which d i m c t l y mimami society is our welfare$ ajrstrsl. BEEU is coneehed ia such a way t h a t each c h i l d w i l l mceive t h e bash naoeasitLea simp3.y f o r being alive. Thuss, i n its positive aspects BLEU is a f a i r l y goad a i m of society.

Another aspsct of B W t s e c c m d c system i s its Pines. Just l i k e i n t h e r e a l world whws people are fined and put i n j a i l f a r beaking lm, s o t o o with BLEU, Children w i l l be f i n d and even t e m p o r a ~ i l yrmorred firsnr the soclo-eb'&ncmic qs.tem i-E they transgress the laws of t h e BLEII. Unai?ce t h e r e a l w b ~ l dw h n e people aan accvmul~tcdebts, BLEU because of its learning focus, will not al3.m t h i s t o h-"ppen. Yet, a l l other aspects of society wiL1 bo zu75leoted by our f i n e ay s t m . BIEills econaaic system w i l l a l s o m i z t w r present day society i n a numbor af o t h e ~ e w i l l use "Bf;EU Dollam" as otpr medium of exchange. We w i l l also aspects. W util.ize many of tha concepts of banking. Tach child w i l l have a bank account where i n conjuncticn with h i s acaMsFic advisor he o r @he w i l l make decisions about purchases. B U N will. a l s o u t i l i z e t h e banking concept of frozen and li uid curpency. A s in the real m ~ l dl i q u i d currenay w i l l be used by the chi?dren t o make h e d i n t s e v w y day &asw whila f?o%en a n ~ e n c yw i l l buy long-term :tans. Yt is i n t i i i s banKing concept t h a t .we w i l l be teaching not only w t h but aloo how t o manage 113 a r e a l econmic environment.

212

Appendixes

Aa indioated by the tana learning i n its title, BLEU w i l l always ba geared toward new learning. We w i l l pay particular, attention t o the n a d i t i o n a l child m l e of being a student. I t dl1 be in thia a ~ whoMI a the gmatest Isatmhg can take place. Because t h i s rob is ao c h w l y valued i n society, it w i l l a l s o be valued highly in BLEU. Yet, with the popuhtian for which BtFO is designed, we w i l l shuctwe our aaadmic progrraa so that it reflects 1 whfch i a dizlactly tylatad t o the child's ongoing ewrydag fife in B W . l'hua, beeides incorpwathg rath, ve w i l l build our auadentic program t o eventually focua upon invostnwnte, pawwritages, and other fintmdel cpncepts. Beyond this, BLFU will also attempt t o s t r u c t m e the emironnsnt $0 pmmote mw appropriate social lemming. Self-help skills as w e l l as vocational skills w i l l also become part of o w pogmim. r'or example, childFBn w i l l take care of t h e i r own bank accounts, inmsmentcs, etc. Thus, whereever possible, the academic ~COI;ZFBIPw i l l attempt t o teach children haw bettm to Liva within B U U by m f l e c t i n g the angoLng dally ward euvixwtmitmt. Naturally, the noa-academic aspects of BLEU w i n reinfwce t l c l a s ~ learning, ~ n

213

Excerpts from the BLEU Manual

FINE PROCEDURES

IDEA: To t h e immediate incident and decrease its probability of moccumance. To c l e a r l y c d c a t e t o t h e child that ha o r she has stap

been Piaed, t h e exact reason fw t h e f i n e , t h e amount of: t h e f i n e a d t h a t the behavior should stop. To do t h i s i n a business-like, non-challenging, non-punitive, nos-sarcastic, but fimn m a w . PROCJZDURE: Staff w i l l c i t e infraction, amount fined, and ask child t o stop

any fined a c t i v i t y . For example q7DavZd,you h i t Joey. Stop h i t t i n g him! You a m fined 20 dollars." If t h e child stops, t h e s t a f f w i l l issue a f i n e s l i p , take t h e d o l l a r s from t h e child and give the child instructions t o take p a w i n t h e (an) ongoing a o t i v i t y If: the f i n e reduces a child t o ground zero, then wound raw procedures w i l l be followed.

.

Zf t h e f i n e pracedwe does not stop t h e behavior, a second f i n e can be given. If t h a t does not %tap t h e behavia?, the Beyond Fine proceaure should be followed.

RULES: 1. Always f i n e liquid a s s e t s first, then savings. 2. Wo child can ever be placed i n a debt situation.

be fined t o zero liquid and savings assets.

A chi.?,d can only

3. As soon aa a child has no 33quid assets, he is considert?d to be a t ground zero. (See below. )

DAILY ENTWCE INTO THE SYSTEU: Any child who is not up (sea definition fop g e t t i n g up) by 7:30 w i l l not take part ill the token economy thal morning. Ha door w i l l be locked a t 7?% and the child w i l l be ignoPed u n t i l 3.2:80. A t 12:00 a t r a y with Basic Lunch Meal # 1 w i l l be placed i n the child's poem and the door relocked. Tne child i s approached again at 7:00 a.m. the next morning. TE the c h i l d refuses t o g e t up and enter t h e system a second day, the same praoedme is followed. If the child refuses t o enter the system, a thiad day, t h e pmcedum i s followed agein* E v e q time a child refuges t o enter t h e system three times, a case s p e c i f i c decision will be made by the s t a f f . As noted above, a c h i l d who refuses t o entm t h e system by not getting up w i l l receive lunch, dinner and a bed during the time he is orl't of t h e system. fie will not receive breakfast simply because he s l e p t thmugh breakfast! Child w i l l be allowed access t o bathroom during meals, but t h i s should be t h e bathroom off h i s room. There should be a m%nimum of contact and bathroom should be locked a f t e r meal.

214

&UlOWD ZERO: Definition

Appendixes

-

Any child who has entered t h e ayntao, but b e t o fines, poem behvtm, oto. ha8 m liquid assets, w i l l be oonsidewl t o bo a t ground zero. If the pmgmm is a t a point w h m no liquid assets can be eaiaed, the child will be asked if he or ehe wants t o erm. If the child seger yes, he is pmsented with the list of: make-up acrtidtiea and asked t o ohoose an activity. Upon oompletion of the task, the child is given birr dollar6 and aan buy eny a c t i v i t y fm which he has enough d o l h s . A ahild w i l l continue i n a make-up s c t i v i t y u n t i l e i t h e r he has canpleted the acrtivity and has liquid assets a, until the mmi pxlag~aarallows an oyportunity t o earn dollars. A t the -letion of a uuke-up activity, the child can cash i n fa* one of the make-up m w d s ur save the dollars fbr anather aativim. f f a ohild has no liquid assets d the gmup scheaule does not allou for? earaing and the child mhraes t o do a make-up activity, he rn she i e placed i n his m haF mom and the daor is locked. The child ia approached every 1/2 hour and asked: "Ars you ready t o mm?" J 3 the child says yes, he then e i h w cbooeee t o do a make-up aatiEvity ox-he joins the schedule, assuming t h a t them a m earning opporrunftiea. If them a m no -tog activities, a child oam only choaaa a make-up m t i v i t y . If the child chooses not t o earn, h i s dlwr is rcalocked and he is approached again L/2 h a later.

C a n e meal times, or bad t h e , any & i J d nho i s a t i l l at grnmd edro w i l l be pmvidad M i c Meals and a mattreaa. The only difference betmen ground and spot e n t e ~ i n gt h e econmy is t h a t at. p m n d zem the child w i l l ba approached every 112 hour and asked if he is rcaady t o *join the econany. Bwic h u s and Hattress with betting w i l l be provided.

Excerpts from the BLEU Manual

OUT

OF CONTROL

215

- mom FINES

IDEA: help t h e child regain control and reenter the aystem as soon aa is possible; t o minimize damage t o the child and people the child is i n %

eontact with; t o minim.Ize interaction, which may be reinfo~cing,with the child u n t i l child is back under contwl.

PROCEWRa: If a child has beon fined twice and is still continuing h i s or he^ nagattve behavior, the child w i l l be told "You a m out of control. Ym are going t o the Quiet Room." WT?1IOUT SPEAKING t o the child, the staff member or staff members a s c m t t h e ch3ld t o t h e Quiet Room (QR) with whatever ftromess i s necessazy. The child is t o rermrin in the QR for a 15 minute base psriod and then t - m e consecutive minutes of quiet.

When t h e child is quiet for the three minutes, he w i l l be removed f z m the QR. T f there is an earning activity, the child w i l l be asked t o join the activity. If there le a spending a c t i v i t y i n p r c g ~ e s s ,the child can i f he has enough do3laPs t o buy i n t o OF baak i n t o an activitys he m y do so, but loses dll psasLbXs savings available for succassful conrpletion of that activity. I f the child does not have enough liquid assets t o bup i n t o the activity, he goes t o h i s room. If a child is placed a t w u n d zero due t o the fine, he can do make-up activities. Opon leaving the QR, the child w i l l be iniimned of the fines he has accrued.

RULES:

1. A child w i l l anly be placed in the QR fw being out o f control, a. A child is consider?& art of conhrol only after he or she has been fined twice over the same issue and has not stopped

the bad behavior,

Children can only be placed i n the QR f o h ~ i t t i n g and proper*trg deatmcthn. b. Snwn-ing w i l l only be fined.

c. Iron-compliance w i l l not, in theory, be a problem. A l l non= compliant children w i l X e l t h a r lose savings OF liquid assets In all cases, the child has the due t o t h e i r non-canpliaace. choice and the s t a f f should not push a child i f he chose@not t o conply. There are built-in consequences t o the noncmplianae and no need f o r us to make an issue in mast cases.

216

Appendixes

. 13 . W E E m I , PROGRAM

'r Spendable

Ccot

Alternative

............................................ 2. Washad .......................................1 3 . Teeth Brwhed ................................. 4 . Hair C d m d ................................... 5. Dressed ..................................... 1 Bonua for all complete....................... Bonus for non-prompted ....................... .. Quiet To enter Dining Room ......................................1 i n Line t o D.R. ........................1

7:OO-7:30 RISIFfG RiOUTniE

1 1

1 1

*6 7

1:30-8:00 BREAKFAST ROOTINE 38. nonus Basic Menu 1:

.............. ...................................... ............. . .......................... B:00-8x30 IlbOn CLENP-UP 10. Make Bed .................................... 11. Sweep Floor ............................ 12. Straighten Raan ............................. Bonus for CampLete ......................... fm N a - p m t c d ..................... Bonus for Quality Job ...................... ):SO-B:45 13. Ward Job .................................... Banus for Conplete ......................... Bonus Mon-p ..................... One Container W i l k . Gne Box Terrible Cold Coreel in Assigned m a t

Menu 2: One Container Milk. One Serving Main Dish F u l l Menu 3: Aa Much as Kitchen W i l l Allow 9 Goad Table Manners ROUTINE

Ram

-S

.....

1:45-11:OO

fm

rompted

............................................ll... ............................... .......................................... ... .................................... 1 ... .................................5l... ..........................................

Cash-In Bank Period #1

a. Downstairs b Outaide.. c Game or Cruds d Visitor i n Rocm e Radio i n Ram......... f Juice Pep Oz

.. . .

...............9...

5 6...

217

Excerpts from the BLEU Manual

Weekend (Co11.t'd)

U:OO

- 11:3015. Earmi Pariod 81 d .in. Each ohild w i l l

................

doing r a k = 2 . . have a work assignment which w i l l provide for 20 coramcl. anmars at 2 CR I1 doS.lar.............

11:30

Cost

SpendaM.t?.

Alternative Alternative

1

Y

1..

- 12:OO416.LUNCH ROUTINE Get o f f ward t o D.R. ................... 17. Quiet i n Line t o D.R. .................. *18. Menus Basic Menu 1: Veg., Milk, Salad i n Assigned Seat Menu 2: Soup, Uain Plate, Salad, M i l k , One Semhg Each Full Menu 3: As Much as Kitchen w i l l Allow.........

.... ..................... 19. Gmd. Mmars... .........................

Alternative 20.

l2:30

- 2r30321.

Earning Pericd #2 Each 1 5 min. doing #olrks2.............. Each chiJd w i l l have a work arrsigment which w i l l provide for 20 c a r m e t responses with 2 CR 2 1 dollax-.......,

Cash-In Bank P e n i d #2 a. PS de

Lit.............................. ....................... ..................... Juice Per ......................

b. irs.......................... c. Game or Cards d. Visitm i n Room e. Radla in Ram....................... f. candy lBar......... g.

Alternative 22.

Oe.

.............1I... 4

Eam~.%% Pwiod 83 ~ a c h15 .in. do ng worb2 Each child can by doing assigned work up t o 20 correct r a q & s e s ~CRQ~........................

......

-

Alternative

?23. Cash-Ta Bank Pmiod I3 a. Outside............................. b. Downstai.re c. Cerds m Gane......................, d. Visitor in R ~ o o m . . . . . . . . . . . . . . . . . . . . . e. Rcldio i n Roan....................... f . Juice Per .........................

..........................

I

218

Appendixes

Weekend (Cmt'd)

- $145 2u. Eeming Pwiod *

4:s

.......... . ..............

Each 15 min. dockg wmk = 2 1% to 20 CR at 2 CR 1

4:SS

- 5:15

...................... .................

*25. DINNER RWTIN!d 26. 90 get to dinner to D.R. *27. Quiet in *28. Henus Besic Menu # l : Heat, Milk, OM Serving, in Assigned Saat Menu #2: Milk, One Sexwing Main Plate......... N 1 Menu: A l l Kitchen Will Allm

.......................

Good Mannsrs

S:15

5:45

.............. .........................

- 5:45 29. Esning Pwicd 65 - 8:OO *30.

.......... ...........

g k - Alternative work = 2 Each child 20 CR @2 CK 1

............. .....................

Cash-In Bar& Pwiod #4 a. Main Evening Activity b. Dounstai~~......................... c. Card or Game in Room.............., d. Radio in Rwm e. T.V. i n Day R o a n . . . . . . . . . . . . . . . . . . . f. Visftor i n Roan.................... g. Juice..............................

- 8:30 SHOWShower ER ROUTIHE ................................ 32. Dressed in P.J.'s ..................... 33. Teeth Brushed ......................... 34. Non-pmmpted... ......................... 8:30 - 9:30 *35. Cash-In Bank Period #S 8:00

31.

1o:oo

- Oa

--

a. S W R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . b. Clothes for ta~vl.pow Pull Choice c. Clethea for tanmrow Single Chofc d. Up 'tfl 10:OO p.m. T.V. i n DayIhp.

......... ....

36. fn Bed Told....................... 37. Quiet for 15 min. after i n bed Up, d i s r u p t i v e . . . . . . . . . . . . . . . . . . . , .

appendix 2 Excerpts from ABCD Program—Staff Manual

Section 4

I. Overview

A. B. C. D. E.

Goal Rationale for Change Younger Patient Population What is a Therapeutic Milieu? Definitions 1. Autonomy 2. Belonging 3. Competence 4. Doing For Others F. Guiding Principles G. Staff Code of Conduct H. Model of Interaction and Intervention 1. Assessment 2. Plan 3. Implementation 4. Evaluation

11. Program Revisions

A. Unit Structure 1. Schedule a. Schedule Guidelines b. Break Down of the Day

219

Plan Alternative Education Plan Alternative Education Plan

ABCD Program - Staff Manual

220

Appendixes

2. 3. 4. 5. 6. 7.

c. Patient Schedule 1" & 2ndShifts 24 Patient-Staff Teams 26 Patient-Staff Teams Alternate 28 Pueblo Assignment 28 Pro-social Teaching 29 Child-Directed Play 30 Family Involvement 31

6. The Bonus System a. Statement of Intent b. Reinforced Behaviors c. Some Bonus Behaviors d. How Bonus System Works e. Bonus System Alternate

Alternative

B. Therapeutic Management 32 1. Behavioral Assessment & Treatment Planning 33 35 2. Reinforcers and the Reward System 35 3. Daily Goals 35 4. Daily Goals Younger Children 36 5. Credit Scoring & Step System 36 a. Definition and Intention b. Leader Score Range (9-10) 39 c. Achiever Score Range (6-8) 40 d. Member Score Range (1-2) & (3-5) 4 1 e. Scoring Guidelines Range (1-1 0) 42 f. Leader Step Privileges 43 g. Achiever Step Privileges 44 h. Member Step Privileges 45 i. Steps of Maturity 46

Excerpts from the ABCD Manual

f. Bonus System Guidelines 50 7. Goal & Credit Meetings 51 a. Morning Goal Meeting 51 b. 1" Shift Credit Meeting (Afternoon Review) 52 c. 2"d Shift Credit Meeting (Evening Wrap-up) 53 d. Afternoon & Evening Meeting for Younger Patients 54 8. Dining Room Guidelines 55 9. Dining Room Guidelines for Younger Children 55 10. Rehsals of School and Rehabilitation Therapy 56 57 11. Learning Tasks

Alternative

Preventative 1 Alternate Interventions 59 1. Introduction 59 a. General Guidance 60 b. Implementation 60 c. Training and Supervision 60 d. Documentation Guidelines for Interventions 60 Planned Ignoring (Extinction) 61 Cueing and Prompting 62 Verbal Warnings 63 5. Verbal Interventions 64 6. Time Away 65 a. Definition & Goal 65 b. Examples of Intervention 65 c. Parameters for Use 65

221

Appendixes

d. Cautions e. Implementation 7. Take a Break a. Definition & Goal b. Parameters for Use c. Cautions 8. Physical Behavioral Intervention 9. Violence Prevention Procedures 10. Brief Restrictions and Separations 11. Mobility Status

Alternative Alternative

222

D. Intensive Interventions 74 1. Introduction 75 2. Rationale for Use 75 3. Community Violations 76 a. Community Violation Behaviors (CV) 76 b. Community Violation Tasks (CVT) 77 4. Safety Violations & Intensive Care Plans 79 a. Safety Violation Behaviors (SV) 79 b. Interventions for SV (ICP) 80 5. Community & Safety Violations for Younger Children 81 6. Safety Violation Intervention for Younger Children 82 7. Community Assessment 83 8. Community Care 84 9. Intensive Staffing 85 85 a. Definition & Intent b. Coach's Role 85 c. Room Times, Transitions, Curfews 86 d. Rehabilitation or School Time 86

223

Excerpts from the ABCD Manual

111. Further Issues IV. Implementation V. Documentation VI. Evaluation

Alternative Alternative

e. Free Time Blocks/Group TherapyIMeetings 86 10. One to One Staffing 87 87 a. Definition & Intent b. Coach's Role 87 c. Room Times, Transitions, Curfews 88 d. Rehabilitation or School Time Spent on Unit 88 e. Free Time 89 f. Phone Calls 89 g. Groups & Meetings 89

VII. Appendix A. Amendments to the Manual B. Amendments to the Schedule in the Manual 1. Hospital Schedule Memo 7-5-00 for Start-Up on 710-00 2. Guidelines for Weekday Hospital Schedule

224

Appendixes

3. Guidelines for 1:lOpm to 2:30pm Time Block on School Days 4. Guidelines for Weekend Hospital Schedule 5. Hospital Schedule Memo 8-17-00 for Adjustment to Start on 8- 18-00 C. Clarifications 1. Abbreviations List 2. ABCD Program Abbreviations List 3. Old Terms vs. New Terms 4. cv vs. sv 5. Continuum of Interventions: LT, CVT, ICP 6. CVT/ICP Response Review 7. Estimation Scales for the Patient's Step 8. Negative vs. Positive Goals 9. BuyingIOpting out of Rehabilitation Guidelines 10. Guidelines for Organizing the 1:OOP.M. to 3:30P.M. Time Block D. New Forms 1. Therapeutic Interventions 2. Daily Credit Scoring and Goals Sheet 3. Milieu Credit Scoring and Step Chart 4. Bonus Tracking Sheet 5. Bonus Card 6. Face Sheet for Daily Report 7. Staff Assignment Sheets a. 1" Shift Wave 1 Check-off Style b. 1" Shift Wave 1 Narrative Style c. l* Shift Wave 2 Check-off Style d. 1" Shift Wave 2 Narrative Style

Excerpts from the ABCD Manual

e. 2ndShift Wave 1 Check-off Style f. 2ndShift Wave 1 Narrative Style g. 2ndShift Wave 2 Check-off Style h. 2ndShift Wave 2 Narrative Style

225

226

Appendixes

Overview

I. Overview A. Goal B. Rationale for Change C. Younger Patient Population D. What is a Therapeutic Milieu? E. Definitions 1. Autonomy 2. Belonging 3. Competence 4. Doing For Others F. Guiding Principles G. Staff Code of Conduct H. Model of Interaction and Intervention 1. Assessment 2. Plan 3. Implementation 4. Evaluation

Alternative Education Alternative

I. OVERVIEW

Riverview Hospital provides high-quality, comprehensive psychiatric care to many of Connecticut's most troubled children and youth. This is apparent to everyone who works here, and should be an ongoing source of pride. At the same time, we're dealing with many problems within Riverview. The children and adolescents who come here are complex and at times difficult to treat. The level of aggression continues to be high,-the work stressful, and the children at times unappreciative of our efforts. Some of our techniques are ineffective, and some approaches that are known to be effective are not incorporated into our programs. There are differences in how the treatment proceeds within different hospital settings-in school, in rehab services, and between different units-that cause problems for both the children in terms of consistency and the staff who must feel competent in all those settings. These are the problems that this program revision is meant to address.

Excerpts from the ABCD Manual

Overview

A. GOAL The purpose of this program revision is to use our knowledge of child development, behavior modification and treatment of mental illness to format a program that will best meet the needs of our patients. Implementation of this program will only be fully accomplished with the assistance and cooperation of the entire hospital staff. We envision that through this change process, a safer, more therapeutic and more rewarding environment for patients and staff will evolve.

B. RATIONALE FOR CHANGE Riverview Hospital currently is comprised of eight hospital units with additional administrative and support staff, most working independently and at times at cross-purposes to our mission of stabilizing psychiatrically ill youth and transitioning them beyond the hospital. We strongly believe an integrated, hospital-wide program design that stresses building competencies in children while maintaining physical safety will be an improvement for all, and will begin a new process of positive program improvement. The program revisions were made to incorporate the best current practice within the hospital-that is, to keep and standardize across the hospital whatever is currently working well. We then added hospital programs, all of them suggested by Riverview staff, likely to help meet our above goal of a more consistent, less confusing, safe and rewarding program for patients and for staff. Nothing was added unless it had broad appeal to staff both within and beyond our committee, and it was consistent with the rest of the program. It is not perfect, nor complete, but we're convinced it's a good start. This program will demand.more creativity and connection from all of us, and our hope and expectation is that this will lead to rewards at every level.

227

228

Appendixes

Overview

YOUNGER PATIENT POPULATION

In consideration of the age and developmental status of the younger patients such as on Pueblo Unit, some adjustments have been made to the program. All aspects of the Program Revision are integrated in to the Pueblo Unit milieu program. The exceptions are in the areas of Unit Structure, Behavior Management, and use of Intensive Interventions. These alterations in programming support the idea of community at Riverview Hospital. They underscore the importance of creative individualized treatment planning, safety, and pro-social teaching and reinforce the cornerstones of Autonomy, Belonging, Competence, and Doing For Others shared throughout the hospital. These alternative strategies are boxed within the text.

Excerpts from the ABCD Manual

229

Overview

D. WHAT IS A THERAPEUTIC MILIEU? The term "therapeutic milieu" has been used interchangeably in the literature with others such as the "therapeutic community" or "environment." For the purpose of Riverview Hospital's work, principles of milieu therapy related to work with emotionally troubled and learning disabled children and adolescents is most central. From this perspective, the therapeutic milieu has been described as a "living and learning" environment, in which the events of group living such as rules, routines, and activities become formats for change. The emphasis is on using the daily events in a child's "life space" to teach social competence skills that can be generalized into other areas. Research has identified qualities of effective milieu programs which are (1) the distribution of responsibilities and decision making; (2) the presence of clarity in treatment programs, roles, and leadership; and (3) a high emphasis on positive staff to patient interactions. Milieu programs tend to specialize functions based on patient acuity, developmental capacities, and the structure of the staff system and the goals of the institution. Gunderson (1978) conceptualized five major therapeutic processes within psychiatric milieus, which he contends exist commonly in a broad range of programs independent of size, length of stay, population, staffing, and philosophy. These processes include containment, support, structure, involvement, and validation. They are briefly described below: 1. Containment: The function of this process is to provide for the safety and physical well-being of patients through the use of appropriate staff-client ratios, locked doors and seclusion when protection for the community is necessary, food, shelter, medical care, and so on. This function is most prominent when there is a high level of patient acuity; and may be manifested by interventions such as "House Care". 2. Support: The function of this process is to facilitate a social environment that enhances the self-esteem of clients by fulfilling needs, demonstrating genuine levels of empathy and unconditional positive regard, providing reassurance in time of stress, actively engaging clients in areas of known competence, and so on.

230

Appendixes

Overview 3. Structure: The function of this process is to create a "predictable organization of time, place, and person" in an effort to clarify roles, rules, and expectations for patients and staff. The teaching of social competence skills is achieved through programmatic activities that allow for reflection and immediate feedback from the community and a consistency regarding consequences and privileges associated with behavior. 4. Involvement: The function of this process is to allow patients to actively participate in their social environment in the areas of decision-making, program development, involvement in the therapy of other residents, and so forth. Patients are encouraged to assume more responsibility for themselves and others, with a major emphasis on the group process generated by the daily interactions that take place in the milieu setting.

5. Validation: The function of this process is to affirm the individuality of patients that underscores the unique aspects of each member of the group. Such actions as regressions, vulnerabilities, symptoms, and limitations are considered meaningful expressions that are accepted and tolerated by the milieu.

Excerpts from the ABCD Manual

WEEKDAY

Alternative

-

AFTERNOON SCHOOL .&

Patients are expected to walk to and from School in a quiet and orderly manner.

a

Patients will be escorted directly to their classroom. NON-SCHOOL DAYS

Alternative REHAB. THERAPY/FREE TIME

=

Prescribed groups, diversional activities and work programs are held during this time.

a

Patients not assigned to Rehab. Therapy at this time may have Free Time, if they have no outstanding consequences.

a

Patients are expected to be prepared for the activity. For example, if the activity is basketball, they should be wearing sneakers.

3%

Patients are expected to participate unless they have a medical excuse.

Alternative AFTERNOON REVIEW (SEE PROGRAM GUIDELINES)

=

Patients will be divided into two (2) groups by classroom assignment. All milieu staff (nursing/child care, teachers, clinical, rehab ... ) should attend. Patients who have not demonstrated a level of appropriate selfcontrol are not eligible for this meeting.

SNACKS

= *

The hospital provides Patients with a snack. Staff or Patients will set up and /or distribute the snacksand will eat it in a designated area on the unit (not within their rooms).

231

232

Appendixes

%

Patients are expected to clean up after themselves.

%

Patients will be informed of their Rehab. activity and will prepare accordingly.

=

Patients may receive medications at this time.

Alternative TRANSITION (NOT >I5MINUTES) ‘fit

Patients are in rooms with doors shut. Patients may be in the day room engaged in a quiet activity.

X

Radios may be played at a low volume.

*;

Talking between walls is not allowed.

*;

Patients are expected to wait for the end of Transition to have any needs met, except for urgent requests. Patients should knock on their doors and wait for Staff to acknowledge them.

3:45 - 4:45 (3:30-430- Weekends)

REHAB. THERAPY/FREE TIME X

= %

Prescribed groups, diversional activities and work programs are held during this time. Patients not assigned to Rehab. Therapy at this time may have Free Time, if they have no outstanding consequences. Patients are expected to be prepared for the activity. For example, if the activity is basketball, they should be wearing sneakers. Patients are expected to participate unless they have a medical excuse.

HAIRCUTS - (ON SELECTED NIGHTS PATIENTS MAY REQUEST TO HAVE A HAIRCUT DONE BY THE HOSPITAL BEAUTICIAN) 4.50 - 6:lO

DINNER / CHECK IN MEETING 3):

Patients eligible to go to the D i g Room, are called at -:-.

Excerpts from the ABCD Manual

Unit Structure

2. Patient-Staff Teams The purpose of the patient-staff team concept is to create opportunities for patients to experience connectedness with others through being part of a small group that meets predictably throughout each day and works cooperatively together. This will be the core of the milieu program, with each staff member responsible for the therapeutic work and social interaction opportunities for their team on each shift. I. On 1st and 2"d shift, each Nursing staff member is assigned as the coach for 2 to 4 patients, and works with them both as a small group and individually for the shift. The coach will also write progress notes and complete other relevant documentation about each assigned patient. Teams will be announced and/or posted at the start of each shift. Depending on unit needs, one nurse on duty may not have a Patient-Staff Team assignment, in order to better oversee milieu planning for the shift.

2. Ideally the 3 to 4 patients of this team will remain the same through 1st and 2nd shifts each day, with only the coach changing when 2nd shift replaces 1" shift. The composition of teams can and should be changed from one day to the next in order to allow patients to develop relationships with all members of the unit community. However, similar mobility statuses will be grouped to allow greater off-unit action for more stable children. 3. There are various activities that the patient-staff team can engage in together including:

a. Meeting to process individual goal assignments (worksheets, journals, interviews, etc.) and share any therapeutic tasks assigned. b. Meeting to exchange feedback on individual progress and determine credit earnings for the shift. c. Group work, either in combination with other patient-staff teams, or as a single team (i.e. a community project for a fair, or framed art for the unit). d. Leisure activities that promote connectedness and positive self-worth (anything from cooking to water polo).

233

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Appendixes

Unit Structure 4. Unless unsafe, every patient will be included in the meetings of his/her

patient-staff team throughout the shift. Patients who are not participating in the milieu will be part of daily patient-staff teams, and even if being physically present at the meetings is not possible, the patients who are restricted can exchange written communication, facilitated by the coach.

5. As the term "coach" indicates, the primary role of the staff assigned to the patient-staff team is a teaching, guiding role. The coach models effective communication, listening skills and problem solving, and actively promotes the concepts of Autonomy, Belonging, Competence, and Doing for Others.

6. On each shift, staff coaches will meet at regular intervals to share information about how their teams are doing, and problem-solve when necessary. If extreme or unusual situations have developed (for example a patient becomes inappropriate, or threatening towards a particular staff member), a coach may ask for a swap of team assignment, or other assistance in determining interventionsregarding the patient.

appendix 3 Excerpts from Sunburst Program Manual

235

236

Appendixes

SUNBURST PROGRAM MANUAL CONTENTS ORDER

I. 11. 111. IV.

Sunburst Philosophy Program Overview Setting Sunburst Schedule A.

Sunburst Weekly Schedule

B,

Sunburst General Weekend Schedule, P o l i c i e s and Procedures

C.

Sunburst Component Descriptions .Self Help Skills/Hygiene .Eating (Mealtimes and Snacks) .Care of Living Space .Meetings .Toy Closet

Earning C r i t e r i a

VI. VII.

A.

Assessment Guide

B.

Earned P r i v i l e g e and Responsibility Levels

C.

Scoring Procedure and Data Sheets

D.

Feedback

Responsible Person Contingencies and Mechanisms A.

P o s i t i v e Reinforcement Tools

B.

Limitations

Program Develovment

Excerpts from the Sunburst Manual

Sunburst is committed to the view that children want and need to trust and be trustworthy, to be autonomous and industrious, to achieve and sustain self-control and self-esteem, to be competent and to combine with others to plan and engage in activities, to enjoy accomplishment and mastery.

237

238

Appendixes

I. SUNBURST PHILOSOPHY

Sunburst is for children who are developmentally in middle childhood (approximate ages 8-12) with emotional and/or behavioral disturbances. The program is one that provides 1) a safe, nurturing environment and 2) one that is predictable. Both are designed to enable the children to relate more effectively with one another and adults and to function more independently. The program is organized to delay gratification and sustain adaptive behavior over longer periods of time, combining behavioral and humnixtic approaches. It is designed to provide clear expectations and boundaries for the children and to assure healthy, growth-inducing responses to the children's safety, belonging and dependency needs since many of the children feel they have been rejected totally. The Program emhasizes behaving, relating, participating and independent functioning while staff interact as "significant others" with children in one-to-one and small group sessions. These sessions focus on encouraging and enabling children to develop problem-solving skills in the social sphere, with awareness of self and self in relation to others. The ultimate goal is the discharge of each child in the comnity as high on the family hierarchy as possible (natural family, foster family, group home, institutions utilizing public schools, residential treatment, self-contained institutions).

Excerpts from the Sunburst Manual

Alternative

11. PROGRAM OV-

Sunburst emphasizes self-worth, autonomy, responsibility, interpersonal relations and problem solving, recreation and personal hygiene. Each child is assigned to a child care worker who functions as an individual resource for the child in relation to cottage program issues. Family-style dining provides a realistic group expedence and the opportunity to take responsibility, exercise initiative, and to develop various interpersonal skills. Cottage jobs provide experience with responsibility, competence and self-care skills. Emphasis on personal hygiene-'isdesigned to facilitate Belf-esteem and interpersonal awareness. Supervised play pmvides for recreation, attendance to guidelines, cooperation and reasonable competition. Sunburst's program is the backbone of the cottage and is designed to facilitate development in many areas. It is the vehicle staff uses to evaluate children and provide appropriate feedback. It allows assessment of participation in tasks, behaving, relating and independent functioning.

239

240

Appendixes

111.

SETTING

Sunburst is a 16-bed ( 8 bedroom) cottage that allows freedom of movement with an underlying structure that communicates consistency and safety. Each bedroom provides space for coonmate living. Closets, dressers, beds and desks are provided for each child and becomes his responsibility. The Cottage also contains a large living room, kitchen, office, two bathrooms, laundry facilities and a toy closet. A "quiet room" is also located in the cottage. Quiet Room use at Riverview is governed by hospital policy, which is consistent for all programs. Cottage staff consists of six child care workers, two nurses, and a program coordinator who choreographs various cottage and extra-cottage activities. All child care workers share the responsibility of developing, evaluating and implementing the program.

Excerpts from the Sunburst Manual

EATING TOGETHER Sunburst has a program t h a t i s designed t o eliminate i n s t i t u t i o n a l ( c a f e t e r i a - s t y l e ) dining and promote a warm atmosphere a t mealtimes, comparable t o family dining. The objectives a r e learning n u t r i t i o n , courtesy and manners; enjoying others; and contributing t o a q u i e t , non-hurried atmosphere. Sunburst e a t s i n a s e p a r a t e roam f r o m other l i v i n g areas. Children l e a r n t o s e t t a b l e s , and c l e a r and wash them when t h e group has finished eating.

241

242

Appendixes

TAKING INITIATIVE AND BEING INDUSTRIOUS Caring about Living Space: On a weekly basis, children a r e assigned jobs; these jobs am t o keep t h e i r l i v i n g space t h a t is, t h e i r cottage clean, and thereby developing a sense of r e s p o n s i b i l i t y f o r one's l i f e space, and l e a n i n g housekeeping s k i l l s .

-

-

Jobs a r e done around lunch time with s t a f f support and supervision and help a s needed. Jobs included are: vacuuaine, dishwashing, putting away laundry, dusting, sweeping, emptying t r a s h , e t c . The children a r e given verbal praise f o r doing a good job and each completed job earns the child 10 cents payable weekly. I f a child does not complete h i s job, or i f he is not present, he does not get paid. Extra jobs can be done f o r e x t r a noney.

-

Meetings: Every evening before snacks, a cottage meeting i s held. In addition t o providing a time f o r everyone t o be together a s a group, it a l s o creates a time f o r children and s t a f f t o t a l k and share with each other concerns and issues t h a t a f f e c t everyone i n t h e cottage. I t is a l s o a time t o r e l a t e and share things t h a t went well and t h a t individuals f e e l good about. One of t h e major events of the evening meetine is feeding back t o t h e children t h e daily scores and l e t t i n g t h e children know where they did well and areas t h a t need work. The meeting is run by t h e children with s t a f f present. Each night a d i f f e r e n t child is selected t o manage t h e meeting. This provides each child with t h e opportunity t o exercise leadership. The Toy Closet: An old storage room has been converted i n t o a toy signout mom, where children may go and sign out toys f o r t h e day. The children have a l a r g e variety of toys t o choose from and a r e given t h e responsibility: (1) t o take care of the toy which they have signed out, and (2) t o be responsible f o r making sure t h a t toy i s returned i n t h e evening. Children signing out toys (bikes, skateboards, etc.) may sign them out f o r t h e whole day on regular school days and f o r one s h i f t (1/2 day) on weekends and vacation days. Borrowing Contracts: Children may not lend o r give any item they have received from hone (clothes, bikes, e t c . ). However, i f they have something they have bought or made and want t o lend o r give it t o another, they may request t o make cut a "Contract" t o have t h i s r e m i n s i n t h e Contract f i l e i n the "proof" of the transaction s t a f f o f f i c e . (See example, next page)

-

Excerpts from the Sunburst Manual

SAMPLE CONTRACT (See "Borrowing Contracts", Preceding Page)

b

CONTRACT Date :

, am going t o

1,

my in return for Sign Sign Sign (Both child and staff sign)

give/lend t o

243

notes Chapter 1: On the Way Up the Hill 1. One night the students made a sign for Camp Quinebaug, named after the reservoir that was part of our camp. From that night forward, “Camp Quinebaug” was the official name of the camp. The students created another sign and placed it in front of the Wiseman tent: doC’s plaCe, for “director of camp,” a nickname that has stuck with me ever since. 2. For more information on Gilead Community Services, see gileadcs.org /whoweare.html. We used to sing, “There is a balm named Gilead that soothes the heartsick soul. / There is a balm in Gilead that makes a person whole.”

Chapter 2: A Place to Start 1. Governor’s Committee on Child Home Study Sub- Committee on Need and Intake Procedures: Adah Atwood, Finnis E. Engleman, Ruth Gilbert, John H. Jackson, and Marjory Siskey, 1 July 1946. 2. Ibid. Also see “Governor Urges Appropriation for Child Study,” Hartford Courant, 21 April 1949: 11. It is interesting to note that Chester Bowles worked on human rights issues with the United Nations and elsewhere. 3. C. Leonard interview, 1 May 1990, Middletown, CT. 4. D. Inglis and E. Marsh, “Use of State Mental Hospitals as a Resource for Children,” American Journal of Orthopsychiatry 28:4 (1958). 5. Connecticut Valley Hospital, Quarterly Report Ending in December 31, 1960. 6. Connecticut Valley Hospital, Annual Report of July 1, 1960 to June 30,1961. 7. Connecticut Valley Hospital, Quarterly Report Ending September 30, 1961. 8. E. Carini, “The Mentally Ill in Connecticut: Changing Patterns of Care and the Evolution of Psychiatric Nursing, 1936–1972,” Ph.D. thesis, Fordham University, 1974. Connecticut Valley Hospital, Quarterly Report Ending in December 31, 1960. 9. H. Gewirtz interview, 23 June 2003, Middletown, CT 10. Ibid. 11. The Snake Pit, 1948, Anatole Litvak, director. 12. A. Spaulding interview, River Views, 94, 22 October 1998. 13. “Responsibility Argued on Straitjackets’ Use,” Hartford Courant, 15 January 1963, 1. 14. C. Leonard interview, 23 June 2003, Middletown, CT. 15. H. Gewirtz interview, 23 June 2003, Middletown, CT. 16. Ibid. 17. C. Leonard interview, 23 June 2003, Middletown, CT. 245

246

Notes to Pages 18–28

18. “Proposed Future Hospital Recommendations for Children’s Services,” Digest of Administrative Reports to the Governor, 25 April 1963 [CSL call number ConnDoc F40]. 19. Connecticut Valley Hospital, Yearly Report Ending in December 31, 1963. 20. E. Wiseman interview, 13 May 2003. 21. Connecticut Valley Hospital, Yearly Report Ending in December 31, 1963. 22. M. Pease- Grant interview, September 2004, Middletown, CT.

Chapter 3: A New Home 1. Although psychiatric hospitals administered hydrotherapy, the use of cold and hot full-body compresses, in the late nineteenth and twentieth centuries, we were told that this particular room was never used for its intended purpose. Nevertheless, it was a hard, cold, windowless room. 2. Marjorie Farmer was a state legislator and well-known family and children’s mental health advocate. 3. For more on Melvin Lewis’s approach to the treatment of young psychiatric patients, see M. Lewis and R. A. King, “Psychiatric Assessment of Infants, Children and Adolescents,” in M. Lewis (ed.), Child and Adolescent Psychiatry: A Comprehensive Textbook, 3d ed. (Baltimore: Williams & Wilkins, 2002), 525–543, and N. E. Moss and G. R. Racusin, “Psychological Assessment of Children and Adolescents,” in M. Lewis (ed.), Child and Adolescent Psychiatry: A Comprehensive Textbook, 3d ed. (Baltimore: Williams & Wilkins, 2002), 5. 4. M. Stahl interview, 2003, Middletown, CT. 5. Connecticut Valley Hospital, Quarterly Report Ending in April 31, 1967. 6. As we shall see, movement in this direction did take place several years later. In a 1969 year- end report entitled “The Children’s Unit at Connecticut Valley Hospital: A Program Description,” Peplow outlines her vision and proposal for the development of the Children’s Unit. This was the first truly comprehensive statement of a philosophy and program description. 7. S. Reale interview, 6 October 1980, Curtis Home, Meriden, CT. 8. T. W. Downey, “A Comparative Study of Residential Treatment Populations: Children’s Unit of Connecticut Valley Hospital and High Meadows, Hamden, Connecticut,” Child Study Center, Yale University, February 1969. 9. Ibid. 10. Connecticut Council of Child Psychiatrists and the New Haven–Middlesex Chapter of the Connecticut Psychiatric Society, Report to the Ad Hoc Joint Committee on the Children’s Unit, February 1969. 11. Ibid. 12. Judge Brenneman’s daughter Amy became the star of the popular evening television series Judging Amy and played the part of a juvenile judge in Connecticut. Her mother was a children’s services worker.

Notes to Pages 29–80

247

13. M. Stahl interview, 2003, Middletown, CT. 14. J. McCain interview, 31 March 2004, Middletown, CT. 15. Ibid.

Chapter 4: A New Direction 1. L. K. Brendtro, J. K. Whittaker, and A. E. Trieschman, The Other 23 Hours: Child-Care Work with Emotionally Disturbed Children in a Therapeutic Milieu (Chicago: Aldine Translation, 1969). 2. Connecticut Valley Hospital, Yearly Report Ending December 31, 1969. 3. Connecticut Valley Hospital Superintendent’s Annual Reports, 1953–1973, Connecticut State Library, RG021, Subgroup 1; Connecticut State Hospital for the Insane/Connecticut Valley Hospital, 1866–1976. 4. Ibid. 5. Ibid. 6. W. Glasser, Schools Without Failure (New York: Harper & Row, 1975). 7. Ibid. 8. Ibid. 9. C. Rich interview, 1995, Middletown, CT.

Chapter 5: Children Do Not Belong in Psychiatric Hospitals! 1. Connecticut Valley Hospital, Quarterly Report Ending August 31, 1967.

Chapter 7: The Evolution of a Milieu 1. F. Miller interview, 8 April 2004, Middletown, CT. 2. E. Shukis interview, 27 March 2003, Middletown, CT. 3. Until the early 2000s the Department of Retardation was renamed the Department of Developmental Disabilities, which used the new term “Asperger spectrum disorder.” 4. H. Cohen, A New Learning Environment: A Case for Learning (San Francisco: Jossey-Bass, 1971). 5. Excerpts from the Bleu manual can be found in in Appendix 1. 6. S. Hodge interview, 29 June 2004, Middletown, CT. 7. Reducing the need for a quiet room was a constant priority. Basically, a quiet room is a small, unfurnished safe place for a child who is physically abusive, damages property, cannot be verbally restrained, and or is in immediate need of a physician. All staff members go through extensive training in both verbal and physical restraint interventions. The quiet room is a last resort. It was always a focus of interest in the search for alternative ways of dealing with an out- ofcontrol child and frequently a reason for a child’s being referred to Riverview from a less secure facility.

248

Notes to Pages 82–89

Chapter 8: Children’s School 1. Although the names of most the architects are missing from our records, Val Carlson’s name appears on the corner of the building. 2. A carol was a small, two-sided room containing a desk and a chair. 3. Behavior management in the school posed some unique problems. If a child was out of control in one of the living units, there were usually enough staff members that the situation could be addressed by one childcare worker while the other(s) attended to the remaining children. That was not the case in the school, however. With a ratio of one teacher to four or five children in each classroom, a child experiencing a difficult time could disrupt the whole class and soon all would be acting out. In response to this situation, Tom Allen, a teacher and educational diagnostician, initiated the “time- out room” in 1979. Based upon the traditional concept of time- out, the room provided a place with limited distractions and stimulation where a child could calm down. Once staff in the room determined that the kid seemed to be in control, he or she would be sent back to class. This approach worked quite well. Children who needed it got individual attention without disrupting the rest of the class. Over time, however, improvements were made and the time- out room transitioned into a behavior management room. In 1983 a childcare worker with an interest in and aptitude for behavior management was selected to be a full-time behavior management staff member. Tony Nalewajek spent a month catching up on the cognitive behavioral literature and working with residential unit staff, Tom Allen, Lou Ando, and the teachers to develop a program. “Time- out Tony,” as he was referred to by the kids, became integral to connecting the school program with the living units. He contacted each unit every morning in person or by phone to get information about how the kids were doing and identifying any potential problems. During lunch break and at the end of the day, he once again communicated with the childcare staff and informed them of any potential child-related issues. When kids were sent to the behavior management room, Tony took a very systematic approach. First, he allowed the child time to calm down and listened to his or her side of the story. Then he worked out the answers to three questions with each child. First, “What exactly happened/what were you doing?” Next, “What did you want to accomplish by your actions?” Finally, “What would have worked better (because what you were trying didn’t work—you’ve been sent to the behavior management room)?” Before each child went back to class, he or she had a plan that would result in better and more productive behavior. 4. L. Ando interview, 13 April 2004, Middletown, CT. 5. L. Ando interview, 8 October 2004, Middletown, CT. 6. E. Donlan letter, 1985.

Notes to Pages 93–130

249

Chapter 9: Recreation in the Children’s Unit 1. J. McCain interview, 31 March 2004, Middletown, CT. 2. Project Adventure is a nonprofit education and training organization whose mission is to create personal growth through challenging adventure-based activities in which students learn to rely on each other. 3. G. Nolan interview, 2 October 2003, Middletown, CT.

Chapter 10: Adolescence 1. P. Brown interview, 9 June 2004, Middletown, CT. 2. K. Kesey, One Flew over the Cuckoo’s Nest (New York: Viking Press, 1962). D. Nolan interview, 2 October 2003, Middletown, CT. Donna Nolan started teaching art, splitting her time between the afternoon recreation program at the Children’s Unit and the Education Department in the Connecticut Valley Hospital Adolescent Program until it moved to Altobello. During this first year she met Gary. With the merger, her position and role were divided: she worked two days a week with the children at the Connecticut Children’s Place and on the other days with either the adolescents or the children at Riverview/Altobello. Although she eventually got her certification as a special education teacher, she decided to pursue her true love as an art teacher. 3. J. Jones interview, 15 March 2005, Middletown, CT. 4. G. Zera interview, June 2004, Middletown, CT. 5. Ibid. 6. P. Brown interview, 9 June 2004, Middletown, CT. 7. O. Clark interview, 9 June 2004, Middletown, CT. 8. M. Stahl interview, 2003, Middletown, CT. 9. According to Ed Toledo (personal communication), the architectural firm for the adolescent buildings was Mahaffrey, Ferguson, Frid and Perry Associates.

Chapter 12: Identity 1. C. Sundell interview, 8 April 2004, Middletown, CT. 2. Ibid. 3. C. Sundell interview, 8 April 2004, Middletown, CT. 4. Ibid. 5. O. Clark interview, 9 June 2004, Middletown, CT. 6. R. Haxton interview, 9 June 2004, Middletown, CT. 7. M. Harrington interview, 9 June 2004, Middletown, CT. 8. L. Goldberg interview, 6 June 2004, Middletown, CT. 9. E. Ryder interview, 9 June 2004, Middletown, CT. 10. R. Sinkewicz interview, 9 June 2004, Middletown, CT. 11. K. Judson interview, 9 June 2004, Middletown, CT. 12. J. Narad interview, 11 March 2005, Middletown, CT.

250

Notes to Pages 131–167

13. L. Ando interview, 8 October 2004, Middletown, CT. 14. A. Kaczmarek interview, 3 June 2004, Middletown, CT. 15. R. Haxton interview, 9 June 2004, Middletown, CT.

Chapter 13: Post-Merger 1. L. Goldberg interview, 6 June 2004, Middletown, CT. 2. L. Ando interview, 8 October 2004, Middletown, CT. 3. With four working committees, Bert Plant developed a revised milieu program referred to as the aBCd Program, as discussed in Bob Sinkewicz’s interview. This is basically a levels program, a major attempt to apply the same basic structure to all residential units. Bob addressed the use of physical restraint in the hospital and significantly reduced the use of this practice. He also stressed the need for data- driven decisions and improved the data collection system, as well as the risk management program. As a superintendent without a history in any of the merged facilities, he effectively quelled some of the resentment that lingered as a result of the merger. During his tenure, Plant’s major challenge consisted of managing hospital census. Despite the construction of Riverview Hospital for Children and Youth as a 107-bed facility, the need for individual rooms placed the optimal census at 90. A shortage of beds was a constant reality, usually with a waiting list for admission and a delay in admissions based on acuity. 4. R. Plant interview, 15 March 2005, Middletown, CT. 5. New England Psychologist, Directory of Psychiatric Hospital and Units, P.O. Box 812068, Wellesley, MA, 02482- 0013, May 2004. 6. J. Narad interview, 11 March 2005, Middletown, CT. 7. Ibid. 8. Ibid. 9. Ibid. 10. P. Colanghi interview, 19 May 2004, Middletown, CT. 11. J. Landau interview, 15 March 2005, Middletown, CT. 12. W. Tirado interview, 15 March 2004, Middletown, CT. 13. P. Briggs interview, 15 March 2005, Middletown, CT. 14. R. Pugliesi interview, 15 March 2005, Middletown, CT. 15. Ibid. 16. K. Dowling interview, 15 March 2005, Middletown, CT. 17. C. Allen interview, 8 April 2004, Middletown, CT. 18. R. Sinkewicz interview, 15 March 2005, Middletown, CT. 19. C. Malinowski interview, 16 June 2004, Middletown, CT. 20. S. Peschuri interview, 24 March 2005, Middletown, CT. 21. J. Klemba interview, 8 November 2005, Middletown, CT. 22. R. Adams interview, 13 May 2003, Middletown, CT. 23. S. Newkirk interview, 13 May 2003, Middletown, CT.

Notes to Pages 167–187

251

24. R. Adams interview, 13 May 2003, Middletown, CT. 25. S. Newkirk interview, 13 May 2003, Middletown, CT. 26. Ibid. 27. R. Delvecchio interview, 3 April 2003, Middletown, CT. 28. J. Resnick interview, June 2004, Middletown, CT. 29. R. Adams interview, 13 May 2003, Middletown, CT. 30. K. Kovall interview, 9 June 2004, Middletown, CT. 31. This quote may not reflect the real policy, though it may describe what happened. In reality, discussions with the SDE and federal authorities allowed the psychiatrist to identify kids who were not psychiatrically stabilized and thus not testable. 32. I. Carrera interview, 15 March 2005, Middletown, CT. 33. J. Resnick Interview, June 2004, Middletown, CT. 34. Ibid. 35. Ibid. 36. R. Adams interview, 13 May 2003, Middletown, CT. 37. J. Resnick interview, June 2004, Middletown, CT. 38. Ibid. 39. Ibid. 40. N. Bhatt interview, 8 April 2004, Middletown, CT. 41. A. Ventrelli interview, 8 April 2004, Middletown, CT. 42. N. Bhatt interview, 8 April 2004, Middletown, CT. 43. A. Ventrelli interview, 8 April 2004, Middletown, CT. 44. Different levels of supervision come with a hospital designation, e.g., oneon- one and supervised outside activity. Children are ranked according to team assessments. Mobility status covers permissions from “no leaving building” to “free to leave with permission.” Children’s mobility ratings can be changed at reassessments. 45. E. Shukis and B. Delvecchio interview, 3 April 2003, Middletown, CT. 46. Ibid. 47. K. Kovall and L. Adams interview, 15 March 2005, Middletown, CT. 48. Ibid. 49. Ibid.

Chapter 14: A Broader View of Change 1. J. Knitzer and L. Olson, Unclaimed Children: The Failure of Public Responsibility to Children and Adolescents in Need of Mental Health Services (Washington, DC: Children’s Defense Fund, 1982). 2. B. Stroul and R. Friedman, A System of Care for Severely Emotionally Disturbed Children and Youth (Washington, DC: Georgetown University Child Development Center, Cassp Technical Assistance Center, Substance Abuse and Mental Health

252

Notes to Pages 187–204

Services Administration [SAMHSA], 1986). Also see the 2002 Community Collaborative Status Report, Annual System of Care Status Report for Community Collaboratives, Connecticut Community KidCare, Department of Children and Families, Kristine D. Ragaglia, JD, Commissioner, November 2002. 3. See Harry Whitings’s comments in 1962, describing the same concern, in chapter 3. 4. In one of those amazing coincidences, my granddaughter, Sara Slingerland, having graduated from the University of Connecticut as a psychology major, was hired by Value Options, the chosen aso. One of her assignments included data analysis of reports from Riverview Hospital. The formal report was presented to the hospital at a grand rounds that I had attended. Value Options proved to be a very valuable service and added to the new face of Connecticut’s children’s mental health system.

Chapter 15: Addressing the Mood in the Milieu 1. M. Peet interview, 2004, Middletown, CT. 2. J. Welch interview, February 2010, Middletown, CT. 3. Ibid. 4. Ibid. 5. Ibid. 6. M. W. Azeem, A. Aujla, M. Rammerth, G. Binsfeld, and R. B. Jones, “Effectiveness of Six Core Strategies Based on Trauma Informed Care in Reducing Seclusions and Restraints at a Child and Adolescent Psychiatric Hospital,” Journal of Child Adolescent Psychiatric Nursing 24: 1 (2011), 11–15; https://www.ncbi.nlm.nih .gov/pubmed/21272110. 7. Ibid. 8. J. Welch interview, February 2012, Middletown, CT. In fact, many years ago Riverview started a day school program because none existed in the area, but closed it when one was established by Elmcrest Hospital in the community. 9. Ibid.

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weB ResouRCes Photographs of Riverview from the National Park Service. http://pdfhost.focus .nps.gov/docs/NRHP/Photos/85001920.pdf. Riverview’s nomination from for the National Register of Historic Places. http:// www.middletownplanning.com/documents/CVH_NRHP_1985.pdf. The State of Connecticut webpage for Albert J. Solnit Psychiatric Center. http:// www.ct.gov/dcf/cwp/view.asp?a=2675&Q=320936.

index Note: Page numbers in italic indicate tables or figures. Abbata, Denise, 110 aBCd milieu program: adaptation of, 150; excerpts from staff manual, 219–34; implementation of, 7, 152, 156, 183–84, 250n3; and residential units, 144; R. Plant on, 138–39 Acadia residential unit, 144, 150, 152– 60 accreditation, 7, 62, 84–86, 101, 109– 10, 113, 128, 130, 142–43, 160, 165 aCute care, 39 Adam, Esther, 37 Adama (later Passaic) residential unit, 150–51 Adams, Linda, 182–85 Adams, Randy, 83, 164–67, 169, 171– 72, 174 Adams House, 98, 152 Administrative Services Organization (aso), 191–92 admissions: age limits for, 6, 24, 43, 60, 76, 197; and child guidance clinics, 13, 14; closed to autistic children, 69–70; emergency, 22; to hospitals, 9, 35, 111, 192; involuntary, 38–39; new, 15, 37, 59, 150; policies for, 25, 39–40, 44, 59–60, 81; and prescreening, 41, 151, 160; rate of, 13–14, 108, 110; voluntary, 13, 60 Adnopoz, Jean, 190 Adolescent Drug Rehabilitation Unit (adRu), 100–103 adolescents: behavior modification techniques for, 81, 99; educational services for, 173–74; facilities for, 6,

100–101, 105, 122; and the merger, 6–7, 117; and milieu treatment philosophy, 80–81; and program development, 5–6, 98–105; and recreational services, 92–93; studies involving, 202–3; together with children, 104. See also Altobello Adolescent Hospital; Housatonic Adolescent Hospital adRu (Adolescent Drug Rehabilitation Unit), 100–103 adult psychiatric hospitals, 5–6, 32, 46, 50, 69 adult wards, 10–12, 15, 50, 59, 99 advisory committees, 3–4, 34, 190–91 advocacy, 10, 28, 32, 38, 61, 100, 136, 186–90 aftercare, 4, 40 Aksu, Joyce, 19, 24 Albany Avenue Child Guidance Clinic, 57 Albert J. Solnit Children’s Center, 7, 205–7 Albertus Magnus College, 92 Allan, Alton, 62, 149 Allan, Tom, 83, 167, 248n3 Allen, Craig, 153–54 Allessi, Sal, 12 Alpha Cottage Unit, 6, 64–70 Altobello Adolescent Hospital: and condition of facilities, 176–77; history of, 100–105, 107; and medical model of treatment, 122–23, 128; and the merger, 112, 117–29, 155, 163–67, 195; and reduced census, 259

260

Index

110; restructuring of, 6; staff of, 23, 96, 99, 149, 150, 154, 176–77, 183 Altobello Youth Center, 114 American Association of Psychiatric Services, 62 Anderson, Debra, 201–2 Ando, Lois: and administrative changes, 83, 112–14, 126, 136, 194; hospital review director, 197–98; and the merger, 7, 118–20, 135; and milieu treatment philosophy, 142; reflections of, 84–86, 130–31, 136– 38; and staff services, 111 Appropriations Committee, 9 Arafeh, Mehaden, 23–24, 27–28, 30, 32–33, 38, 41, 44, 93 Arboscello, Ronald, 183 aso (Administrative Service Organization), 191–92 Asperger spectrum disorder, 247n3 Association of Child Psychiatric Clinics, 38 Association of Child Psychiatry, 38 autistic children: admissions closed to, 69–70; behavior modification techniques, 6, 64–65; and cottage institutions, 64–70; and educational services, 69, 174; facilities for, 6, 22, 29–30, 35, 45, 68; and play therapy, 3, 47–50; and program development, 38; public awareness of, 5; and recreational services, 57, 67– 68, 95–96 Autistic Unit, 6, 22, 29–30, 37, 64–70, 79, 83–84 autonomy, 9, 22, 28, 32–33, 138–40 auxiliary, 63, 96, 182 Azeem, Muhammad Waqar, 202–4, 203 Baldwin, Raymond, 8 Bartolotta, Michael, 61, 96

Beers Hall, 5, 15–16, 20, 68 Behavioral Health Department, 194 behavioral health services, 69, 136–40. See also aBCd milieu program Behavioral Learning Environment Unit (Bleu): and the merger, 122; origins of, 6; overview of, 72–79; phase out of, 144; presentation of, 62; and recreational services, 72, 76, 94; and Silvermine Building, 152, 182 behavioral therapies, cognitive, 106, 156 behavior disorders diagnosis, 8, 13, 25, 45, 109 Behavior Management Program, 83, 112, 178–79, 248n3 behavior modification techniques: and adolescents, 81, 99; and autistic children, 6, 64–65; in classroom, 174–75; and milieu treatment philosophy, 65–66; and play therapy, 47–50; R. Plant on, 139–40 Berzins, Everists, 102–3 Bhatt, Nachi, 176–77 Bishop, Peter, 37 Blasko, John, 10 Bleu. See Behavioral Learning Environment Unit (Bleu) Bleu ii residential unit, 120, 163 Bleu staR program, 76 Bleu: The Behavioral Learning Environment Unit (manual), 71, 211–18 Block, Robert, 62 Bloomberg, Wilfred, 4, 11–12, 17, 32– 33, 43 Bowles, Chester, 9 Boylin, William, 103 Boynick, Dave, 51 Brendtro, Larry K., 36 Brenneman, Margaret, 28 Bricker, Al, 161, 183

Index Bridgeport Family Day School, 83, 90, 101, 166 Bridging the Gap Committee, 112 Brief Treatment Unit, 98 Briggs, Peter, 110, 149–50 Brown, Bill, 92 Brown, Peter, 98–99, 101 budget, 5, 33, 41, 42, 60, 95, 125 Bureau of Behavioral Health, 194 Burnham, Randolph, 45, 71 Bush, George W., 170 Cambria, Donna, 167–68 Camp Laurel, 51–52 Camp Pioneer, 57, 65 Camp Quinebaug, 3, 4, 24, 41, 51, 52– 58 Capt (Connecticut Aptitude Performance Test), 170–71 Carlson, Val, 5 Carrera, Ismael, 170–72 Case (seclusion and restraint) program, 138 Cassp (Child and Adolescent Service System Program), 186–88 Catchatera, Anna, 103 Cautella, Joseph, 37, 65 “cautious clinical judgment,” 35, 39 CBHaC (Children’s Behavioral Health Advisory Committee), 190–91 census, 23, 29, 35, 110, 170, 250n3 Central Connecticut State University, 40, 92, 108, 176 central placement team (Cpt), 196 Cerino, Marie, 136 Chamberlain (Treatment) Unit, 103, 155 Chapman, Clara, 45 Chase, Roland, 57 Child Advocate Office, 194, 201, 204 Child and Adolescent Service System Program (Cassp), 186–88

261

child guidance clinics: and admissions, 13, 14; Albany Avenue Child Guidance Clinic, 57; Bridgeport Family Day School, 83; and community services, 108; in Essex, Connecticut, 137, 154; and Psychology Department (msu), 47; and the residential treatment model, 8 Childhood and Society (Erickson), 206 child psychiatrists: and administrative changes, 16, 24, 62, 144, 149– 50; and consultation services, 5, 30, 36–37, 111, 147; and the medical model of treatment, 104, 128; and medications, 44, 159; need for, 22, 27–28, 38, 41, 43–44 child psychology, 41, 108, 204 children: on adult wards, 10–12, 15, 50, 59, 99; advocacy for, 10, 28, 32, 38, 61, 100, 136, 186–90; diagnoses of, 8, 20–21, 38, 69, 147, 157; and interaction with staff, 71, 77–79, 132–33; lack of mental health facilities for, 8, 13; and managed care, 191–93; and parents, 44, 65, 111, 184; placement services, 5, 38–39; together with adolescents, 104; unification of services for, 14–19. See also autistic children Children’s Behavioral Health Advisory Committee (CBHaC), 190–91 Children’s Defense Fund (1982), 186 The Children’s Place (tCp). See Connecticut Children’s Place (tCp) Children’s Task Force, 22, 112 Children’s Unit (CvH): construction of, 5, 17–18, 34–35; and Department of Psychology, 3, 15, 24, 45; and educational services, 82–91; facilities for, 5, 21, 34; new direction for, 34–44; origins of, 4, 8, 10–15; recom mendations for separation, 22–32;

262

Index

renaming of, 59–63; and R. Wiseman, 31–33, 41–42, 58; structure of services, 36–40 Children’s Village, 2 Children’s Welfare Center, 12 Child Study Committee, 9 CJts (Connecticut Juvenile Training School), 23, 143, 170, 195 Clark, Oliver, 101–3, 124, 126 client hassle index, 75 Cliff House, 100–103 clinical services: and administrative changes, 102, 114; development of, 202–4; and the Gilead House, 4; provided by, 37–38, 62; recommendations for separation of, 22; review of, 80; and treatment philosophies, 122 clinical staff: and administrative changes, 24, 114; and the Clinical Staff Organization, 109, 113; and community services, 107; facilities for, 70; growth of, 37; and milieu treatment philosophy, 40; and partial hospitalization, 110 Clinical Staff Organization, 109, 113 co-directors, appointment of, 32–33 coed housing units, 6, 68, 79–80, 144, 148 cognitive behavioral therapies, 106, 156 Cohen, Harold, 71 Colhanghi, Pat, 148–49 collective bargaining agreements, 127 Committee on Welfare and Humane Institutions, 9 community-based children’s mental health programs, 186–90, 192, 206 community collaborative initiatives, 7, 136–37, 141, 159, 189–90, 192, 206 community resources: deficiency of, 13, 146–47, 154; providing, 107–8,

195; and the residential treatment model, 146; and Riverview Auxiliary, 63; studies involving, 11, 39–40 community services program development, 6, 110–12 “A Comparative Study of Residential Treatment Populations: Children’s Unit of Connecticut Valley Hospital and High Meadows, Hamden, Connecticut” (Downey), 25–27 Connecticut Aptitude Performance Test (Capt), 170–71 Connecticut Association of Child Psychiatrists, 32 Connecticut Children’s Place (tCp), 7, 61, 94, 98, 155, 198–99, 201, 205 Connecticut Department of Mental Health. See Department of Mental Health Connecticut General Assembly, 9 Connecticut Juvenile Training School (CJts), 23, 143, 170, 195 Connecticut Nurses Association, 115 Connecticut Office of Policy and Management, 106 Connecticut Service Corps, 3–4, 32, 40, 50–51, 53, 57 Connecticut Valley Adolescent Unit, 98–100 Connecticut Valley Hospital (CvH). See Children’s Unit (CvH) Consolidated Care Standards, 109 Consolidated Facilities Standards, 142 construction: of adolescent facilities, 6, 105; of Autistic Unit (Alpha Cottage), 66; of Children’s Unit (CvH), 5, 17–18, 34–35; completion of, 41, 83, 112, 122, 134; delays with, 121; and funding, 21, 110; legislation for, 5; and the merger, 118, 120–22, 134; politics of, 30 continuum-of-care model, 107, 112

Index Cook, Carol, 62–63 Copeland, Bruce, 98–99 Cottage C (Kiwani residential unit), 45, 79, 143, 149–50 cottage coordinators, 22–23, 43, 67, 71, 76, 79, 83, 162 cottage institutions: for autistic children, 64–70; and behavior modification techniques, 168; construction of, 34–35; and East Campus, 180; recommendations for, 9–10; Seagull, 79–81, 148; security of, 121; Sunburst, 79, 80–81, 83, 148, 162– 63, 235–43; timeline of, 6 Council of Child Psychiatrists, 27–28 Council of Social Agencies, 8 court-ordered evaluations, 160 Cpt (central placement team), 196 Cunningham, James M., 8 CvH (Connecticut Valley Hospital). See Children’s Unit (CvH) Damata, Rick, 95 Davis, Bob, 57 Davis, Cy, 198 Davis, William, 99 dCf. See Department of Children and Families (dCf) dCf Region III, 187 dCYs (Department of Children and Youth Services), 6, 57, 59, 69, 89–90, 100 dds (Department of Developmental Services), 191 Delomo, Matt, 177–78 Delvecchio, Robert, 84, 96, 167–69, 180–82 Dempsey, John, 5, 20, 30 Department of Children and Families (dCf): and administrative changes, 205; advisory committees and agencies, 191; continuing education for

263

staff of, 40; and continuum-of-care model, 107; and educational services, 91; and funding, 187–90; and Housatonic Adolescent Hospital, 98; and the merger, 124, 162–63; and parents, 184; Program Review and Evaluation Unit, 197–98; and the residential treatment model, 98 Department of Children and Youth Services (dCYs), 6, 57, 59, 69, 89– 90, 100 Department of Continuous Quality Improvement, 194 Department of Developmental Disabilities, 247n3 Department of Developmental Services (dds) (formerly Mental Retardation), 191 Department of Education, 167, 169 Department of Health, Division of Mental Hygiene, 10 Department of Mental Health, 5, 10, 12, 16, 30–32, 41–43, 55, 100 Department of Mental Health and Addiction Services (dmHas), 141, 191 Department of Mental Retardation (dmR), 69–70, 191 Department of Psychology (CvH), 3, 15, 24, 45 Department of Public Works, 35, 105, 121 Department of Retardation, 6, 152, 247n3 Department of Social Services (dss), 191 Deras, Judith, 37 developmentally disabled children, 151–52 Devlin, Earle, 107 diagnoses of children, 8, 20–21, 38, 69, 147, 157 Dickson, Donna, 36

264

Index

Diddario, MaryAnn, 114, 126 diminishing restraints, 203 director of Children’s Unit, search for, 30–33 discharge process: and admission age limits, 60; and aftercare, 40; and community collaboratives, 159; lack of skilled staff, 38; and length of stay, 192, 204; meetings about, 172– 73; and quality of treatment, 196; staff interactions with patients, 180; and treatment philosophies, 151 Division of Mental Hygiene, 10 Dix Hall, 15, 20 dmHas (Department of Mental Health and Addiction Services), 141, 191 dmR (Department of Mental Retardation), 69–70, 191 Donlon, Elizabeth, 86–89 Doverman, Max, 12, 13, 14 Dowling, Kevin, 124, 129, 151, 152 Downey, T. Wayne, 25–27 Drew University, 1 dss (Department of Social Services), 191 Duffendack, Kathy, 62 Dulio, Don, 95 Dunbar, Darlene, 194, 197, 200–201 Durham, George, 65, 68, 71 early intervention, 147 East campus (old Riverview), 122, 140, 143, 145, 164, 180 educational funding, 89–91 educational guidelines, state and federal, 167–72 educational services: for adolescents, 173–74; and autistic children, 69, 174; Bridgeport Family Day School, 90, 101, 166; CJts, 23, 143, 170, 195; and dCf, 91; high school, 173–79;

Jake’s Place, 76–77; Long Lane School, 40, 90, 115, 154; and the merger, 163–67; Pueblo residential unit and school, 122, 129, 143, 144– 48, 164, 182–85, 183–84. See also RiverView School educational treatment philosophy, 40, 69, 81, 83, 174–75 “Effectiveness of Six Core Strategies Based on Trauma Informed Care in Reducing Seclusions and Restraints at a Child and Adolescent Psychiatric Hospital” (Azeem et al.), 202–3 Elmcrest Hospital, 110 emergency admissions, 22 emergency procedures, 119, 188 England, Eleanor, 62 Erikson, Eric H., 206 Ettenberg, Ruth, 112 facilities: for adolescents, 6, 100– 101, 104–5, 122, 176–77; for autistic children, 6, 22, 29–30, 35, 45, 68; for Children’s Unit (CvH), 5, 21, 34; conditions of, 15–16, 20–21, 100–101, 176–77; construction of, 6, 34–35, 105, 121–22; and cottage institutions, 6, 9–10, 34–35, 64–70, 79–81, 121, 168; destruction of by patients, 70; lack of, 8, 13; and medical model of treatment, 58; timeline of, 6. See also residential units Fairfield Hills Hospital, 10, 98 family therapy room, 112 Farmer, Marjorie, 14, 22 Federal Children with Disabilities Act, 178 federal education guidelines, 167–72 Field, Izzy, 96 field trips, 18–19 Finkelstein, Sydney, 17

Index “flexible funding” model, 189–90 Flood, Kathy, 57 Flynn, Betty, 19 foster care, 2–3 Frank, Tom, 30 Fredricks, Karen, 37 French, Edward, 110, 112, 113 Friedman, Robert, 186–87 Friez, David, 57, 61, 101, 127 funding: of Albert J. Solnit Center, 206–7; and aso, 191; and construction, 21, 110; and dCf, 187–90; educational, 89–91; “flexible,” 189–90; and legislation, 9–10; and limitations, 42; and media attention, 6; and RiverView School, 89–91 fund-raising, 63, 96, 182 Fuqua, Willie, 19, 94 Garber, Norton, 36 Gewirtz, Herbert, 12, 13, 14–15, 16–17 Gilead House (now Gilead Community Services), 4 Gilman, Tom, 131, 137 Glasser, William, 40, 83 Goldberg, Lewis, 62, 126, 135 government assistance, 6, 27 Gracon, Sylvia, 23 Graffignino, Ned, 30 Grasso, Ella, 59, 62 Green, William F., 11 group living, 37, 43, 93–94, 102, 161, 192 group psychotherapy, 12 Gruendel, Janice, 107 Gurwitt, Alan, 36 Hagen, Jean, 161 Harrington, Mark, 122, 125–26 Hartford Advocate, 200 Hartford Courant, 6, 15–16, 30, 43 Haviland Hall, 65, 68 Haxton, Robert, 103, 122, 124–25, 134

265

Hayden, Lisa, 151 Hayms, Michael, 62 “Helping Children Deal with Loss” workshop, 111 Hewitt, Jeffrey, 71, 76 Hickox, David, 37 Highland Heights, 30–31 High Meadows Residential Treatment Facility: and administrative changes, 112, 118; closing of, 201; comparison of treatment philosophies, 25–26; departmental conference, 115; and governmental educational guidelines, 90; origins of, 5, 10–11; and S. Newkirk, 165–67 high school, 173–79 Hirshman, Donna, 57 Hodge, Loretta, 60 Hodge, Steven, 68, 76–77, 83 Holy Apostles Seminary, 92 hospital designation, 46 hospitalization: and admissions, 9, 35, 111, 192; appropriateness of, 3, 21, 45, 69, 108, 192; involuntary, 38–39; long-term, 26, 51; partial, 35, 108, 110–11, 113; post-hospitalization, 131; safety during, 163 Housatonic Adolescent Hospital: and Adams House program, 152; closing of, 174–75; and dCf, 98; history of, 98; and the merger, 150, 164–67, 195; review of, 110; staff of, 98, 117– 20, 129–30; and treatment philosophies, 122–24, 128 House Bill 441, 5, 9 Houser, Chuck, 165 Hubbard (Evaluation) Unit, 103, 155 Hull, Margaret, 37 hydrotherapy room, 22, 62, 64, 246n1 iCp (Intensive Care Program), 154 iCu (intensive care unit), 35, 70–72

266

Index

individual education plans (ieps), 172–73, 176 individual treatment plans (itps), 172–73 Inglis, Dorothy, 11 insane asylums, 5, 45–46 Institute of Living, 14, 30, 62, 150 insurance reimbursement, 142 intake policy, 35, 39–40, 150 Intensive Care Program (iCp), 154 intensive care unit (iCu), 35, 70–72 involuntary hospitalization, 38–39 ITPs (individual treatment plans), 172–73 Jake’s Place, 76–77 Johnson, Louise, 12 Johnson, Yvonne, 62, 84, 95, 111, 113, 114 Joint Commission on Accreditation of Health Organizations (JCaHo), 109, 123, 128, 130, 132, 142–43, 196 Joint Commission on Accreditation of Hospitals (JCaH), 62, 84, 86, 101, 109, 113, 134 Joint Committee of State Mental Hospitals, 10 Joint Committee on the Children’s Unit, 28 Jones, Joyce, 99, 103 Journal of Child and Adolescent Psychiatric Nursing, 202 Journal of Orthopsychiatry, 11 Judson, Krista, 129 juvenile court, 8, 13, 28 juvenile delinquents, 71 juvenile justice system, 156, 160 juvenile review committees, 111 Kaczmarek, Adam, 131–34 Karpinski, Janice, 103, 122

Karwan, Mike, 12, 57, 92 Kass, Andrew, 124 Kennedy, Bobby, 51 Kennedy, Dave, 67 Kettle, Ronald, 11 KidCare program initiative, 136, 159, 187, 190, 192 Kiwani residential unit (Cottage C), 45, 79, 143, 149–50 Klemba, Jane, 80, 162–63 Knitzer, Jane, 186 Kovall, Karen, 169–70, 182–85 Lakota residential unit, 143 Lamstein, Matt, 3, 55 Landau, Jeffrey, 149–50 Langlois, Jerold, 23, 57 Launi, Charles, 4, 31, 32, 34, 42, 57, 60–61, 101–2 leadership style, 129, 193 Learning Center, the, 86–89 Lee Crabtree Associates, 22 legislation, 5, 6, 59, 89–90, 100, 178, 194 length of stay, in hospitals, 7, 109, 140–41, 146, 152–53, 192, 204 Leonard, Charles, 10–11, 16, 17, 30 Lester Case Study, 47–50 Lewis, Melvin, 22 Lippman, Abraham, 45 Lobis, Robert, 126, 145 Long Lane School, 40, 90, 115, 154 long-term hospitalization, 26, 51, 108 long-term inpatient treatment, 8, 22 Lustick, Michael, 103, 104 Lynch, John, 103, 126 mainstream, 50, 76, 178 Malinowski, Chris, 153, 159–60 Maloney, Frank, 61 managed-care philosophy of treatment, 109, 161, 191–93

Index management philosophies, 106–7, 132–34 Manhasset residential unit, 144, 152– 60, 175 manuals for cottage programs, 80–81 Marchand, Gene, 198 Marcus, Mark, 61 Marsh, Elias J., 10, 11 Marshall, Peter, 4, 5, 30–33, 34–37, 40, 42, 64, 82 Martinez, Jorge, 189 Maslow, Abraham, 1 McCain, Judith Raczkowski, 22, 29– 30, 93, 112, 114 McConaughy, James, 9 McDermott, Rita, 62 McGavin, Brenda, 112 McRae, Willard, 189 measure of treatment, 74–76, 75 mechanical restraints, 7, 132–33, 140, 148–49, 152–53, 201–2, 203 media attention, 6, 7, 15–16, 30, 43, 199, 200, 204–5 Medicaid requirements, 109, 135 medical model of treatment: adapting to, 173, 178, 186; at Altobello Adolescent Hospital, 122–23, 128; and child psychiatrists, 104, 128; and children’s wards, 46; and facilities, 58; and leadership style, 129; and medications, 126, 173, 181–82; and the merger, 7, 79, 97, 117–18, 122, 126, 130, 135, 160; and milieu treatment philosophy, 5; restrictions of, 181; and Riverview Hospital for Children and Youth, 109; utilizing aspects of, 58, 102 medical records, 60, 97, 112 Medical Staff Organization, 109 medications: and child psychiatrists, 44, 159; and medical model of treat-

267

ment, 126, 173, 181–82; and nurses, 23; and staff, 25; in treatment philosophies, 149, 157–58 Mendelson, Peter, 194, 197, 199 Mental Health Association, 14 Mental Health Facilities Standards, 142 Mental Health Services Administration, 139 mental health treatment philosophy, 1, 39–40, 69, 108, 186–93, 205 merger: and accreditation standards, 130, 142–43; and adolescents, 6–7, 117; Altobello Adolescent Hospital, 112, 117–29, 155, 163–67, 195; and Bleu program, 122; change to medical model of treatment, 7, 79, 97, 117–18, 122, 126, 130, 135, 160; and construction, 118, 120–22, 134; and C. Sundell, 7, 118–20, 122–23, 126–27; dCf, 124, 162–63; and educational services, 163–67; Housatonic Adolescent Hospital, 150, 164–67, 195; and L. Ando, 7, 118–20, 135; and learning from the past, 200; and nurses, 117– 18, 129–31, 134; and recreational services, 173, 175, 179, 181; and R. Wiseman, 127; and Silvermine Building, 16, 105, 112, 117–19, 120, 121–22; volunteers, 195–96 Meridith, Charles, 15 Merritt Hall, 5, 22–23, 29, 64, 67, 79, 82, 98, 99 Merry, David, 37 Meskill, Thomas Joseph, 6, 41–42, 45, 69 Michigan State University (msu), 3, 15, 47, 50, 63 Middlesex Community Collaborative (formerly Middlesex System of Care group), 188, 194

268 Middlesex Community Hospital, 37 Middlesex County, Connecticut, 188– 89 Middlesex Hospital Family Advocacy Program, 188 Middlesex Interagency Council, 112 Middlesex Memorial Hospital, 111 Middletown Head Start program, 111 Milardo, Carmelo, 61 milieu treatment philosophy: and adolescents, 80–81; and behavior modification techniques, 65–66; clinical staff, 40; L. Ando on the, 142; measure of, 74–76, 75; and medical model of treatment, 5; and mutual aid model, 155–57; and recreational services, 58. See also aBCd milieu program Miller, Frederick, 67, 79 Miller, Robert, 19 mobile emergency program, 188 motor-math program, 68 Munez, Fernando, 201 Muno, Helen, 122 Murphy, Jim, 67 mutual aid model of treatment, 155– 57 Nalewajek, Anthony, 83 Narad, Joan, 129–30, 145–48, 200 National Association of State Mental Health Program Directors (nasmHpd), 203 National Institute of Mental Health (nimH), 186–87 Neff, Marcie, 201, 204 Neilson, Neil, 115 Nelson, Louise, 16, 18, 19 New England Psychologist Directory of Psychiatric Hospital and Units (2004), 143–44 New Hampshire College (now South-

Index ern New Hampshire University), 114–15 New Haven-Middlesex Chapter of the Connecticut Psychiatric Society, 28 Newkirk, Sarah, 164–67, 168 New Learning Environment, A (Cohen), 71 New London County, Connecticut, 188–89 Niedoroda, Cindy, 57 nimH (National Institute of Mental Health), 186–87 No Child Left Behind federal standard, 169–70 Nolan, Donna, 99, 249n2 Nolan, Gary, 96–97 No Nexus Unit, 166 nonverbal communication, 64–68 Normandin, Judith, 101–4, 114, 128 North Campus (formerly The Children’s Place), 205 Norwich Hospital, 3, 10, 11, 51, 52, 55, 59, 61, 127 nurses: on Children’s Unit, 23; and Clinical Staff Organization, 113; Connecticut Nurses Association, 115; and hospital structure, 16; interns, 189; and medications, 23; and the merger, 117–18, 129–31, 134; and residential units, 144, 146, 162, 177; and treatment philosophies, 40 Oates, Bob, 98, 102–3 O’Brien, Eugene, 36 O’Brien, Jacqueline, 113 occupational therapy room, 183 O’Day, Jack, 18 Office of the Child Advocate, 194, 201, 204 Olson, Lynn, 186 O’Neil, Nancy, 103 open-door halfway house, 103

Index The Other 23 Hours (Brendtro, Whittaker, and Trieschman), 36 outpatient care, 111 Paige Hall, 20 parenting skills workshop, 111 parents of children needing treatment, 44, 65 partial hospitalization program (pHp), 35, 108, 110–11, 113 Passaic (formerly Adama) residential unit, 144, 150, 151–60 Pathfinder Workshop, 107 patient designation, 56, 58, 130 Patterson, Earl, 101 Pawelkiewicz, Walter, 107 Peace Corps, 3, 51 Pease-Grant, Marcia, 19–21, 24, 29, 37, 126, 150, 154 pedagogies, evolving, 105 pediatric services, 37, 147–48 Peet, Melodie, 7, 60, 194–97, 198–200 Peplow, Suzanne, 19, 23–25, 29 Perlman, Lou, 16–17, 19 Perrin, Edward, 101 peRsY (Psychiatric Emergency Response System for Children and Youth), 188 pervasive developmental disorder diagnosis, 69 Peschuri, Sangeeta, 160–62 pet therapy, 108, 180–81 philosophies. See treatment philosophies “A Philosophy of Treatment and Education (1970–1971)” annual report, 39–40, 42–43 pHp (partial hospitalization program), 35, 108, 110–11, 113 physical restraints, 16, 103, 132–33, 138–40, 148–49, 163, 202–3, 203, 250n3

269

Pin Oaks Project, 96 placement services, 5, 38–39 Plant, Robert, 7, 137–42, 192, 194 play groups, 111 play therapy, 3, 47–50, 111 pnmi (private, non-medical institutions), 109–10 politics, 16–17, 30, 101 positive reinforcement, 81 pre-admission interviews, 41, 151, 160 President’s Commission on Mental Health’s Select Panel for the Promotion of Child Health (1978), 186 principals, 164–67 private, non-medical institutions (pnmi), 109–10 private hospitals, 108, 134, 192 program development, 5–6, 38, 98– 105, 110–12 Program Review and Evaluation Unit, 197–98 Project Adventure, 96, 249n2 “Proposed Future Hospital Recommendations for Children’s Services” (1963), 17–18 Prue, Tom, 93, 113, 126 psychiatric consultation services, 5, 30, 36–37, 111, 147 psychiatric emergencies, 38 Psychiatric Emergency Response System for Children and Youth (peRsY), 188 psychiatric study homes, 8–10 Psychoeducator Training Program, 114 psycho-pharmacology. See medications psychotherapy, 12 psychotic children designation, 8–10, 13 Public Act 77-43, 6, 59 Public Works Department, 105

270

Index

Pueblo residential unit and school, 122, 129, 143, 144–48, 164, 182–85 Pugliesi, Richard, 151 pupil services staff, 172 quiet room, 80, 247n7 Quinebaug, Camp, 3, 4, 24, 31, 41, 51, 52–58 Quinipiac residential unit, 143, 148– 49 Quinto, Ronald, 62, 82, 166 Ragaglia, Kristine, 131, 136, 187 Randazzo, Dolores, 92 reaccreditation, 134 Reale, Susan, 12, 24–25, 92 Reardon, Jacqueline, 36, 113 recreational services: for adolescents, 92–93; for autistic children, 57, 67– 68, 95–96; Bleu program, 72, 76, 94; building of staff for, 12, 23, 30, 40; and Camps, 3, 4, 24, 51, 52–58, 65; on Children’s Unit, 92–97; evolution of, 98–99; facilities for, 100– 101, 104; and group living, 93–94; and the merger, 173, 175, 179, 181; and milieu treatment philosophy, 58; origins of, 6, 18; and RiverView school, 95–96; staff, 12, 23, 30, 40, 92–97, 106, 108, 110, 123; and Sunburst program, 81; volunteers for, 51, 92–93, 96–97 referral services, 5, 38–39 Regan, David, 83 Rehabilitation Departments, 92, 99, 173 rehabilitation model of treatment, 97, 108, 126, 144, 206 Renn, Irving, 19, 82 request for proposal (Rfp), 188 Residency Training Program, 38 residential treatment model: and

Amy Wheaton, 117; and community resources, 146; and dCf, 98; and Housatonic Adolescent Hospital, 122; need for, 8; at Riverview Hospital for Children and Youth, 102; timeline of, 5, 7; utilizing aspects of, 58 residential units: and aBCd milieu program, 144; Acadia, 144, 150, 152–60; Bleu ii, 120, 163; campus overview of, 143–44; Kiwani, 45, 79, 149–50; Lakota, 143; Manhasset, 144, 152–60, 175; and nurses, 144, 146, 162, 177; Passaic, 144, 150, 151–60; Pueblo, 122, 129, 143, 144–48, 164, 182–85; Quinipiac, 143, 148–49; Sachem, 144, 160–64, 175; and Silvermine Building, 53, 143, 164, 182; and treatment philosophies, 151 Resnick, Jay, 169, 173, 174–76 respite programs, 159, 189 Ressler, Lyle, 60, 113, 122 restraints: mechanical, 7, 132–33, 140, 148–49, 152–53, 201–2, 203; physical, 16, 103, 132–33, 138–40, 148–49, 163, 202–3, 203, 250n3 Rfp (request for proposal), 188 Rich, Charles, 43–44, 45, 62, 149 Riverview Auxiliary, 63, 96, 182 Riverview Child and Adolescent Psychiatric Hospital, 7 Riverview Hospital for Children, 59–63, 106–16. See also Children’s Unit (CvH) Riverview Hospital for Children and Youth: administrative changes, 126–30, 198–201; age limit of admissions, 197; C. Sundell on, 118–23; facility construction, 121–22; under hospital standards, 142–43; L. Ando on, 130–31; management philoso-

Index phies, 132–34; and medical model of treatment, 109; as new Albert J. Solnit Children’s Center, 205; as new name of merged hospitals, 117; and reaccreditation, 134; and residential treatment model, 58; staff of, 61–62; as training hospital, 204; transfer of adolescents, 7; and treatment philosophies, 122–26; waiting time reduction, 203 River Views, 96 RiverView School: administrative changes, 164–65; dedication ceremony for, 6, 45; educational philosophy, 83–86; funding, 89–91; and Learning Center, 86–89; original, 180–82; recreational services, 95–96; student teaching at, 108; unification with hospital services, 82–83 Roccanello, Chris, 96 Rogers, Carl, 1 Rokeach, Milton, 1 role-playing, 71–72 Rollefson, Virginia, 62 Root, Mark, 76, 124, 202 Rossi, Linda, 131 rotating shifts, 113–14 Rusczek, Frank, 154 Russell Hall, 99, 100 Russo, Terry, 60 Ryder, Ellen, 61, 101, 102, 127–28 Sachem residential unit, 144, 160–64, 175 Saint Raphael Campus (Yale-New Haven Hospital), 39 Salcedo, Louis, 62 Sarason, Seymour, 112 Sarofin, Michelle, 7, 202, 204, 205 Schact, Herb, 115 scheduling philosophies, 123

271

schooling. See educational services Schools Without Failure (Glasser), 40, 83 Seabury, Brett, 55 Seagull Cottage, 79–80, 148 seclusion, 103, 132–33, 138–40, 202–3, 203 secondary school, 173–79 Segal, Leslie, 126 Select Committee for Children, 200 Senate Bill 1441, 89–90 Senate Bill 1446, 6, 59, 100 separation of children and adults, 18, 31–32, 59 Service Corps, 3–4, 40, 50–51, 57 service review team (sRt) model of care, 189 Sheehan, Laureen, 188 Shepard, Ernest, 43 Shew Hall, 5, 20 Shukis, Edward, 67–68, 84, 180 Shuman, Dwight, 36 Siegel, Leslie, 159, 200 Siegel, Sarah, 57 Silvermine Building: as autistic children facility, 45, 66; Bleu program, 152, 182; as central building of the Children’s Unit, 5, 21, 34; construction of, 17; housing medical records, 60; as intensive care unit, 70; Jake’s Place and, 76; and the merger, 105, 112, 120, 121–22; Pueblo residential unit as addition to, 53, 143, 164, 182; temporary accommodations in, 35 Silvermine Complex, 6, 41, 82 Sinkewicz, Robert, 128, 154–59 “Six Year Progress Report of the Children’s Program” (1971), 43 social work, 24, 27, 31, 108, 111, 144 Social Work Department, 150, 155, 175 Solnit, Albert, 30

272

Index

Sotir, Alex and Norma, 52 South Campus (formerly Riverview), 205 Southern Connecticut State University, 108, 114 Spaulding, Allan, 62, 82 Spaulding, Andrea, 15, 92 special education students designation, 172 sRt (service review team) model of care, 189 staff: of Altobello Adolescent Hospital, 23, 96, 99, 149, 150, 154, 176–77, 183; clinical, 24, 37, 40, 45, 70, 107, 109–10, 113, 114; consolidation of, 120; continuing education for, 40, 114–15; deprofessionalization of, 130; and discharge process, 38, 180; of Housatonic Adolescent Hospital, 98, 117–20, 129–30; interaction with children, 71, 77–79, 132–33; limited, 12; and medications, 25; pupil services, 172; recreational, 12, 23, 30, 40, 92–97, 106, 108, 110, 123; of Riverview Children’s Hospital, 61–62; and rotating shifts, 113–14; scholarship of, 204; services provided by, 60, 110–12; shortages, 41; training of, 113, 138– 40, 202 Stahl, Margery, 6, 7, 23–24, 29–30, 35– 37, 104, 112–14, 117–19 State Advisory Committee, 190 State Bureau of Mental Hygiene, 8 State Child Welfare Division, 8 State Receiving Home at Warehouse Point (now The Children’s Place [tCp]), 127, 198 Stewart, Al, 92 Stewart, Margaret, 76, 92, 182, 195 St. Jean, Diane, 37 Stroul, Beth A., 186–87

structure of services, Children’s Unit, 36–40 Stubbe, Dorothy, 126 student teaching, 108 study homes, psychiatric, 8–10 Subcommittee on Operations report, 8–10 substance abuse, 136, 157 Substitute Bill 198, 194 Suchutliff, Leonard, 98 Suerken, Robert, 90–91, 167 summer school, 40 Sunburst Cottage, 79, 80–81, 83, 148, 162–63, 235–43 Sunburst Program Manual, 80 Sundell, Carl: background of, 23; and Camp Quinebaug, 24, 57; as consultant at High Meadows, 112; director of recreation, 92–93; and the merger, 7, 118–20, 122–23, 126– 27; quality assurance tasks, 62; retirement of, 131; on Riverview Hospital for Children and Youth, 118– 23 Suttenfield, Virginia, 37 A System of Care for Severely Emotionally Disturbed Children and Youth (Stroul and Friedman), 186–87 System of Care initiative (formerly Cassp model), 187–88 Task Force on Mental Health Services for Children (1965), 43 Taylor, William, 62 tCp (the Children’s Place). See Connecticut Children’s Place (tCp) teaching assistance, 111 therapeutic milieu. See milieu treatment philosophy Thomas, John, 16 Tirado, Wilson, 149–50 token economy program, 71–72, 77

Index Towbin, Kenneth, 114, 126 Tracy, James, 37 training manuals, 71, 211–18, 219–34, 235–43 Trasente, Arnold, 197–98 treatment philosophies: and behavior modification techniques, 65–66; comparison of, 25–26; development of, 39–42, 45–47; and discharge process, 151; educational, 40, 69, 81, 83, 174–75; group living, 43; and High Meadows Residential Treatment Facility, 25–26; Housatonic Adolescent Hospital, 122–24, 128; and managed care, 109, 161, 191–93; medications, 149, 157–58; and mental health, 1, 39–40, 69, 108, 186–93, 205; and nurses, 40; residential treatment model, 58; on residential units, 151; and restraints, 132–33; Riverview Hospital for Children and Youth, 122–26 Trieschman, Albert E., 36 Trinity College, 92 Unclaimed Children: The Failure of Public Responsibility to Children and Adolescents in Need of Mental Health Services (Knitzer and Olson), 186 Undercliff Hospital, 52, 100, 104, 107 unification, 13, 14–19, 82, 104–5, 205 University of Connecticut, 108, 197, 198 University of Connecticut School of Social Work, 37 Valentine, Ken, 178 Value Options (administrative service organization), 191 Ventrelli, Anthony, 176–79 voluntary admission, 6, 13, 60 volunteers: community, 2, 108, 206;

273 Connecticut Valley Adolescent Unit, 98–99; and the merger, 195– 96; from Psychology Department (CvH), 24, 45; for recreational services, 51, 92–93, 96–97; staffing the early Children’s program, 12; from Wesleyan University, 4

waiting time, 201–4 Walker-Huff, Susan, 62–63 Walsh, William, 115 Ward 91 (all-girl unit), 37 Ward 92 (all-boy unit), 23 Weeks Hall, 5 Wehage, Roger, 37 Welch, Joyce, 7, 198–202, 204 Wells, David, 95–96 Wesleyan University, 3–4, 9, 52, 55, 71, 92 West campus (new Riverview), 122, 143–44, 145, 183 Wheaton, Amy, 67, 82–83, 84, 117 Whiting, Harry S., 11–13, 15, 16–17 Whittaker, James K., 36 Wild, Ann, 57 Willard, Marilyn, 57 Williams, Janet, 200–201 Wiseman, Eunice, 18–19, 51, 52, 55 Wiseman, Richard: background of, 1–4, 5–6; in charge of Autistic Unit, 64, 68; as co-director of the Children’s Unit, 31–33, 41–42, 58; and continuing education for staff, 40; and the merger, 127; providing staff education, 40; retirement of, 6, 115–16 Wissier, Rosemary, 57 Woodward, Dolores, 164, 167 Woolston, Joseph, 190 Yale Child Psychiatry Training Program, 62, 149, 160

274

Index

Yale Child Study Center, 5, 8, 22, 30, 62, 145, 149, 204 Yale University School of Public Health Administration, 60, 194 Young Parents Assistance Program, 111

Zeigler, Edward, 45 Zeller, William W., 14 Zera, Gary, 99–100, 101, 124 Zera, Ronnie, 96, 99, 103, 126 Zitnay, George, 83, 164–65

titles witH asteRisks (*) aRe also in tHe dRiftless ConneCtiCut seRies

Dennis Barone, editor Garnet Poems: An Anthology of Connecticut Poetry Since 1776* Michael E. Bell Food for the Dead: On the Trail of New England’s Vampires Jon C. Blue The Case of the Piglet’s Paternity: Trials from the New Haven Colony, 1639–1663* Peter Bohan and Philip Hammerslough, Introduction and Notes by Erin Eisenbarth Early Connecticut Silver, 1700–1840

Brad Davis, editor Sunken Garden Poetry, 1992–2011 Dan W. DeLuca, editor The Old Leather Man: Historical Accounts of a Connecticut and New York Legend Richard DeLuca Post Roads & Iron Horses: Transportation in Connecticut from Colonial Times to the Age of Steam* Anne Farrow The Log Books: Connecticut’s Slave Trade and Human Memory* Dr. Mel Goldstein Dr. Mel’s Connecticut Climate Book

Al Braden The Connecticut River: A Photographic Journey through the Heart of New England

David K. Leff Hidden in Plain Sight: A Deep Traveler Explores Connecticut

Susan Campbell Tempest-Tossed: The Spirit of Isabella Beecher Hooker

David K. Leff Maple Sugaring: Keeping It Real in New England

James Clark Connecticut’s Fife & Drum Tradition*

Eric D. Lehman Becoming Tom Thumb: Charles Stratton, P.T. Barnum, and the Dawn of American Celebrity* Eric D. Lehman Homegrown Terror: Benedict Arnold and the Burning of New London* Laurie Lisle Westover School: Giving Girls a Place of Their Own Dione Longley and Buck Zaidel Heroes for All Time: Connecticut’s Civil War Soldiers Tell Their Stories*

James F. O’Gorman Henry Austin: In Every Variety of Architectural Style Brian O’Rourke Breakfast at O’Rourke’s: New Cuisine from a Classic American Diner Jon E. Purmont Ella Grasso: Connecticut’s Pioneering Governor* Jerry Roberts The British Raid on Essex: The Forgotten Battle of the War of 1812*

Kevin Murphy Crowbar Governor: The Life and Times of Morgan Gardner Bulkeley*

Chandler B. Saint and George Krimsky Making Freedom: The Extraordinary Life of Venture Smith

Kevin Murphy Fly Fishing in Connecticut: A Guide for Beginners

Leslie Starr Welcome to Wesleyan: Campus Buildings

Kevin Murphy Water for Hartford: The Story of the Hartford Water Works and the Metropolitan District Commission

Markham Starr Barns of Connecticut

Elizabeth J. Normen, editor African American Connecticut Explored

Renée Tribert and James F. O’Gorman Gervase Wheeler: A British Architect in America, 1847–1860*

Matthew Warshauer Connecticut in the American Civil War: Slavery, Sacrifice, and Survival*

Richard Wiseman Riverview Hospital for Children and Youth: A Culture of Promise*

Matthew Warshauer Inside Connecticut and the Civil War: One State’s Struggles

Jelle Zeilinga de Boer Stories in Stone: How Geology Influenced Connecticut History and Culture

Donald E. Williams Jr. Prudence Crandall’s Legacy: The Fight for Equality in the 1830s, Dred Scott, and Brown v. Board of Education*

Jelle Zeilinga de Boer and John Wareham New Haven’s Sentinels: The Art and Science of East Rock and West Rock*

For more information on the Driftless Connecticut Series, please visit us online at http://www.wesleyan.edu/wespress/driftless

RiCHaRd wiseman holds a doctorate in clinical psychology from Michigan State University. He started his hospital career in 1962, when he moved to Portland as a psychologist at Connecticut Valley Hospital in Middletown. In 1964, he developed a summer camp program for the state’s psychiatric patients. That’s when he first came in contact with the state’s youngest psychiatric patients—the children. In 1969, Wiseman was named codirector of the children’s unit and helped ready its move in 1971 into a new facility. In 1975, all mental health services for children were transferred to the Department of Children and Families; the facility was renamed Riverview Hospital, and he became superintendent. Since his retirement from Riverview in 1989, he has taught psychology at Middlesex Community Technical College and he was coordinator of the Child and Adolescent Service System Program (Cassp) for Middlesex County. He lives in Cromwell, Connecticut. louis ando was the superintendent at Riverview Hospital for Children and Youth from 1997–1999 and has also served in several leadership roles at the Connecticut Department of Children and Families. He lives in South Glastonbury, Connecticut.

aBout tHe dRiftless ConneCtiCut seRies The Driftless Connecticut Series is a publication award program established in 2010 to recognize excellent books with a Connecticut focus or written by a Connecticut author. To be eligible, the book must have a Connecticut topic or setting or an author must have been born in Connecticut or have been a legal resident of Connecticut for at least three years. The Driftless Connecticut Series is funded by the Beatrice Fox Auerbach Foundation Fund at the Hartford Foundation for Public Giving. For more information and a complete list of books in the Driftless Connecticut Series, please visit us online at http://www.wesleyan.edu/wespress/driftless.