At Little Ark, every waking moment of a patient's life is governed by the
Psycho-Educational Model, or PEM, which is a highly sophisticated and
rigidly structured program for behavior modification developed by Boys Town
and licensed by them for use in psychiatric hospitals and Special Education
programs throughout the country.
Utilizing PEM, the minutest details of a patient's behavior in his or her
daily routine are closely scrutinized, and then quantified with points;
positive points are earned for appropriate behavior, especially meeting
individual "target skills," and negative points are earned for
inappropriate behavior. A patient earns positive points, usually twenty
five at a time, for successfully performing the minutiae of daily
living---rising on time, brushing one's teeth, dressing, etc. Negative
points are earned for failure to perform these tasks in a satisfactory
manner, as determined by the staff. In school, up to one hundred points
can be earned in each class for such things as "participation,"
"following instructions," or even "cleaning up."
Demonstration of a "target skill," perhaps saying
"please" or "thank you," earns double points.
Conversely, negative points, usually in multiples of one hundred, are
earned for negative behavior. Points, negative as well as positive,
continue to be amassed throughout the late afternoon and evening, with
positive points earned for participation in after-school activities,
preparing for bed, etc.
Positive and negative points are recorded on colored sheets of paper, each
entry signed by a staff member, which the patients must carry with them at
all times. Loss of a sheet results in an automatic two-hundred-point
penalty on the replacement sheet. The color of a patient's sheet indicates
a patient's level of achievement on the previous day.
A white sheet, or "level A," indicates that the child had a final
balance of at least thirteen hundred positive points the previous day, and
thus is entitled to certain special privileges, i.e. being able to buy two
items instead of only one at the snack bar run by the "merchandising
group," permission to play video games in the cottage, taking showers
first, or freedom to leave the hospital grounds with a parent or social
A green sheet, "level B," indicates that the patient accumulated
a total of at least eleven hundred points the previous day, and the
privileges for this patient are only slightly fewer than for those children
on "level A."
A gold sheet, "level C," indicates the accumulation of less than
nine hundred positive points, and usually means that the child experienced
trouble on the cottage or in school the previous day. "Level C"
patients must take their showers last, may not play video games or buy
anything from the snack bar.
A blue sheet is a warning to other patients and staff that a child is on a
Critical Care level, and is indicative of serious misbehavior, usually of a
violent nature. A child on a Critical Care level must be accompanied at all
times by a Therapy Aide, most often a burly male. The amassing of positive
points is not enough, in itself, to get a child off a CC level. Points
earned by the patient are kept in a "bank account" on the cottage
until the child has demonstrated to the staff that he is no longer a threat
to himself or others.
Refusal to carry a sheet immediately lands a patient in the Alternate
School Program, a kind of educational solitary confinement and the
hospital's equivalent of an Island of Lost Souls.
The goal of PEM is the immediate reinforcement of positive behavior and the
discouragement of negative behavior. Most, if not all, of the children who
end up in Little Ark have experienced nothing but criticism and personal
devaluation all their lives. They have repeatedly been told that they are
"bad" or "worthless," and they have absorbed this
lesson deep into their psyches. As often as not their frequently bizarre
behavior patterns are learned methods of getting their needs met in totally
dysfunctional social situations. In the past, negative behavior was their
only means of achieving positive results, such as getting attention. It is
this Gordian knot of self-destructive behavior that must be untied and
redone, squared into new behavior patterns that are acceptable and useful.
The staff at Little Ark is trained to "catch them being good" and
immediately award positive points for observed positive behavior, and to
this end teachers and cottage staff must often react spontaneously, in
contrast to the predictable awarding of positive points for following
From an early age, often since infancy, most of these sexually abused,
physically and emotionally battered children have dammed up their emotions
behind a wall of confusion, grief, pain, and sheer terror. Even being aware
of what they are feeling and why, much less being able to share their
feelings, can be extremely difficult, and so "expressing
feelings," such as a patient telling a staff member that he or she is
disappointed because a family member did not show up for a scheduled
meeting, as opposed to acting them out in assaultive or other negative
behavior, is an act that is virtually always rewarded on the spot with
Conversely, negative behavior such as physical or verbal assault instantly
results in the awarding of negative points, usually in measures of one
hundred depending on the seriousness of the offense. Failure to accept the
negative points, which the patient must record on his or her sheet and have
signed by the staff member, results in additional negative points for
"not following instructions." If six hundred negative points have
been awarded and the patient still refuses to comply, which is often the
case, or if the patient becomes verbally abusive or explodes in rage, which
also frequently happens, a Crisis Intervention Team, or CIT, will be
A Crisis Intervention Team consists of two or more Therapy Aides, one
always a woman, who have been extensively trained in the techniques of
non-injurious restraint. A CIT will also include a nurse, and either the
cottage psychiatrist or a psychiatrist on call. The members of the CIT will
first attempt to "talk the patient down," allowing the child to
bring himself under control, accept the negative points and remain in
class. If this strategy does not work, the patient will be taken back to
the cottage---by force, strapped into a stretcher, if necessary---where the
accumulation of negative points will be recorded. An alternate strategy,
which can only be initiated on the orders of a psychiatrist, involves
wrapping the patient in a "calming blanket," actually a heavy
canvas sheet, for up to fifteen minutes.
A patient may at any time request extra medication to help him or her calm
down, and a nurse will bring it in pill or liquid form to be taken orally.
If a patient refuses to voluntarily take medication and remains in a
hyperactive state, a psychiatrist may order an injection of a tranquilizer,
usually Thorazine, if it is required to calm a patient. After the
injection, which is usually administered in the buttocks, the patient will
be forcibly removed to the cottage, where he or she may be strapped onto a
bed in a procedure called "four-point restraint" until the drug
takes effect and the patient is no longer deemed out of control. Little Ark
has the highest incidence of four-point restraint among mental hospitals in
the state, but it is also the most sparing in its use of potentially
dangerous and crippling psychotropic drugs.
In the event of two or more patients displaying explosive behavior at one
time, as in the case of occasional riots on the cottages, "Dr.
Redstone" is paged on the PA system and asked to come to the affected
area or areas. "Dr. Redstone" is a code signaling that all
available personnel should converge as quickly as possible, preferably on a
dead run, to the trouble spot.
Under PEM, if a child accepts and records on his sheet the awarding of
negative points before the CIT is called, he is, either immediately or
later in the day, permitted to earn back positive points, up to half the
negative points previously awarded, by "practicing" a particular
skill---usually a recitation of desirable behaviors in a stressful
situation. Thus, if a child has earned two hundred negative points for
aggressive behavior, he or she may earn back one hundred positive points by
citing the four specific behaviors associated with the target skill of
"Avoiding Conflict": walk away; don't encourage the continuance
of conflict; ask staff for assistance; follow staff's instructions.
There is a "Crisis Room" in the school, a padded area with an
overstuffed sofa and chairs staffed by two Therapy Aides, usually a man and
a woman. As an intermediate step before the CIT is called, a patient may be
sent to the Crisis Room by a teacher, or the child may go there voluntarily
if he or she feels the need to "take time out" to relieve stress.
A patient automatically receives six hundred negative points for going to
the Crisis Room, but may immediately earn back three hundred positive
points by practicing a Target Skill with an aide. Upon returning to class,
especially if the child has voluntarily removed himself to the Crisis Room,
a patient will receive from his teacher an additional fifty to one hundred
positive points for "avoiding conflict" or "expressing
feelings"---double points if the displayed behavior is the child's
individual Target Skill for the day.
The Alternate School Program is in a doubly secured area within the larger
secure complex of the hospital. ASP is where the sickest, most
intransigent, toughest and most dangerous children attend school.
A locked door midway down the corridor linking the cottages and the school
opens into a hallway ending at locked exit doors. Off the hallway are two
classrooms linked by a small area where there is a toilet and a computer
room. Except for lunch, MICA, TAP and AA meetings, ASP students spend the
entire school day in this relatively small, locked area. There is an
intercom in each of the two rooms, and a "calming blanket" is
always kept close at hand. There are always a minimum of two Therapy Aides
assigned to ASP---more when one of the children is deemed on "critical
care," often the case, since the aide assigned to that child is
responsible only for that child, and must always stay within arm's reach.
In the regular school program, patients of all ages change classes, walking
the short distances between rooms under close supervision. In ASP, the
teachers come to the patients. During the summer when Fugue is in charge of
ASP he will teach "Conflict Resolution" three times a week,
reviewing and practicing individual Target Skills with the students placed
in his care. All other subjects, including occupational and recreational
therapy, will be taught by teachers who come to the sealed-off area.
Overall responsibility for the program is Fugue's; his will be a constant
presence as he sets the tone of the classroom, constantly monitoring the
atmosphere and watching for signs of the explosive behavior that is so
common among these patients. He has been here before, as the only teacher
ever called in to substitute for John Marsden, the skilled, eternally
patient, deeply compassionate and incredibly resilient teacher who trained
in PEM at Boys Town and who is in charge of ASP during the regular school
year. Fugue knows what to expect, and he wryly views his role as a
combination ringmaster and den mother, protector not only of the patients
but also of the other teachers, not a few of whom are understandably
anxious about entering and being locked up in the tense, isolated realm
Fugue refers to as Shangri La. As Fugue sees it, the role of the therapists
and other teachers is to educate and heal the patients of Shangri La to a
point where they can leave the hospital; his sole job is to modify their
behavior to a point where they can return to the hospital's regular school
Patients are sent to ASP for a variety of reasons. Some are overtly
violent, with a long history of chronic assaultive behavior toward peers
and adults. Others are of such a height, weight, and level of aggression
that they are deemed to pose an unacceptably high potential of risk to
children and staff if given the relative freedom of movement in the regular
program. Still others have a history of "elopement," the
hospital's quaint technical term for running away. Many have made numerous
suicide attempts, or have a history of self-abuse. Many more have a history
of sexual aggression, while others have psyches so fragile that they cannot
function in the regular program. What all ASP patients share in common is
that they have been judged to require intense levels of supervision at all
Some patients are sent directly to ASP on the basis of their initial intake
evaluation, when they are kept in isolation, observed and given a battery
of psychological and intelligence tests over a period ranging from a few
days to two weeks. All patients who have been transferred from a Detention
for Youth facility for psychological evaluation are automatically placed in
ASP, regardless of their intake evaluation. The majority of ASP patients
have been transferred there after repeated episodes of violence or other
disruptive behavior in the regular school program.
ASP patients are escorted to their confined school area by Therapy Aides
fifteen minutes after the other students have gone to classes, and escorted
back to their cottages fifteen minutes before the end of school. They are
never permitted outside the locked buildings of the hospital, except, in
the case of the boys, into the fenced-in recreational area adjoining the
Intensive Care Unit. They are not permitted to attend evening social or
recreational programs with the other children.
Upon being referred to ASP, each patient must fill out a
"contract" with his or her primary therapist. The contract
specifies what pattern of inappropriate behavior was responsible for the
referral. Specific Target Skills are listed, as well as "clinical
options"---what the patient is permitted to do in order to relieve
stress, actions such as taking time out, writing in a journal, asking for
extra medication, or requesting that the teacher call the child's
therapist. Finally, except for DFY children and elopement risks, the
contract specifies exactly what the patient must do in order to be
transferred out of ASP back to the regular program. The contract is signed
by both the patient and therapist, and given to the ASP teacher.