Choosing Residential Treatment Centers with Family Engagement (When It's Necessary)

A year or so ago I commented on the real shortcomings of some residential treatment centers (RTCs) focused on child and adolescent behavior and mood problems, especially those associated with the CALO group (https://childmyths.blogspot.com/2017/07/calo-and-transferable-attachment-love.html). As we have seen repeatedly for many years now, residential treatment in the form of psychotherapeutic programs or of “specialty schools” can feature cruel, unsafe, and ineffective practices that aggravate existing problems—sometimes by forcing young people to “confess’ to behaviors that never occurred, or by using isolation and restraint as punishment.

In more than a few cases, the problems that cause a child to be placed in a RTC are ones that can be overcome by treatment of the family as a group and especially by training of parents in management skills. But often families do not realize the difficulties that are developing with a child’s behavior until adolescence is upon them and they are faced with a large, strong, defiant individual who is able to act out sexually and whose aggressive actions can have serious outcomes. When children become involved with drugs and gangs, when they threaten their parents or siblings, when they are frightening to school and neighborhood contacts, when the police are summoned, there may be few choices open except residential care.

The question is, does a RTC simply incarcerate the young person, or does it provide treatment that will make possible a return to society and a normal developmental trajectory for education and work?  How can a family decide which RTCs will provide this help, and which will simply keep the child off the streets for the time being?

Peter Gillen, writing in the September 2018 Brown University Child and Adolescent Behavior Letter (a very useful source!) notes the challenges presented by children with severe emotional disorders who present chronic safety issues in their homes, as well as in their schools and communities. He describes a “roller coaster” of treatment successes and failures that lead to continued needs for mental health care, and the revolving door of services that cuases children to think of themselves as “bad kids”. Gillen also points out the real criticisms of RTCs such as “the significant costs, the lack of empirical evidence demonstrating their clinical effectiveness, the potential iatrogenic effects from exposure to others’ maladaptive behaviors [potentially both those of other children and of staff members—JM], the disruption to the caregiver-child attachment bond, and the poor maintenance of post-discharge progress” (p. 6). As a result of these criticisms, Gillen comments, a workgroup has recommended a set of principles with shared values that should govern what they call “therapeutic residential care” (TRC).

An important principle suggested by the workgroup is “building a strong partnership with families and engaging them in a meaningful way throughout the residential process”. Family involvement and contacts appear to lead to more successful completion of treatment and better outcomes for the children. Examples of family involvement are “integrating caregivers [parents and family members] into the daily routines of the residential programming, considering caregivers as the experts of their children’s needs, and improving the overall family’s functioning”, including sibling relationships as well as relationships between parents and the child in treatment.

In an exemplary program at Bradley Hospital in Providence, RI, families participate in weekly family therapy, have phone contacts updating them on issues like schoolwork, and have home visits. At a weekly Family Night, “families are invited to attend a one-hour family-style dinner with a free meal for all, followed by a one-hour caregiver support group with free child care fro siblings. Family Night brings families together with a focus on practicing the real-world skills of sitting and talking together as a family”—without cellphones.

Gillen notes about the Bradley Hospital program that one of its ways of partnering with families is to recognize and discuss their ambivalence about the decision to place a child in a residential program. These families recognize on the one hand the safety issues of keeping a child in the home and community, but on the other hand feel sadness and guilt about what they perceive as their failure, as well as concern that the child will feel unwanted and unloved as a result of the decision.

Historically, many RTCs have fostered the view that families need to deliver a challenging child to the ministrations of staff, need to stay out of the picture except for paying the fees, and can expect to receive the child back at some point (perhaps age 18), “fixed” or otherwise. Certainly some RTCs severely limit children’s contacts with family members other than parents, particularly if their programs claim that they are focused on child attachment issues. Gillen’s article notes the lack of evidence for effectiveness of programs with these positions, and I would point out the strong possibility that such programs can be part of the “school to prison” (or other institution) pipeline.  

Most parents who feel they need RTC care for a child will ask questions about the physical facility and about the experiences the child will have. Gillen’s comments suggest that the time has come for parents to explore carefully the role they themselves will play in residential treatment.  The idea of family engagement has been an important part of preschool education philosophies for many years, and it is associated with improved outcomes for children. It may well prove to be an equally important factor in residential therapeutic care for children and adolescents.