April 23, 2014

Adolescent Care, A Landscape of Change

Twenty years ago, when a young person needed out of home care for behavioral and emotional challenges, it was a pretty good bet that he or she could get help at a nearby psychiatric hospital facility followed by day treatment or sub acute care. Options such as wilderness therapy, community based residential services, emotional growth schools, therapeutic boarding schools, and young adult transition programs were largely unknown, or not in existence.

Times have changed. With the advent of Managed Care in the insurance business coupled with severe cutbacks in the funding of mental health benefits in most insurance plans, the once, booming psychiatric hospital industry has fallen on hard times. At the same time, there has been an explosion of alternative programming to fill the void left when traditional care options became limited.

So what of these alternatives? What are they, and what might come next? In the next few paragraphs I hope to provide you with a brief overview.

Therapeutic Wilderness or Outdoor Behavioral Health

Tracing roots to University based survival courses and wilderness leadership initiatives, the Outdoor Behavioral Health industry has grown rapidly in size and scope over the last ten years. Originally, most wilderness programs provided intense, three-week survival courses for troubled youth utilizing a combination of outdoor skills coupled with brief therapy initiatives, after which the client returned home, or possibly went on to other services. Solo trips by clients near the end of placement, along with a guided reunion with family members capped off the client’s sojourn. Mother Nature’s beauty and imperviousness to mortal manipulations often had high impact on a youth who was otherwise embroiled in addictions and a negative peer culture.

Today professional counselors, utilizing sophisticated testing provided in the field along with involved, intentional psychotherapy that also connects the family via letters and weekly phone contact with therapists, are yielding promising results. The length of stay has become more variable with research indicating that longer stays may significantly improve outcomes. College courses, professional conferences, improved government and industry regulation and formal outcome studies all indicate the effectiveness and importance of this intervention.

Residential Treatment Programs (RTC’s)

Fifty years ago, it was thought by many that a child placed in residential care may need to remain in services for several years. Early pioneers focused much of their work on minimizing outside parental involvement while attempting to manage all phases of a young person’s life. Over time it has become increasingly apparent that care in the more structured and protected confines of a residential program needed to become more permeable. One can now find programs that won’t admit a young person without the promise of full family participation. Residential care often was driven by a doctor/nurse medical model that failed to take into account group dynamics, community living concerns, or other factors. We now see greater attention to milieu therapy, cross training of professional and paraprofessional staff, as well as integration of multi-discipline assessments.

RTC’s, now less restricted by insurance edicts, can provide highly innovative programming. Specialty services not approved for insurance reimbursement such as art therapy, experiential education (ROPES courses, team building exercises, multi-family initiatives, etc.), therapeutic home passes, community service, and specialized therapy for adopted clients or others have emerged. RTC’s now come in more shapes and sizes. Working ranches, combining professional psychotherapy, provide certain interventions; while smaller, gender specific community based programs may serve clients with other needs.

Emotional Growth Schools

Around thirty years ago Emotional Growth Schools came onto the scene. Relying on periodic, high impact, focused workshops related to mastering each phase of human development these schools work to help a youngster master crucial skills. The workshops are under girded by structured scheduling, including formal academics and robust recreational programming as well as a peer culture that takes advantage of the needs for young people to experience healthy rites of passage and group support. In recent years there has been a trend to incorporate more formal psychotherapy into these environments while drawing on past successes. Typically utilizing a fixed length of stay of twelve to eighteen months these programs provide a cost effective way to help. These schools are evolving to meet the needs of increasingly involved and informed families. One such school is pioneering an Internet based family support group where one can receive understanding support and direction from other parents experiencing the same difficulties.

Therapeutic Boarding Schools

In some ways, all of the schools and programs mentioned in this article are therapeutic boarding schools. For our purposes, we will focus upon schools whose emphasis is more on academics, but who serve young people who require significant emotional and behavioral support. Many students in these settings have benefited from prior placement in outdoor, residential, or emotional growth programming, but may be at risk if they were to return home due to the “toxic” nature of the community or their need to further internalize change. Therapeutic Boarding Schools often combine elements of formal school settings to aid acceptance into private schools and colleges. Many students need review of earlier schoolwork to fill gaps in their learning while others have not filled the promise of their academic and leadership gifts. These programs are usually very open to the community in terms of service and learning. Several incorporate parent education and ongoing family therapy to augment other therapy or individual counseling. For some, therapy is on an “as needed” basis. Although these schools are more relaxed than RTC’s or other programs, there is still a strong emphasis on the maintenance of a safe environment. These programs cannot tolerate what may occur on a regular public or private school campus in terms of illicit substances, emotional abuse, negative subculture images, etc. Many of these schools are now having impressive success in college placements. These schools are increasingly able to minimize the relapses so often experienced when a young person returns home directly from more structured and restrictive levels of care.

Young Adult Transition or Independent Living Programs

Some young adults are ill prepared for college, career, and independent living. Those who struggled as adolescents can be overwhelmed by the freedoms and responsibility they yearned for just months or years before. Programming in which focused, highly structured initial phases of services are gradually relaxed culminating in private apartment living replete with laundry, cooking, jobs, college or trade school within a local community can actually enhance transition into young adulthood. From clients with some form of functional deficit to those who have been over-indulged or classic under-achievers these programs can be highly effective. Coupled with substance abuse groups, optional (or mandatory) psychotherapy, career counseling, internships, remedial education courses and other supports these programs have grown in numbers and variety.


In visiting over one hundred and fifty schools and programs over the past ten years, I note an amazing transformation of programming in most settings. The best of individual psychotherapy techniques is now combined in wilderness settings while residential programs increasingly take advantage of the outdoors to effect change. There are programs that utilize the wilderness for three days each week, after which formal school and psychotherapy is offered. It seems that there is more openness to finding what works, and using it, as opposed to believing that one has the corner on the market. Look for more such transformations to come in the next wave of change.

Nationalized Networking

Often local resources can be limited. The belief of the adage, “least restrictive, closest to home” in terms of placement may not always hold true. If one can find more effective, less costly services on the other side of the country should those services be immediately dismissed? I have found several programs that provide regional support services while carefully re-integrating a youngster back into the community in ways that are superior to many local services. On the other hand it is imperative that networking between local outpatient services and schools and programs serving a national clientele be solid. Much is lost when transitions are not done in a thoughtful way. One group of professionals is particularly effective in helping this to happen. Educational Consultants who specialize in assessing and then matching a challenged youngster with appropriate services nationwide, and then help with transition home are available throughout the country. Most devote twenty to thirty percent of their time each year to visit schools and programs to determine how best their clients can be served. Their experience allows families to sort through the preponderance of Internet websites and linked information to find the placement options. To be able to tour a facility and made a decision certainly beats educated guessing. The Independent Association of Educational Consultants (www.ieca-online.com) has over three hundred members nationwide.

Six years ago, a small group of programs and schools came together to address issues related to our industry. They had concerns over how services were regulated. They noted the tendency of some to prey on families through false advertising, guarantees, or mislabeling of services. They also hoped to build a collegial atmosphere where ideas and strategies to help those in their care could be improved. The National Association of Therapeutic Schools and Programs (“NATSAP”) as grown to over one hundred and thirty programs (www.natsap.org). Without such national efforts, consumers, as well as professionals, can be at risk when placing outside of the home.

As this industry continues to evolve it will be exciting to see what other changes are in store. Advances in communication methods, as well as in the information superhighway, along with discoveries in psychopharmacology and neurobiology all will have an effect on how we help others. As one combines those with the advances in program and school development it is possible, even in the face of the struggles we see our clients face to be optimistic.

Kimball DeLaMare, LCSW, has been working with youth and their families in treatment settings since 1979. He is the proud father of three great children and the grateful husband of his wife, Lisa. His work with the National Association of Therapeutic Schools and Programs and as one of the founders of the Island View Residential Treatment Center and of the Oakley School has brought some of his most cherished time in his professional life. He can be contacted by email at: kdelamare@ivrtc.com.

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