By R. Dean Porterfield, M.A., N.C.C., L.P.C., MHSP
Making the decision to send your adolescent daughter or son away to a residential treatment program is likely to be one of the most difficult decisions a parent will have to make. It takes a great deal of courage to admit that you are unable to provide the necessary care for your teen in your home environment, and ultimately turn over their care to a residential program specializing in attending to the challenging needs of today’s adolescent. As a professional, it can be equally difficult to make a recommendation to a family that you feel that home is not the best place for their child at this time, and they need to receive specialized services in a residential setting. This article will focus on ways we as professionals can best support families that have a child in residential treatment, and perhaps provide some insight so that we can give effective and supportive feedback to those families going through this experience. Having worked for an Outdoor Therapeutic Program as a Family Service Counselor, and an Administrator, experience has taught me that the adolescents we serve have a much greater success rate if their parents are supportive of the process, and actively work to better gain understanding of day to day programming. Though there can be numerous questions and issues that need to be explored in depth to help the parent understand the process, these are just a few of the common ones I have encountered over the years.
Admission: As a program or referring professional, it is essential that the family feels as comfortable as possible with the program into which they are admitting their teen. I frequently inform families that the staff and I have a passion for what we do, and we can easily rave about the program; but it is essential that they speak to other families who have lived it. Referring to other parents that have had their teen go through the program for consultation helps the family make a better informed decision. It is also a good idea to have the family tour the facility before making a decision. During that tour they will likely have interaction with key staff, and even with those teens enrolled at the program. A question I like to ask after such a tour is, “Does it feel right?” If the question is yes, and they also felt like they related to the families they contacted, then it is likely a good fit. If they are hesitant, then it is important to convey that if they feel they are going to have a hard time buying into programming, then the process will not be as beneficial for their child as it could be. This whole admission piece is so crucial, and is typically handled by an admissions director, and a referring professional such as an educational consultant or therapist.
Adolescents Grow In Groups: Many programs utilize the group process model in which a teen is placed in a group of about twelve peers that have similar issues. These groups typically have individuals that are in different phases of their treatment; some have been in the program for several months and some are new to the process. In the group process model these teens are charged with holding each other accountable, and creating a positive peer culture. It is very important that the families of these teens understand the impact of this group. Many times parents want their teen to be treated on an exclusive individual basis, and thus have many individual sessions. Though it depends on the program, most of the treatment is done in a group setting. By the time a teen has reached the level of dysfunction that they need a residential treatment program chances are they have already had numerous individual sessions by therapists and psychologists. These teens are more likely to listen to their peers when it comes to treatment issues such as depression, anxiety, authority conflict, and family conflict. The senior most members of the group can help teach the new members; their ability to do so is a measure of their internalization of the skills they have acquired. This is not to say that individual sessions are not productive, but doing the work in front of their peers helps keep them accountable, and avoid possible manipulation. After all, who best to point out a teens manipulation than another teen that is very well educated on the same mechanisms of defense.
This group comes to represent more to than just individuals residing together. It is a community, and a family within which the teen must function. The group dynamics will push the teen to manifest the issues that brought them to treatment. Parents frequently get worried when their child is acting out, but if the program does not witnesses these manifestations it will be very difficult to address them in a direct manner. Transference often occurs; meaning that the teen will identify members of the group or staff to project issues they have with family members. The group process helps the teen learn to build productive relationships with others. The family benefits from these skills without having to suffer through the trials associated with learning the skills. This relationship building is one of the most important parts of programming, especially since many of today’s teens lack relationship building skills as a result of internet instant messaging in which the teen builds online relationships.
Follow the Rules: One of the greatest problems that occur in programs is that the family does not follow the rules and guidelines established. Many are very enabling, or just feel that they are above the rules. When a family does not abide by these rules they are role-modeling to their teen that adhering to rules is not important; likely the very behavior that sent their child to treatment. When the program sets the rules it provides an opportunity for the parents to take a break and let the program be the “bad guy”. Those families that assure that they understand the programs boundaries and rules have a greater likelihood of success. It demonstrates that they too have authority figures.
Interventions and Consequences: In a residential setting, the goal is to create an artificial environment that will help present situations in which core issues can be addressed. Most depend on natural and logical consequences to both appropriate and inappropriate decision making. Parents often have a difficult time understanding why their teen received a significant consequence for minor misbehaviors. First, it teaches the teen to think ahead and reinforce that their decisions will have consequences they must suffer. Second, if the teen is so daring as to risk gaining a consequence in a setting that is so controlled, then it is likely that the risk would have been greater at home and leading to significant real life consequences. It is difficult at times for parents to understand these interventions, especially when it affects such things as passes, and privileges related to family interaction.
Interventions that require consequences for the entire group can be difficult for parents to handle, especially when their child is not involved. It is important that the teen learn that the actions of a few can affect the whole group. The lesson is that their actions profoundly affected the family, and thus their family had to suffer consequences as a result of one person. This helps the teen better understand how their parents felt, and it also builds empathy and the desire to help members of the group discover resolutions to problems that could potentially affect the group.
United Front: It is important for all parties involved, including the program, parents, and referring source to be on the same page. When this team presents to the teen as a united front then the teen is less likely to manipulate. If this does not occur, the teen will likely attempt to divide all involved and ultimately manipulate to get their way. This is not to say that families can’t disagree with the program, the parents should feel free to present their concerns, but not make the teen aware of the disagreements. The parents and treatment team will have to work to come up with a resolution, and support one another on decisions made. Once the message is sent to the teen that all involved are committed to them working their treatment, then they are more likely to become more actively involved in the process.
Level/Stage Systems: Most all programs utilize level or stage systems to help monitor the progress of the teens in the program. Each level advancement represents progress towards resolving identified issues in the teen. Helping guide the family as to what to expect as their teen works their way through the stage system makes the treatment process easier for the family.
Initial phase of stage system: Typically the first few stages are focused on helping the teen understand that they need help, similar to the stages of AA. The other piece that needs to occur is acceptance of their placement; and this is both for the family and teen. The teen will also learn the rules of the program, and a great deal of focus is placed on behavior modification. Those that struggle with authority and family conflict, as well as poor anger management issues, will likely find these initial stages difficult. At some point, parents get concerned that their child is faking or fronting the program. At these early stages, that may be a very accurate assessment. Though it is believed that if they demonstrate a behavior long enough, it will soon become habit. The teen is encouraged to focus on themselves and not as much on solving specific group issues, which is the task for the leaders of the group. They also have to learn to ask for and accept help.
Middle phase of stage systems: During these stages the issues begin to be addressed at a more cognitive level. The teen begins earning more privileges, and is required to take on more responsibility for themselves, and the group in which they belong. In terms of progress, the analogy can be used that the teen is sitting on the fence, and can fall either way, meaning that they are making better decisions, and getting to the core of some of their primary issues, but they can still fall back into some negative patterns. The key is for the teen to establish consistency in working through treatment issues, and become instrumental in resolving group issues. The challenge comes in balancing their individual needs and the group’s needs; this is a needed skill when they return home and have to balance their needs along with their family’s needs. At the later part of this phase, the teen presents very well. Many parents become anxious and begin thinking about prematurely removing their child from the program (this specific topic will be addressed later in greater depth).
Final phase of stage system: At this phase the teen has basically acquired all the basic skills they were lacking; rather it is skills for dealing with depression, anxiety, or poor anger management. The focus is now on the teen using those skills on a consistent basis and be able to effectively generalize those skills to real life situations. They get less guidance from staff during this part of the stage system, and expectations become more abstract. Internalization is tested in several ways, but the primary way is to gauge how effective the teen is in teaching their acquired skills to others, and how well they can present to others not familiar with them how much they have progressed; this is typically done on facility tours to potential families. It is sort of like an internship to assure that the skills are solid. Most parents think that this part of the stage system is smooth sailing; but the reality is many struggle during this phase. With each new stage comes increased stress and responsibility, at these times these kids are likely to attempt to revert back to some of the inappropriate coping strategies from the past, leading the parent to feel no progress has been made. The programs goal is to not let those familiar ineffective coping strategies work by not reinforcing them, and thus the teen is forced to us their newly acquired skills to function. Those that struggle the most are the ones that have a difficult time standing up to peers, and were likely “followers”. Thus, it is essential they gain these skills so as to gain confidence in standing up for themselves, and making them less vulnerable to relapse. At this time the referring professional becomes more involved by helping identify the best aftercare plan; which may be home or more structured setting like a boarding school. This phase is also crucial for closure and allowing the teen to grieve the fact that they will be leaving the programming and losing significant relationships. Parents often times want to cut this short, not realizing the significance.
Stage systems or level systems vary from program to program, but have the same goal in helping guide the teen through the treatment process. For most programs completing the stage system signifies completion, as well as a higher success rate.
Don’t Set Time Frames: Each teen develops and grows through the program differently. One of the most detrimental things a parent can do is set a time frame with their teen as to when they need to complete a program, or a date in which they will remove them from the program. If pressured to complete by a certain date the teen may stop working and feel overwhelmed. A parent at times feels guilty in placing their child in the program and thus gives them a date that they will pull them from the program if they continue do well. Well, with most teens, they will perform what you want to see and not truly deal with their issues in hopes that the parent will follow through on their promise to pull them. A teen will not put all their effort into the treatment process if they feel there is a chance they could be removed early from the program; the parents are wasting time and money if they do not commit to the program. If a teen does not receive any reinforcement on their pleas to get pulled from the program, the chances are greater that they will accept the challenge and get more out of the experience. There are times in which a parent can’t help but to remove their child, such as for financial reasons. It is still a good idea to lead the teen to think that they are in the program until completion. The program will work with the parents to procure the best possible discharge in cases like this.
Active Participation: Parents need to be encouraged to participate in all activities designed for them. Such as regular visits to the program for family sessions, phone calls, and passes. If the teen witnesses the parent making the effort to be part of the healing process, and willing to make some changes the greater the likelihood that the they will be committed to changing themselves. There are times that parents want to be too actively involved, and thus interfere with the programs modality of treatment. Also keep in mind that siblings tend to be greatly affected by this process, many feel that the teen in treatment is draining the family and getting all the resources.
In summary, helping guide a family with a teen in residential treatment is essential to the prognosis and overall success. Families need to understand that this is a “process”, and ups and downs are to be expected to the very end as the teen and family heals. It is essential that the program holds up their end of the deal and does everything they can to bring comfort and support to the families of these teens.
R. Dean Porterfield is the Program Administrator for Three Springs, Duck River Program in Middle Tennessee. He has earned a BA in psychology and a Masters in Counseling from West Virginia University. Dean is a Licensed Professional Counselor, Mental Health Service Provider, and a Nationally Certified Counselor. He has been with Three Springs, a provider of adolescent treatment programs in nine states, for over six years.