by Sarah Finney, MS, LMFT, and Dr. George Posner, ECS
When families seek help for a child who is struggling with emotional, academic, substance abuse or behavioral problems, they often retain the assistance of professionals within their community, such as therapists, psychologists, and tutors who can work with the child and family on an outpatient basis. At times of crisis, they might place their child in an acute psychiatric facility, followed perhaps by an Intensive Outpatient Program. For the majority of struggling youth, this level of intervention and support might be what is needed. However, in some cases, a recommendation for a longer-term residential school or program may be indicated. Reasons for a longer term residential program may include acuity of behaviors or issues, need for containment, removal from current negative peer group, resistance to less restrictive levels of treatment, or lack of resources in the home community to meet the specific needs of the child. In the past, families seeking residential options have considered enrolling their child in boarding or military schools. This was predicated on the assumption that a 24-hour/7 day a week structure was required. Though these traditional settings provided structure, they rarely provided the supervision or therapeutic remediation that was necessary for success. In addition, many families found that these schools still had active, negative peer cultures similar to the ones they were attempting to remove their child from in the first place. Though their thinking was correct in that their child needed removal from their negative peer culture, increased structure, and 24 hour/7 day a week supervision, they often overestimated what these schools could provide, and underestimated what their child needed. Their intentions were good, but their lack of knowledge often made matters worse.
Fortunately, during the past two decades, a range of privately funded residential options has become available. There has been a rapid growth of residential options from less than a dozen ten years ago, to several hundred today. Even when selecting from what, in our view, are the highest quality options, there are still over a hundred from which to choose. Residential care for adolescents is a rapidly changing field. The opening of new schools and programs, changes in staff at existing programs, creation of specialized programming, new schools and programs targeting specific populations, and use of newer therapeutic or academic models and techniques creates a wider range of options. To better understand the range of new, private pay options, it is best to consider residential placements as a set of categories.
These centers provide a highly contained, short-term (2 weeks to 3 months) opportunity to focus on neuropsychiatric evaluation. They use a medical model (medically trained director, licensed clinicians and 24 hour nursing staff), and combine a wide range of formal testing with 24/7 observation to provide assessment, diagnosis and treatment recommendations.
Therapeutic Wilderness Programs
These programs are outdoor, clinically oriented and experientially based. Students are assigned to a small peer group (6-9 students) where they most often spend the majority of their stay (3-10 weeks). Each peer group has at least one Master’s or PhD level clinician who provides individual treatment planning, individual and group therapy, and weekly consultation with the student’s family over the phone. The student and family communicate primarily through a weekly letter writing exchange, which is guided by the therapist. In addition to the clinical services, the student also works on an outdoor-based curriculum intended to challenge the student and allow them, over time, to develop competency and self-esteem, among other objectives. These programs provide 24/7 structure, supervision and observation, and can also provide psychological testing. Therapists at these programs can provide professionals with excellent assessment and treatment recommendations. Because of this capability, wilderness programs re often used as a stepping-stone to longer-term treatment. High quality therapeutic wilderness programs tend to be nurturing environments and are not behavioral boot camps, though some media attention has lead to confusion about this in recent years.
Many of us are familiar with traditional boarding schools, which have been available for over a century. It is important, however, when assessing these schools for children with special needs, to consider some key points. Although these schools have general goals regarding the development of good character, the boarding school day focuses primarily on academic and sports programming. Therapy is typically found on an outpatient basis and is usually kept confidential from the school. There is a significant amount of time spent at home and on vacations (approximately 4 months). Suspension and expulsion are the primary consequences of misbehavior, and if expelled, the yearly tuition is generally forfeited. The student’s primary mentor is typically an academic advisor. There is little family involvement while the student is at school, and weekends tend to be poorly supervised. Though boarding schools can provide wonderful academic, athletic and social opportunities, they are not appropriate for a student struggling with significant emotional, social, substance abuse or other difficulties.
Emotional Growth Boarding Schools
These schools generally focus on group versus individual processes, and attempt to strike a balance between a student’s academic and emotional growth. The length of stay is determined by a specific emotional growth curriculum, which tends to fall between 16 and 24 months. Most of these schools tend to have limited programming for specific clinical needs (e.g., substance abuse, adoption issues, grief and loss), and typically no individual therapy. There is limited individual treatment planning and traditional family therapy, although parent workshops are offered to complement the emotional growth curriculum. There is also highly regulated family contact (i.e., one short contact weekly or bi-weekly; home visits delayed 8-12 months; parent visits limited to attending workshops). These schools target students who have mild emotional, social and learning difficulties, have experienced some difficulty in their home environment (divorce, loss of parent etc.), or have delayed social-emotional development compared to their peers. In recent years, many Emotional Growth Boarding schools have attempted to overlay clinical services on their emotional growth model, which has proven to be more or less effective depending on the school.
Clinical/Therapeutic Boarding Schools
Individual, group and family therapy are provided at various levels at these schools, and the clinical, residential and educational services are balanced and integrated. There is individual treatment planning provided for each student, and psychiatric services are available should the student require psychotropic medication. The main contact for the student and family is the primary therapist, who is usually licensed, and Masters or PhD level trained. Though clinical services are provided, these schools also place significant emphasis on academic (limited services for students with learning disorders), recreational and social opportunities. In this setting, the student is expected to function at a relatively high level, and because of this expectation, a high degree of containment is not offered. An interview may or may not be required prior to enrollment, which is offered year round rather than at specific times of the year. There is usually some form of level system offered, and visitation and vacation are based on level and clinical determination. The minimum length of stay is typically 12 months.
Residential Treatment Centers
In these settings, treatment goals are the primary focus, and individualized treatment planning and intervention is emphasized. To this end, these centers provide fully integrated services (psychiatric, clinical, academic, residential and recreational), a significant level system, and special topic group therapy (e.g., grief and loss, adoption, social skills, trauma recovery). Nevertheless, they also tend to include a fully accredited school program, although the emphasis is more therapeutic than educational. There is usually a significant substance abuse treatment program offered to those students who require it. The frequency of all therapy is higher as compared to the models above, and there is a much higher degree of supervision, including awake night staff and smaller staff to student ratios. Nursing and medication management is available at higher levels as well. Family and home visits are based on individual needs, and intervention within the family system is emphasized. At some programs, there is a great deal of energy spent on maintaining a therapeutic milieu and positive peer culture. An extremely high level of structure and containment is typically offered, and therefore there is less expectation for a student to exhibit a high level of functioning. These programs offer rolling enrollment based on need and appropriateness, and many of the hundreds of programs around the country offer various and specific treatment models (e.g. positive peer culture, behavioral, relationship-based). The average length of stay ranges from 3-12 months.
Character based models (e.g., Hyde Schools) have a traditional boarding school structure (refer to above), but with an emphasis on family work and character development. Sports, education, community services, performing arts and group process are all offered and viewed as vehicles for development of character (e.g., effort, integrity, courage). These schools (like the boarding schools described above) do not offer any integrated clinical services, since they view the problems of youth as ones of character, rather than as psychological or psychiatric.
Outdoor-based models are group focused, with ten to twelve single gender students living in rustic/primitive campsites. These models encourage responsibility through self-sufficiency, and use a “Come with nothing, earn everything you get” philosophy. There is limited communication among groups, a behavioral focus, and often the use of Native American symbolism in their curriculum. The family service worker is the primary contact (many are Master’s level trained), and most frontline staff are Bachelor level trained. Less individual treatment planning occurs, though some special topics groups and psychiatric services are offered. Home visits are determined by level, and parent programs are offered with as much as monthly parent visits. These schools and programs have year round enrollment, and average length of stay is 10 –18 months.
When considering the hundreds of options available to struggling youth, it is important to note that one model is not inherently better than another. What is most important is the correct match between the particular youth and the most appropriate school or program available. Though this decision can feel overwhelming to families, the importance of finding the right fit at the highest quality school or program is essential. Through ongoing efforts, we continue to dedicate our practice to helping families make the most informed and appropriate decisions in this regard.