Keywords

Chapter Highlights

  • The need for family involvement in the treatment of adolescents in residential settings is well understood. However, providers are often unsure of how to best meet this need.

  • The purpose of the book is to provide foundational information for conducting family therapy in adolescent residential treatment settings, which providers can draw on to increase their effectiveness.

  • The cost of treatment is considered and the implications for therapists and healthcare systems are discussed.

  • General definitions and terminology used throughout the book are presented to orient the reader.

  • The chapter concludes with a discussion of the rational for the organization of the book and highlights some of the commonalities across chapters.

Most counselors and therapists would agree that engaging the whole family and working with the entire system locally is the preferred approach when working with children and adolescents. Nevertheless, families with a troubled adolescent or young adult may find themselves in a position where community-based outpatient treatment has failed and they are in need of additional support. When this is the case, families and social agencies may turn to inpatient treatment to address contributing factors. Adolescents and young adults in residential treatment present with significant mental health concerns , including conduct disorder , oppositional behavior, depression and anxiety , drug and alcohol abuse, and eating disorders , to name a few. Parents may fear that without some type of out-of-home placement the child will end up in repeated psychiatric hospitalizations , or worse, incarcerated. Even though the problems may be severe, making the choice to send a child away to a program is often a heart wrenching decision and parents may be susceptible to guilt as a result (Frensch and Cameron 2002).

Families who place their child in a residential program will need support from therapists at home and in the program as they struggle to navigate the challenges that will arise while their child is placed in treatment. Although there is some disagreement concerning what exactly constitutes residential treatment (e.g., Lee and Barth 2011) parents are able to choose from a variety of programs with different structures, purposes, and methods. Among the options are emotional growth schools, therapeutic boarding schools , and residential treatment centers . Given the various approaches to treatment, it is important for parents to research and understand the different options. When this process is overwhelming, it may be helpful to enlist the help of an Educational Consultant that specializes in matching individuals with treatment options . Educational Consults spend a considerable amount of time learning about various program options so that they can be effective in helping families make decisions that will best address the needs of the child.

Once the adolescent is in treatment, therapists within the program are tasked with engaging the family in therapeutic activities. For some time now it has been recognized that children do better in residential care when their family is involved in the treatment process (e.g., Jenson and Whittaker 1987). Accordingly, it is now recognized within the industry that programs must have family involvement and work to modify the home environment that the child will eventually return to after discharge . Although this is understood, the separation between the child and parents makes it difficult to deliver traditional family therapy . This creates unique challenges for practitioners working in these settings. They must become proficient in working directly with the individual in treatment, as well as with the family, both directly and indirectly. Often family members are hundreds of miles away and may only be available by phone or for brief family visits a few times during the entire course of the program. Even when families live near the program, practitioners may find there are other barriers, such as a lack of motivation , abandonment of the child, and lengthy stays in residential programs (Burns et al. 1999) that make conjoint treatment difficult. Family therapists are often required to be creative and find unique ways of engaging the family. Once treatment is completed in a particular program, aftercare plans must be created and families will need help in determining what type of follow-on care is needed and how to modify family life to regulate the environment for the returning adolescent.

As will be seen throughout this book, significant efforts have been made to overcome the challenges inherent in delivering family therapy in these settings and a number of specific interventions have been developed to better involve the family. However, there remains a need to establish the effectiveness of those interventions and models, which has become increasingly apparent over time. Historically, the research in this field has been criticized for being limited to descriptive data or correlational analysis, without reliable measures or longitudinal data (e.g., Hattie et al. 1997). Although more rigorous methods have been used recently, the majority of the research continues to be concerned with program evaluation that is focused on the individual, rather than on determining what specific assessment methods and treatments approaches are effective with this population (McLendon et al. 2012). This leaves the field vulnerable to reproach from those who see residential placements as less effective and ignores the importance of the family in the process. Accordingly, more research is needed to strengthen the place of family therapy in residential settings for adolescents and young adults. The purpose of this chapter is to show how the book addresses the concerns and challenges outlined above in a comprehensive manner.

Cost of Treatment

Before delving into the contents of the book, some background information on costs is warranted to provide needed context. Demonstrating the effectiveness of family therapy services in adolescent residential treatment is only the beginning of what will be needed to solidify this treatment option in the marketplace. Over the last two decades the cost of health care has become a significant concern (e.g., Crane 1995) and efforts have consistently been made to improve care while also containing costs. A number of authors in the field of marriage and family therapy have called for greater integration of cost evaluations when conducting family therapy research (e.g., Christenson and Crane 2014). This will be especially important for those who research treatment in residential settings since the cost of this type of treatment is exponentially higher than community-based programs and interventions . This is true for both privately and publically funded institutions.

As noted in Chap. 20 of this book, there is a significance difference between private and public residential facilities in terms of type and quality of care (Behrens and Satterfield 2006; Lee and Barth 2011); however, the per day cost is not necessarily significantly different. Therefore, since more information is available for the cost of private programs, data concerning such programs will be used in this discussion. The Envoy Group (2016) provides some cost data on residential programs and show that residential treatment centers cost between $1500 and $3500 per month. They also show that a therapeutic boarding school will cost between $2500 and $10,000 per month, while short term intensive programs cost between $10,000 and $12,000 per month. The first author of this chapter worked at short-term intensive program for a number of years where the typical cost per week was approximately $5000. If an adolescent were to stay in a program like this for 2 months, the total cost would approach $40,000.

Given the high costs of these types of programs it begs the question of who pays for this type of treatment. Again, the type of program (i.e., private versus public) plays a significant role in answering this question. For private institutions, there are basically three options: (a) out-of-pocket private pay; (b) private insurance ; and, (c) healthcare loans (The Envoy Group 2016). Out-of-pocket private pay is self-explanatory, but may involve contributions from family, friends, and co-workers. Some healthcare loans are available directly to the individual through insurance companies (e.g., www.unitedmedicalcredit.com) and others are available through enrolled provider organizations (e.g., www.prosperhealthcare.com). These services can be used to provide the funding up front, but of course, have to be paid back.

The third option mentioned above is private insurance, which can involve a number of complex systems and transactions. Some policies have a provision for inpatient treatment, but most insurance companies will not pay for private residential treatment outright, though they may be willing to pay for the discrete individual and family therapy services delivered within these settings. One option, sometimes taken advantage of by programs, is to provide the family with a claim for the therapy services provided to the child, which they can then give to their insurance company in the hopes of obtaining reimbursement . However, because private programs do not typically credential directly with any insurance companies there is no guarantee of payment. Some high-end so-called Cadillac insurance plans may cover private residential treatment, but this is the exception and not the rule.

The other type of program mentioned above is public residential programs. As implied in the title, these programs are usually funded by the government. Most often Medicaid funds are applied to pay for this type of treatment. However, adolescents may enter a public residential program through a number of mechanisms, including the juvenile justice system and organization that provide child services (e.g., foster care programs). Because of the high cost of this type of treatment, it will be essential for those in this field to demonstrate the cost effectiveness of their services, and to date little to no work has been done in this regard. Accordingly, in Chap. 20 there is a significant focus placed on cost evaluations and the need for more research in this area. Given the importance of this topic for the field we felt it prudent to emphasize it again here. The purpose and placement of the other chapters in the book is described more fully below.

Definitions and Consistency Across Chapters

Before moving on to a description of the contents of the book, a word is needed about the use of definitions used throughout the text. One thing that characterizes the work in the field of adolescent treatment is the unique terms and descriptions individuals use to describe the treatment setting and/or the interventions they use. In fact, it is not uncommon to hear people use the same term for very different programs and interventions. However, throughout this book every effort has been made to be consistent in the definitions used. A useful example can be seen in the field of wilderness therapy . Some people will apply this term to any program that involves the therapeutic use of the outdoors, while in reality there are two very distinct forms of this type of intervention. In the text, we use the term therapeutic wilderness program to denote wilderness programs without professional clinical support, while the terms wilderness therapy and Outdoor Behavioral Healthcare (OBH) refer to programs with licensed clinical staff and formal mental healthcare. These definitions are clearly identified in the chapters for which they apply. We have also made efforts to provide some consistency across chapters in the form of chapter highlights. Each author provided approximately five brief statements that offer an overview of the contents of the chapter. This was intended to give the reader a way to quickly evaluate the information contained in the chapters and determine whether what is presented meets their needs at any given moment.

Chapter Contents and Organization

The background information provided in this chapter reveals a number of areas that need to be considered when detailing adolescent residential treatment in a comprehensive manner. These include

  • The decision to initiate treatment

  • Supporting the family during the process

  • Engaging the family in treatment

  • Therapy while the family is separated

  • Onsite family therapy

  • Aftercare decisions

  • Research on treatment.

Each of the bullets points are intentionally and thoroughly covered in the material selected to be included in this book. However, for the purpose of organizing the book, these seven areas were further delineated into three broad categories, and the book is divided up into parts, each of which covers one broad category. Some of the chapters may touch on more than one category, but all chapters fall solidly within at least one of the three parts of the book, which are (1) Family Therapy during Separation; (2) Onsite Family Therapy; and, (3) Research and Outcomes. What follows below is a brief overview of the chapters that make up each of these three parts of the book.

Family Therapy During Separation

The section on family therapy during separation contains nine chapters and covers a variety of topics relevant to this type of work. The first chapter in this section, Chap. 2, has useful information for providers about how to employ family focused letter writing while the adolescent is in treatment. The authors of this chapter show how impact and accountability letters can be used to help adolescents engage in the treatment process and begin to change the family system . In Chap. 3, the authors describe their use of Narrative Therapy to help a struggling youth shed his problem saturated story and engage in constructing a new story with the help of his family. This chapter provides a detailed description of the intervention and sample questions providers can use to engage in this kind of work in their own practice . Chapters 4 and 5 introduce the topic of video game addiction , which is rapidly becoming a core presenting problem in residential treatment. In Chap. 4, the author lays the groundwork for understanding the addictive nature of video games, which is crucial for designing an effective treatment approach. In Chap. 5, the author extends this conversation to the implications for family therapy while the adolescent is in residential treatment. Practical suggestions are made for assessment and intervention when this is a primary concern . In Chap. 6, the reader will find a first person account of the decision making process for sending a child to residential treatment, what it is like to participate in these programs, as well as some information about their own experience with outcomes. This is accomplished through a modified case study approach in which the participants were also the authors. The chapter also includes a substantial amount of information about Educational Consultants and how therapist can work effectively with them. Chapter 7 introduces the idea of a parallel process , meaning that the parents need to be engaging in their own concurrent therapeutic work while the child is in treatment. A sample treatment plan is provided for those who are interested in working with parents still at home. Chapter 8 contains a discussion of some of the factors that should be considered when making the decision to send a child to treatment. Along with Chap. 6, this chapter can be used by providers to gather helpful information that will empower them to support parents who are struggling to make this decision. Chapter 9 discusses aftercare planning, which is a crucial task when a child approaches the end of their stay in a program. As can be seen in the description above the contents of this section, there are a number of tasks and techniques therapists should be aware of to be effective in delivering therapeutic services . However, in residential settings therapists are often expected to do more than just provide therapy; generally, they are also expected to lead the treatment team . Accordingly, Chap. 10 was included to provide some guidance on how therapists can be effect in this crucial role.

Onsite Family Therapy

The section of the book about onsite family therapy begins with a chapter on the emerging models of family therapy that are being used in adolescent residential treatment (Chap. 11). The author reviews both those models that have been effectively used already and a number of approaches that could be adapted to work with adolescents in residential treatment. In addition to treatment models, there has also been some focus in the literature on how adolescents arrive at treatment (e.g., Tucker et al. 2015). Accordingly, Chap. 12 was included to give the reader information on Interventions as a mechanism to encourage an adolescent or young adult to enter treatment. Interventions have grown in popularity and are usually facilitated by an individual trained in a particular model. Interventions involve as much of the family as possible and the process is described in this chapter. Chapter 13 provides a description of fundamental aspects of addiction that all practitioners working with substance abusing adolescents should know. The chapter also includes a review of some of the major models of substance abuse treatment used with adolescents and how these can be adapted for use in residential settings. Regardless of the specific type of setting, most therapists who work in this type of environment will experience resistance from both the adolescent and the child’s parents and/or guardians . Accordingly, it is important to know how to help people move toward engagement in treatment. Chapter 14 addresses this issue and provides a framework for how to engage parents using a stages of change approach. In Chap. 15, the authors discuss how to engage the family in Outdoor Behavioral Healthcare and touch on the utility of adventure therapy in helping adolescents to change. This chapter would have also fit in the first part of the book, but it was included here because of its discussion of the overall process of working with families, including selecting a program with a home therapist and onsite work once the adolescent has been placed. Chapter 16 provides the reader with information about the use of family sculptures and reflecting teams . This type of activity can be used effectively during family workshops , which are discussed more fully in Chap. 17. Chapters 18 and 19 are both brief chapters that describe models of family involvement as used in two different programs. These descriptions are intended to help therapists gain a better understanding of the options available to them when it comes to family involvement and onsite family therapy . Chapter 18 also provides a research-based argument for how research on family involvement should be structured in the future.

Research and Outcomes

As will be evident as one actually reads the chapters outlined above, while there are a number of ways to integrate family therapy into adolescent residential treatment, there has been little effectiveness research conducted to support the use of any specific model, despite the basic understanding that family involvement improves outcomes (Hair 2005). Accordingly, this last part of the book was included to promote research in this field and support those who might be interested in participating in such an endeavor. The first chapter of this section describes qualitative, quantitative, and mixed methods and outlines a number of studies that could be conducted to promote family therapy in residential settings (Chap. 20). This chapter also discusses the importance of investigating the cost-effectiveness of family therapy in this field, which given the high cost of treatment will be needed to justify the place of adolescent residential programs in the marketplace. The next few chapters provide actual examples of the types of studies outlined in Chap. 20, along with practical suggestions for being effective in using each of the three methods. Chapter 21 contains a description of a mixed methods study that looked at outcomes related to the use of clinical consultation within the REStArT model . Chapter 22 details a quantitative study that surveyed youth about coping strategies they use, and the authors provide a number of suggestions for how family therapists can use the results of their study. Chapter 23 is based on the results of a qualitative study that looked at communication patterns in families before and after participation in a therapeutic wilderness program. Chapter 24 completes this part of the book with a discussion of program evaluation . These authors describe the major components of program evaluation and factors that need to be taken in account to ensure the results are useful to families and stakeholders . The final chapter of the book, Chap. 25, is intended to provide a synthesis of the material presented in the book and discuss how well the objectives of writing the book were met. As noted above, there are many challenges associated with working with adolescents in residential settings and our purpose was to provide practical information that will help individuals and organizations to provide quality services that benefit the family.

Conclusion

Overall, the chapters included in this book provide detailed information, beyond what is available in the literature currently, about how to work with adolescents in residential placements. Those who read these chapters will gain a greater understanding of the importance of research in establishing the place of family therapy in these settings and improve their ability to deliver services. They will also learn how to navigate some of the challenges associated with providing care to these clients and gain specific knowledge about interventions that can be used to promote change in the identified patient and family. This type of information has historically been learned piecemeal as a therapist gains experience in treatment over months and years. Accordingly, it is hoped that this book will help speed up this process and provide a foundation that therapists can use to build their clinical skill. Although this information should be immediately useful to those in this field, as always, the information presented herein should be seen as groundwork that can be used to further inquiry and research focused on these settings.