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74 MARCH 2005
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residential programs

Difficult decisions: Lessons learned from one family's story of residential placement

William H Evans

Parents of children with severe emotional and behavioral challenges face difficult decisions when considering residential treatment. Through his own family's story, the author offers strategies for evaluating programs and asking the right questions.

"Jamie” was an extremely capable and inquisitive child. A straight-A student and an athlete, he met the usual challenges of childhood with resilience. But Jamie’s life changed in many ways when his parents got divorced. Being separated from his father was difficult for Jamie, and at age 13 he became involved with alcohol and drugs. With the drugs came a lifestyle of death, despair, and a close connection with a subculture that supported drug use and every negative value imaginable. Jamie was a young man in crisis.

Over the course of several years, Jamie was seen by three sets of competent therapists, hospitalized twice, and arrested several times. After all of this, we – his mother and I – Were left with a handful of diagnoses and a son who was in severe crisis. We were at the end of our rope. Jamie was severely addicted to alcohol and drugs, was abusive to almost everyone, refused to obey any rules, mutilated his body to the point of permanent scarring, and was allowing himself to be abused by criminal adults so that he could obtain drugs.

As mental health professionals, my wife and I have spent our professional careers dealing with parents and children who are in crisis. However, being on the consumer side of service delivery was a new experience that provided us with a different perspective and a newfound respect for parents and families with teenagers with emotional and behavioral problems.

Taking Action
Parents of children and youth with severe emotional and behavioral problems soon discover that there are numerous roadblocks to seeking effective treatment. Most states have laws that restrict parents' ability to deal effectively with their children's serious behavior problems. Parents are legally and civilly responsible for the actions of their children, but they have very little legal authority to intervene in a serious way In most states, for example, parents can neither have their child drug tested nor receive the results of a drug test unless the child gives authorization. Additionally, in most states, parents must receive the child's permission before placing him or her in a treatment facility. Parents can go through complex and lengthy legal proceedings to have their children hospitalized, but emergencies usually demand immediate action. Add to this the difficulties with managed care, where treatment often benefits the bottom line rather than the patient, and you have a very difficult situation.

We knew that something had to be done immediately to help Jamie. Our son was dying, and we could not depend on the juvenile system or outpatient treatment to effectively deal with his problems. We were not willing to sit idly by and wait for Jamie to commit a serious felony so that his problem would be judged suitably serious for some type of residential treatment, and we recognized that the private care Jamie was receiving was simply inadequate for his needs.

We concluded that the only way Jamie was going to recover was by being removed from his deviant subculture and placed in a residential facility where he would receive intensive drug and alcohol treatment. We wanted a facility that would enable Jamie to continue his education, assist him in assuming responsibility for his behaviors, and build the kinds of behavioral skills necessary for success in adult life.

The Search for a Program
Once we made the decision to place Jamie in a residential facility, we began an intensive and systematic search to identify the facility that would best meet his needs. We researched residential programs whose orientations ranged from medical to wilderness survival. We wanted specific information about their educational and treatment programs, average length of stay, and – most important – outcomes experienced by people who had completed their programs.

The information we received was at best confusing and very general. Very few facilities had any real information concerning their program’s effectiveness. Many institutions indicated that their programs were highly effective, and we were provided with testimonial evidence, but when we pressed for specific numbers, we discovered that virtually none of the institutions had any data on program effectiveness or outcomes of the youth they had graduated.

Equally disturbing were the answers we received when we asked how youth progressed through the treatment programs. In most cases, the answers suggested that there was little if any organized system of program advancement. There were some programs that had well-thought-out plans that were specifically linked to improvements in the youth’s behavior, but these were few and far between. What was abundant across institutions was the barrage of mail, videos, advertisements, phone calls, and promotional offers that we received.

Parents are extremely vulnerable when they are selecting a program for a youth who is in crisis. The emergency that necessitates immediate action has usually been preceded by years of troubles that have left the family grasping desperately for answers. Parents need truthful and relevant data concerning program effectiveness and specific information about treatment programs. They are not helped by slick promotional materials that are designed to sell, not serve.

Making a Choice
Like other parents, we were forced to rely on less than perfect information in making our decision. We listened to testimonials of parents and youths who had been in various programs, and we judged the programs in relation to what we thought our son needed and what we believed should be involved in a good treatment program. We did, however, have the advantage of being trained mental health professionals and knew the questions to ask and the components to consider.

Given our experience, we offer questions for parents to ask when selecting a residential program for their child (Table 1). These are offered with the understanding that a residential program should be considered only after extensive efforts have been made at family and individual counseling. Parents must also realize that they will probably not receive complete answers to all of their questions. Parents may also benefit from the help of a mental health expert who has experience in residential treatment facilities and can assist them in evaluating programs.

Table 1


1. Does the program have a clear corporate history and organization? Some programs have a very checkered history and have reorganized under a variety of names to hide relevant information. A red flag should be raised when a program has a complex organizational structure with interlocking layers of corporations that may be designed to thwart accountability.

2. Does the program have the components that you or a trusted mental health professional believe should be present? Ask the following questions:

  • Is there a clearly coherent structure to the daily life of residents, duties of the staff, educational program, and counseling services?

  • Is the educational program sufficient in terms of materials, staff, and subjects taught?

  • Is the program organized around some type of “level" system that allows students to gain privileges in relation to their progress?

  • Does the program promote success, or does it appear to be reactive and focus on punishment?

  • Are aversive consequences used in the program, and if so, what type?

  • What type of behavior-management plans are used, and are there examples for review?

  • Are there programs that help parents learn new management and communication skills?

  • Is there a program to aid in the youth’s transition back to the home?

  • Is there a parent support group?

  • Is the staff adequately trained, and is there ongoing training?

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  • How do staff members communicate with youth and parents about program progress?

  • What happens when there is a rule infraction, and are there varying degrees of rule infractions?

  • Is there training to aid youth in generalizing skills?

  • Will a comprehensive treatment plan be developed and periodically reviewed by parents, the youth, and staff?

3. What is the history of the facility? How have problems been handled in the past? Parents should be cautious if told there have not been any problems.

4. Does the facility have data to support claims of success? Do they have data concerning the ongoing success of program completers? What is the average length of stay in the facility?

5. What are the reasons youth have left the program?

6. What type of aftercare is provided after youth leave the program?

7. Do you get direct, coherent, and easily understood answers to your questions?

8. What do parents and youth who have participated in the program have to say? What were the strengths and weaknesses of the program? What were the biggest problems and how were they addressed?

9. How are emergencies handled? How are staff members trained to handle emergencies? Is there medical treatment available?

10. Are rules posted in the facility? Are there a variety of activities? Is the facility clean, structured, and in good repair? Go to the facility and talk with staff members, teachers, and patients.

When we made our choice, it was more like an act of faith than a reasoned decision. But the program we selected did have the components that we thought were needed. It would remove him from his deviant peers and would not allow him to leave of his own volition. Moreover, the orientation of the program fit with our beliefs concerning good treatment practices, and program managers stated that they needed to collect data concerning program effectiveness, that such data would be very helpful to parents, and that they were planning to collect such data. It was in the context of these assertions that we committed our son to their care.

Placing Jamie in the Program
We knew that Jamie would not go voluntarily into a residential program; he was completely attached to his deviant subculture and was substance dependent. We hired an “escort service" to take him to the residential facility. The escorts arrived at our house and, after a short meeting with us, entered Jamie’s bedroom, awakened him with our assistance, and quickly removed him from our house. We talked to our son and told him that we loved him, that he was being escorted to a residential facility, and that we would be in contact with him there. He was surprised at the suddenness of the actions and protested, but left without a struggle. What we did was difficult, but it was not as difficult as watching our son die.

The program called us when Jamie arrived that night, and we received weekly calls from his case manager detailing his activities and progress. He was free to write to us as often as he wanted but was not allowed to call until he reached a certain level in the program. This elimination of direct communication was positive because it made manipulation nearly impossible and forced Jamie, his mother, and me to focus on the treatment program.

Jamie’s first letters were filled with promises to improve his behavior if we would only allow him to return home. As expected, he indicated that he had learned his lesson and that he had put his troubles behind him. We responded with letters encouraging him to become fully engaged in the program and put his efforts into recovery and developing the skills he would need to be a successful adult.

The program in which we placed our son was in a remote location – in another country, in fact. It was highly structured, used a level system for advancement in the program, and required youths to attend school 8 hours a day, 6 days a week. Youths attended counselor-directed sessions each day and periodic intensive 2- to 3-day workshops in which they dealt with their behavior problems. The curriculum was self-paced, accredited, and involved certified teachers. The food was more than ample, the facilities reflected local standards, and medical care was provided. My wife and I got the type of facility we wanted – not a country club, but not Devil’s Island either.

Involving Parents in the Program
The program required us to participate in a series of parent training seminars. These seminars would help us to deal with Jamie while he was in the facility and restructure our interactions with him when he came home. They would help us develop home-management plans and address critical transition issues. These workshops are crucial for parents and should be a required element of any residential program. It is not enough to simply place your child in a residential program. Rather, what is needed is a coherent program that will change the communication skills of all family members. Without this, behavior change is only temporary.

Parents should not stop asking questions once an appropriate treatment center is found. They should check the credentials of those they accept advice from, including presenters in workshops, to determine if the credentials are appropriate. Parents should expect coherent answers when they ask questions about specific program components or activities. Be suspicious of programs that fail to provide answers or are overly defensive.

Parents should expect residential programs to provide them with some data that will guide them in their continued participation. These programs can be a tremendous financial drain on everyone in the family. Parents naturally do not want to spend more than necessary, and when they ask questions about withdrawing their children early, they should be provided with answers based on data rather than speculation. Residential programs should be able to provide some evidence of the life effectiveness of those who withdraw early versus those who complete the program. Without this type of information, parents have no way of knowing if the money they will spend is worthwhile, or if it will do little more than warehouse their child for a period of time.

Once parents receive data, they should look at it with a critical eye. Data are sometimes collected with the intent to promote and sell rather than seriously examine program effectiveness. Data that show that a majority of parents liked the workshops or thought the residential program was good for their child are interesting but incomplete. It would be more relevant to know what youths believe about the treatment program and how they adjusted 1, 2, and even 5 and 10 years after leaving the program. Questions that address the youths' perceptions of the residential program’s effect on their ability to interact with others, their use ofillicit substances, their education, and a host of other factors are relevant questions that parents have a right to ask.

Program Expectations of Parents
Those managing the program have the right to expect parents to actively participate in workshops or seminars and follow the suggestions of staff concerning their involvement in the child's treatment program. Parents will most likely hear their child make a variety of claims about unfair treatment and related matters. They should not necessarily believe every claim made by their child; manipulation is often a great skill of youth who manifest severe behavioral and emotional problems. Parents who fall prey to this manipulation do little to enhance their child's treatment program and actually reduce the probability of success.

Parents must also realize that they cannot question the wisdom of every intervention used with their child. Parents must realize that, in some ways, they were not able to effectively deal with their child's behavior and that they must trust the staff to do what is best. This is not to suggest that parents must be blindly obedient and not listen to serious allegations raised by their child. Rather, parents need to be reasoned in their approach to staff and realize that a better outcome will result when staff and parents cooperate and support each other.

Finding New Hope
The expression “Hope for the best, but plan for the worst" is good advice. There might be a dramatic improvement in a child's behavior, and there may not be a need for residential placement, but plan as if there will not be a change. A residential placement might be in order if you think that your child is out of control, the behavior problems are worsening, or the therapy that can be provided in the current setting is ineffective. In these situations, it is better to seriously consider program options before the situation becomes completely untenable than to wait and become a victim of circumstance. This allows time to examine programs and seriously consider what residential placement means for you, your child, and your family. Failure to take this deliberate step may mean that a decision about residential treatment will be made during a crisis when emotions are running high and there is little time for rational decision-making.

Jamie’s Outcome
Jamie was in the program for 18 months, 4 of which were in a transition facility. Upon his return, he finished his last year of high school with excellent grades. He has the usual problems of a young person finding his way through the world. He is not perfect, but neither is he addicted. He is employed and intends to go to college. There are good days and bad days – but there are more good than bad.

Jamie recognizes that what we did was absolutely necessary. He has told us that he would have died if we had not sent him to the residential program. He is not bitter about the placement but is regretful that he lost several years of adolescence to drugs and bad choices. There are issues that he must deal with every day and choices he must make. Some of these will be wise and well reasoned, and some will not be, but at least now he has the opportunity to live his life, which is the best gift we could have given him.

It is often difficult for parents to see how problems can be resolved when situations are at their worst. But children do overcome their difficulties, and families can be healed. It is this promise of hope, recovery, and a successful future that must be nurtured “regardless of the setting.

This feature: Evan, W.H. (2001) Difficult Decisions: Lessons Learned From One Family's Story of Residential Placement. Reaching Today's Youth Spring 2001, Vol. 5, issue 3. pp. 42-45.

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