Aftercare is an essential component of successful residential treatment programs. I don’t think any residential program can quite reach its potential without some form of follow up after discharge. It is of considerable benefit to children and their families, although not quite in the way I had imagined it would be.
For years I worked in residential programs for children and adolescents where we did our best to treat troubled children, using everything we had learned about children and child development and socialization. And, of course, behavior. We discharged children when we thought they we ready, secure in the knowledge that we had done our best for them, and moved on to new children and new challenges.
Then, in the mid 1980–s, I went to work in a program that had just received a grant for an aftercare worker to provide follow-up services to children and families after discharge. Their most tenured child care worker was assigned to provide the services. He began attending family sessions with the social workers a few months prior to discharge and then made home visits after discharge to “support the gains made in treatment.”
Our star resident was just beginning the 6-month termination process when I started with the agency. Six months prior to his projected discharge, he began taking home passes every week. At the end of the summer, he went home on a two-week trial discharge. If all went well, he would remain at home, returning to the program only for a farewell dinner celebration.
All went well and he was discharged as expected. He was, after all, a model resident. More than that, he was a model teenager “sensitive, perceptive, caring. And his family had participated actively throughout treatment.
Within two weeks, things blew up. Seriously. Major temper outbursts, screaming and yelling and property damage. It was all the aftercare worker could do to keep the family from throwing the kid out.
We were all shocked. As were the child and family. What could possibly have gone wrong? We had to take a serious look at our program.
We formulated several hypotheses and made several changes in our program.
1. We saw two problems with the two week trial discharge. First, with expectations so high for children to do well and remain at home, neither the child nor the family were likely to admit to any problems during the two week trial, even to themselves. Admitting failure was not an option. Second, with discharge as the prize at the end of the two weeks, children and families were highly motivated to avoid problems.
We decided to schedule a two-week trial discharge well in advance of the projected discharge date and would not make any final plans for discharge until after children returned. This seemed to reduce the pressure on children and their families. It allowed them to be more open about their experiences during the two weeks and provided time to address concerns before scheduling a discharge date.
2. Weekend passes do not provide a good indication of how children and their families will get along after discharge. Children are likely to be seen and treated as guests or visitors on weekends rather than as members of the household. Everyone prepares for weekend visits. Families complete chores and plan activities in advance of the visit. Children come home with clean clothes. Everything is ready. There are no responsibilities around school “any problems had been handled at the program and homework would be completed on Sunday evening after children returned.
During early stages of treatment, this is a good thing. It allows children and parents to enjoy each other and repair relationships without the pressures of daily living “things such as chores and homework and coordinating things in the morning so everyone can get up and through the bathroom and fed and off to school and work on time.
During the final three months prior to discharge, we sent children home for two nights during the week. If things went ok, they would have an additional pass on the weekend. “Ok” meant not that there were no problems, but that problems were managed reasonably well.
3. We needed to wean children off our point system prior to discharge. Our point system was designed to support our treatment program (rather than to control the kids). Children needed to know prior to discharge that they were capable of maintaining the gains they made in treatment without the support of the point system, since they would most certainly have to do so after discharge.
We developed a weekly point system for children beginning the termination process. Points were totaled and privileges awarded at the end of the week rather than daily. After several weeks of success on the weekly point system, children went off the point system and enjoyed all privileges. Any problems were handled informally, much as families handle problems in their homes.
4. We needed to change expectations for discharge. Children and their families had high expectations for discharge after their hard work and success in treatment. Neither the children nor their families were prepared for problems after discharge.
We began telling children and families that they should expect the same kinds of problems after discharge that they had before they entered treatment. They should not be surprised by problems. Rather, they should be confident that they had the skills and abilities to manage those problems successfully whenever they occurred.
5. Discharging children at the end of the school year or at the end of the summer posed challenges for children and their families. While discharging children at the end of the school year or at the end of the summer seemed like a good idea, it was not. The transition home involves challenges, no matter how well children and families did during treatment. There was no need to add additional challenges ov another major transition from summer to school or vice versa.
We adjusted our discharges to fall within the school year. For children who were projected to discharge near the end of the school year, we moved their discharge dates up so that they discharged 30 days or more before the end of the school year. Hence, they went home to continue all the habits they had developed around going to school.
For children who were projected to discharge during the summer, we delayed their discharges until they had returned to school and been successful for at least 30 days, again returning home with habits around going to school well established.
With these changes, problems following discharge decreased markedly. After three years, the grant for our aftercare worker expired. Meanwhile, state funding had not increased although other expenses had. We could no longer provide formal aftercare services but continued to maintain contact with children and families more casually after discharge. Nevertheless, children continued to experience a high rate of success, with 84% of our children doing well based on a five-year followup. Doing well was defined as remaining at home and “still in school, completed school, or employed.”
The indirect benefits of our aftercare program “the feedback we got about the success of our treatment and discharge procedures “were more beneficial to children and families than the service itself.
I am reminded of one of the tenets of Systems Theory: Systems that get no feedback cannot adjust themselves.
Programs that get no feedback about the success of their services cannot improve those services to meet the needs of their clients. Follow-up is essential.