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121 MARCH 2009
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RESIDENTIAL CARE

Untreatable in this environment

John Stein

When I was working in residential treatment, I would from time to time get referrals for children who were in other facilities. Some of the reasons given as to why they were seeking placement still stick in my mind. “Untreatable in this environment.” “Has derived maximum benefit from treatment.” “Would benefit from a more structured environment.” All of these said to me ““We can’t manage this kid!” And they certainly couldn’t treat him. They were throwing kids away.

My first experience with residential treatment was in a small, secure facility to treat hardcore juvenile offenders who had been adjudicated as delinquent. It was the end of the line. We had to accept all boys who were sent to us, and we had to keep them until they were ready and able to be released back to the community “home, foster care, or group home. Discharging a boy who was too difficult or too dangerous was not an option. There was nowhere else to send them. That was the purpose of our facility “to treat those boys.

Consequently, we found ways to manage and treat boys with very challenging problems.

And so I believe that facilities have an obligation to make a full commitment to each and every child they accept for treatment. And I know it is possible to do so.

My next position was in a more traditional residential treatment setting for treatment of children from ages seven through eighteen years. It was a somewhat larger facility with several small cottages located on a large wooded campus. We had some boys with some very challenging behaviors. And we had some girls with behaviors that might have been even more challenging. The youngest seemed to be the most volatile. Before long, staff were telling me we had to get rid of certain kids. She was too much trouble. He was too dangerous. We couldn’t treat her. He was taking too much staff time “it wasn’t fair to the other kids.

They were expending more energy on trying to convince me that we could not handle and treat certain kids than they were spending on looking for ways to manage and treat them. And so they were right “the kids had become untreatable. Because the staff had stopped trying to treat them. They had given up.

I explained that I did not believe in throwing kids away and did not entertain any discussions about getting rid of kids. But I did provide staff with support. I needed to show my commitment, both to the children and to the staff. If staff seemed to be overwhelmed by a particular child, I would take him or her away for awhile, outside or to my office. Even if they calmed down relatively quickly, I would usually keep them for an hour or two, until they began to look not just ready but anxious to return to normal activities. When a child was too upset to leave with me, I would stay with the child and send the staff and the other kids off to have some fun time, maybe for ice cream.

I did not leave work at the end of the day until things were settled. And staff could call me any time of the day or night. Sometimes I could offer suggestions by phone. Other times, I chose to return to work.

Eventually, staff became just as committed to each and every child as I was. Consequently, they began looking for ways to treat and manage difficult children instead of looking for rationales as to why they couldn’t and why the children had to be discharged. And eventually, they began to take pride in not having to call me.

I have found that throwing kids away leads to what I call Multiple Placement Syndrome. It has most of the features of Oppositional Defiant Disorder and some of the features of Conduct Disorder. But it is neither. It is simply vulnerable children who have been in several placements in a relatively short period of time. Perhaps some changes were due to circumstances beyond their control, such as abuse or a foster family’s circumstances changing, such as a job out-of-state. More often, changes had something to do with children's difficult and dangerous behavior.

But the more changes children have, and no matter the reasons for the changes, the more difficult and challenging children's behavior becomes.

The popular wisdom is that children are testing limits in a new placement to see what they can get away with. I believe that the children are testing, not to see what they can get away with, but for security. They cannot commit to a placement because they do not feel that their placements are committed to them.

They know they are difficult. They know that there is a line that, if they cross it, they will be thrown out. They need to know exactly where that line is in order to feel secure. The closer they get to that line, the more anxious they become. They cannot know exactly where the line is until they cross it. Once they find it, by crossing it, they get thrown out. And start all over. And they are just a little more damaged.

The only way to treat these children is to remove the line. To convince them that there is no line. And to be patient. It takes a total team effort and a total commitment. Someone has to break the cycle.

That’s what residential treatment is for.

I don’t mean to imply that I never discharged a difficult child. My policy was firm, but it was not inviolate. I did make exceptions. But they were rare. I once discharged a boy who ran away on his second weekend and was picked up in the neighborhood with a firearm he had stolen. I believed that accepting him back would be a clear and present danger to other residents and staff, given his ability to arm himself so readily in the neighborhood and his desire to do so.

And there were a few boys who did not appear to be able to improve in our program after many months, or who began to regress. We would talk with them. When they agreed that they would like another opportunity in another program, we arranged a preplacement in an appropriate program. If they were accepted and agreed to make the change, we made the arrangements. The one who was not accepted, we kept. All did well in their new placements. We had not “thrown them away.” They had made the change. The one who stayed also began to do well and eventually returned home and got a job.

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