Listen to thisConsider a residential unit – one which claims to use principles of systems – based family therapy. The structure is not unfamiliar. Children and adolescents are admitted because they, or their parents, or the state welfare department, or medical personnel, or the courts deem that they require treatment outside the home. Once each week, their families arrive for a family therapy session, wherein the "real" work is done. If the session goes well, the family might stay on for a meal with the child, or might take the child home for weekend leave. For the remainder of the time, the children and adolescents are cared for by child care workers, who operate a program that includes a range of play and activity experiences, living-skills practice, and a high degree of control of difficult behavior.
The therapists believe that the therapy sessions are the main vehicle for bringing about change. They see the direct-care staff as doing little more than looking after the children in the time between therapy sessions. If a problem should arise, the job of the residential staff is to control the child until the next therapy session – or, if the problem is serious, until an extra session can be scheduled. The therapists do the "real" work.
The child care workers, of course, often believe that the "real" work of change is done in their interactions with the children. Therapy is largely a self-indulgent activity carried out behind closed doors, which bears little relevance to the day-to-day program, which often disrupts the unit’s schedule and upsets the children, and which results in additional instructions to be carried out in the coming week. It is okay for the therapists they do not have to live with the children. They can construct elaborate interventions, but direct-care staff have to cope with the aftermath, which sometimes involves an increase in disturbed or disturbing behavior.
Of course, the therapists may harbor a conviction that residential treatment is a second-best option. If their therapy skills were better, they would be able to treat every family on an outpatient basis. Committed to notions of family therapy, they are never entirely happy with admitting the "identified patient" and involving the family only peripherally. They strive to develop their therapy skills, attending conferences and workshops, with the result that not only their clients but also their child care colleagues are exposed to whatever is the latest intervention. The better their family therapy skills become, the less difference they seem to make in the day-today operation of the program, the greater the gulf becomes between what happens in the therapy room and what happens for the rest of the time on the residential unit. As this happens, the greater the tensions become between therapy and direct-care staff. Therefore, the more the direct-care staff tends to see their role as one of benevolent control.
Part of this pattern (for it is one that is repeated with alarming regularity) is the involvement and attitudes of the non-resident family members. The program includes an extraordinarily high proportion of "resistant" families. Often, it is "discovered" that their commitment to their child is illusory. As the therapeutic program continues and the child or adolescent begins to show signs of greater control or stability, parents seem not always to share the optimism of the staff. They begin to find excuses for not having the child return home just yet; they accuse the unit of being too much like a "holiday camp," or they begin to ‘undermine" the therapeutic suggestions. Child care staff may become protective of the children and develop negative opinions about the parents. There are longer staff meetings, as therapists help their direct-care colleagues work through their anger at being undermined or their feelings that certain parents are rejecting, unmotivated, or belligerent. When children finally return home, staff are dismayed at how quickly parents resume their previous complaints and how thoroughly they seem to reject the skills they have been taught.
Durrant, M. (1993) Residential Treatment: A co-operative competency based approach to therapy and program design. New York/London: W.W. Norton
