Residential Treatment” has been under assault for some time, as you may know. Critics have made claims about its shortcomings, many of which are absolutely true. But residential treatment is not just one model. There have been several models available to families that have been successful, time tested, and outcome supported. Sadly, many of these programs have failed to survive or have been forced into dramatic changes from the pressures they face.
The unsuccessful and even hurtful residential programs have been the “warehouse” models that provide a long-term living situation for large groups of children. These programs typically offer behavior modification along with recreational activities and socialization. By necessity, educational programs are connected to them, but they usually have lower expectations and are able to avoid teacher credentialing in meeting state licensing requirements.
So, does an “ideal” care model actually exist with clinically intensive residential treatment and quality education for children suffering from psychiatric illnesses? Everyone can agree these young people need a safe, well-supervised environment when struggling with suicidal behaviors, manic episodes, psychotic thinking, or post-traumatic stress. What would prevent us from offering them and their families a private school experience in a clinically focused residential setting? If you have an ample, well-trained staff and require parents to participate as part of the solution, wouldn’t this be an ideal model of “Integrated Care”?
Integrated Care can have many dimensions, but the question with each is – what is being brought together and for what purpose? The care model I’ll describe was developed at Wellspring, a multi-service mental health and educational agency in Bethlehem, Connecticut. It offers three levels of integrated care: Intensive residential treatment combined with special needs education; the use of different treatment modalities acting in concert; and a blend of transitional step-downs, day school and outpatient services in a continuum of care. All of this is contained in a private school environment, with the personal integration of the resident-student woven through each level. I’ll begin with the integration of treatment and education.
At Wellspring, clinically intensive residential treatment is integrated with education in a way that is unique in the realm of therapeutic schooling. Each component is accredited by top-flight agencies – Wellspring by the Joint Commission (JCAHO) and its Arch Bridge School by the New England Association of Schools and Colleges (NEASC) – the same agency that accredits Harvard and Yale. The Arch Bridge School serves Wellspring’s residential programs – children’s, adolescent, and young adult – and also functions as a Day School for students bussed from surrounding districts. Since its accreditation by NEASC in 2012, the Arch Bridge School has been designated each year as a School of Excellence by the National Association of Special Education Teachers (NASET).
Outcome studies have continually verified the effectiveness of both components. In 2014, an independent evaluation survey of Wellspring by the CT Department of Children and Families found that 100% of residential students answered “Yes” to the statement – “I like being in this program since it’s helping me and my family.” Wellspring’s internal survey of parents, residents and day students asked – “Would you recommend the Arch Bridge School to others?” Over a five-year period ending in 2014 the mean response on a scale of 1-7 was 6.7.
In 2012, the NEASC survey team made the following statements in its evaluation:
“Educationally and emotionally, the Arch Bridge School is on the leading edge in many of their philosophies and designs. Culturally, Arch Bridge’s family atmosphere and unyielding commitment to excellence would be the envy of most schools.”
“One of the most outstanding resources of the Arch Bridge School is their staff. They are exceptionally well-trained and deeply passionate about helping and teaching this population. The Arch Bridge School staff experience their mission as transforming, and in many cases, saving lives. This was confirmed time and again by staff at all levels, parents, and the students themselves.”
At the second level of integrated care – that of program – the reason for success is apparent. The basic approach to treatment and education is personal and relational, which is integrative in its own right. The personal dimension is based on a cultivated awareness and response by staff to the unique nature and gifts of each resident or student. This involves a deeper look at the individual than diagnosing a disorder or a learning disability. It is a concerted effort to see, affirm and foster this “personal” core through staff relationships. Joined with clinical experience and skill, this approach gives depth to how behavioral and learning issues are addressed and helps stabilize the treatment and educational process.
Examples abound. Debbie’s deep response to animals in the animal program awakened a self-discovery that led her to become a veterinary assistant upon graduation, with the hope of someday becoming a vet. Gina’s love for cooking was apparent when her mother discovered her avidly watching the food channel when she was four years old. She rediscovered this passion at Wellspring, where it became the basis for her entire educational program. With graduation she enrolled in culinary school. Shauna was mired in negativity and treatment resistance when she hacked into Wellspring’s computer system to read her clinical chart. To her surprise, after some initial uproar, she was lauded for her audacity as a detective and for her evident gift for computer science. Though initially expressed in “bad” behavior, the recognition and affirmation of her underlying gift opened the door to active involvement in treatment and a positive discharge. Each of these residential students had been stuck in negativity, hopelessness and depression; suicidality was part of that. Yet through the recognition and affirmation of a unique gift each found a practical lifeline to a future that supported the hard work of change.
At Wellspring, the personal and relational approach is fully integrated into program design. Disorders and learning disabilities are complex; but so are people. Because each person responds differently to different media, no single modality or approach can meet all the needs of a given individual. Program design must be comprehensive to address the different aspects of a disorder, but it should also be holistic to touch the mind, heart, body and spirit of a person.
Treatment is centered by individual therapy twice a week and family therapy once a week. Milieu therapy in the school and residence supports this work with particular attention to peer and staff relationships. As parental relationships become transferred to the milieu staff in their “parenting” roles, the acting out of these patterns is focused back into the individual and family therapy. Multiple interactive group therapies concentrate on developing self-assertion, caring feedback, caring confrontation and conflict resolution. These skills in turn funnel back into the family therapy and the bi-weekly parent support and multi-family groups to address problems and reconstitute family relationships. In these different ways, the interpersonal world of the resident becomes a practical school of relational development.
The integration of different modalities can have a synergistic effect on treatment, but this is accomplished only through close collaboration – no small matter to achieve. An essential part of the mix is the twice-weekly Emotional Expressive group, designed to evoke and express the blocked emotions of sadness, anger, pain so basic to affective disorders and PTSD. Primary therapists are present in these groups to integrate these basic emotions through follow-up individual work. This becomes a bridge in turn to convert raw emotional expression into effective and appropriate communication of feelings in family therapy.
Creative-expressive groups – art, sand tray, and drama improvisation – evoke and reflect a sense of self, a sense of “who I am.” Surprisingly, these creative media work in concert with the physical activities of animal therapy, garden therapy, work therapy, and adventure program for the same end. The individuality expressed through creative media has its embodied counterpart in the instinctual self-revealed by the resident side by side with staff and peers in hands-on work. These land-based media also build ego-strength through learning how to work and developing a work ethic to meet the challenges real life presents.
Land-based programs are often thought of as a clinical luxury, but at Wellspring they are considered essential. Richard Louv, in his book The Last Child in the Woods, has coined the phrase “nature deficit disorder” to characterize the unhealthy effects of young people’s increasing disconnection from nature through fixation on virtual reality. Camping, canoeing, ropes course, and the camaraderie of shared work and play experiences, make involvement with nature inviting and help correct this imbalance.
From a belief in the whole person, Wellspring is intentionally counter-cultural in this regard. Immersion into soil that grows vegetables and flowers is different than just getting dirty, though in an adolescent’s mind it may start out the same. Getting to know a chicken, a lamb, a goat, or a rabbit can be a revelation to an adolescent otherwise cut off from direct experience. So can camping out in the woods. Most adolescents have never engaged in community service – never helped in a soup kitchen or washed cars to raise money for a local ambulance service that also serves them. They discover satisfaction in helping others.
Not to forget the medical dimension of integrated care. Each residential program is supported by quality psychiatric care and 24-hour nursing coverage. Both are supported in turn by nutritional consultation and guidance. Unlike outpatient care, a supportive residential setting can test medications to see what’s actually needed and what helps, in contrast to medication add-ons for symptom control. As the resident becomes healthier through treatment, medications can be either discontinued or diminished.
This brings us to the third level of integration – the continuum of care available to residents, students and families as they progress in treatment. This continuum is multi-faceted and situational. As a resident-student progresses in the residential context, they may step down to less intensive treatment similar to a typical therapeutic school. If living locally, they may attend the Arch Bridge Day School while participating in some residential groups and meeting with their primary therapist in individual and family work. Young adults may attend college classes while in residence, preparing for eventual return to full-time college. Or they can take a part-time job while in residence as preparation to live independently nearby. They can then be in partial care and spend two or three days a week at Wellspring, connecting with friends in residence while seeing their primary therapist as an outpatient.
In other words, a care continuum is fashioned individually based on readiness and flexibly blended services to provide the necessary support. Residential step-down opportunities include day-school, therapeutic schooling, part-time employment, outpatient therapy, and off-campus living as available options. The intent is to provide support through established relationships, because continuity of relationship is a crucial factor in managing transitions. While the goal is always to make these transitions as seamless as possible, change is never seamless. It can, however, be made less bumpy and disjointed.
Wellspring’s model of integrated care provides clinically intensive residential treatment in a private school environment. It fosters personal integration with continuity of relationship to stabilize the process. But a model differs from the work required to make it reality. This work is arduous and never-ending, but having the right framework focuses right action, and the results support the continued effort. The Wellspring model of integrated care ascends through four levels beginning with the person, extending through comprehensive and holistic programming, to the integration of treatment with education, to a continuum of care suited to the individual and family. Although it is always a work in process needing continual adjustment, for young people with psychiatric problems – it works!