Psychiatric hospitalization is a disruptive event for any individual, especially for a child and family. However, brief the hospital stay – and stays are very brief these days – the person, the child, and the family has to cope with medications, restoring relationships, making an awkward and difficult return to school or employment, and finding a way to resume meaningful activities and interests. No transition can be seamless; no after-care easy.
If the person, particularly an adolescent or a young adult, suffers from depression and has resorted to the negative coping skills of drug abuse and self-harm that often accompany it, recovery can be complicated and unstable. Family relationships have usually become strained, often explosive, and the need for further hospitalization is ever-present. Younger children may continue to be out-of-control, unable to be safely contained within the home or school setting. These are complex, multi-faceted problems, which outpatient treatment, however “intensive,” is often inadequate to address.
Families usually don’t consider residential treatment as a viable option. While parents may desperately need respite for themselves, they also know they need more than a holding tank for their child, and a holding tank, regrettably, is all that some residential facilities have to offer. Containment has benefits, no doubt. It can relieve parents from having to forcibly restrain their out-of-control child and can save the adolescent and young adult, temporarily at least, from further substance abuse, self-injury and even suicide. But the containing situation has to offer families more than mere control of their child. It must provide a “womb,” a container for healing that can provide the real work of transition.
What is that “real” work? Family therapy is its cornerstone, much as parents might like to avoid facing this unpleasant truth. The myth that the child can be “fixed” outside of the family system has been debunked long ago. Although the child may be the identified “patient,” it’s the family system that usually needs “fixing.” Parents may have done the best they can with what they know, but what they know is what they’ve learned consciously and unconsciously from their own parents, and problems are handed down through generations. Foster and adoptive parents may conveniently blame the child’s unknown parents who came before them, but this simply dodges acceptance of their own parental responsibilities.
If residential treatment is to provide a viable transition, the whole family needs to be actively involved. Family therapy must be regular and intensive if relationships are to be restored or, in some cases, newly developed. The capacity for honest emotional communication must be opened to establish heart-to-heart connections. New parenting skills have to be learned and practiced both in the therapeutic milieu and on weekend visits home, as soon as it is safe for the child to venture home. These visits cannot be little vacations from treatment where parents and kids tiptoe around each other, not wanting to rock the boat. They have to extend the work already begun in family sessions with clear tasks set forth for the parents and the child, not the least of which is to learn how to play and have fun together, because families in trouble have usually lost that gift. The successes and the problems that arise need to be processed in family sessions following the visit. Only when this work has been honestly undertaken and parenting and communication skills have been developed and practiced is the child ready to return home to parents who are actually prepared to receive him.
Substance abuse, self-harm and suicidality complicate the family process, because visits home must be safe and closely monitored by the parents. Containment and random drug testing maintain sobriety within the residential setting, and slips on home visits need to be processed as learning opportunities and indicators of readiness for discharge. Both the adolescent, young adult and parents are involved in psychoeducation about drugs and drug abuse. AA meetings for substance abusers are attended while in residence and on home visits, so that commitment to sobriety and support can be established prior to transition.
Positive peer relationships are a crucial need for adolescents and young adults, who often use drugs and drinking as ways to belong. Children, adolescents and adults that need residential care often have poor social skills and lack the ability to form meaningful friendships. Interpersonal skill training is, therefore, a necessary component of the transition process. Clients need to learn how to assert themselves appropriately, ask for what they need, deal with limit-setting and confrontation, and develop the capacity for honest dialogue and conflict resolution.
All that are enrolled in residential treatment need to learn how to work on themselves. They have often heard this phrase and can parrot it back, but haven’t a clue what it means. To be prepared for transition and after-care, they need to develop healthy coping skills in place of negative ones. They need to experience therapy, not as something “done to them,” but something that works for them and in them to improve their lives. Perhaps the most crucial dimension of therapy involves emotional expressive work to become aware of feelings and learning how to explore and express them appropriately in relationships. It is this positive experience of therapy that can help an adolescent or a young adult to be active agents in their outpatient treatment, which depends so much on what they bring to it.
Because mental illness and behavioral problems interfere with concentration and study, academics suffer accordingly. Children, adolescents and adults have often fallen behind or have dropped out of school. School within the residential setting has several tasks. Small classes, personal attention, support for different learning styles, help with learning disabilities, and appreciation of different gifts are all aspects of academic work that help to diminish shame and build self-confidence that makes return to mainstream education possible.
Good psychiatry and a competent nursing staff are important elements of residential treatment that support stabilization and transition. If the residential program provides containment and quality medical support, medications that were initiated in brief hospital stays can be monitored over time, changed, or stopped altogether to determine what works or doesn’t and what is essential or unnecessary. In outpatient treatment, by contrast, medication adjustment is riskier and not as easily undertaken.
What outpatient treatment can address only piecemeal, residential treatment can address simultaneously and in process, but only if the program is consciously designed to do so through a multi-modal approach. Transition from psychiatric hospitalization to after-care can be approached gradually, step by step, and is less precipitous. Readiness for transition can be monitored by how the child and the family actually function in response to the challenges they face. It supports a kind of transition that diminishes the threat of recidivism and repeated hospitalizations and protects against the shame attached to them.
What I am presenting in terms of transition and after-care needs is an actual description of residential treatment at Wellspring, a multi-service mental health agency in Bethlehem, Connecticut. Wellspring has residential programs for young children, adolescent girls and young adults that are specifically designed for transition from psychiatric hospitalization. Each program is situated in a spacious country home with barns for animals. Each is surrounded by woods and fields, a flowing stream or a nearby pond. Each program is small, intimate, homelike and personal – the opposite of an impersonal institutionalized setting. Families are included in the treatment according to the specific needs of the residential population. Children need to have their parents very present, so parents are brought into the residential for meals and play and bedtime activities. Adolescents don’t need their parents hovering over them, but want them actively involved in weekly family sessions, parent support and multi-family groups. Young adults need their parents to be available for family sessions but want them to be supportive of their efforts at independence.
In the children’s residential program, parents are encouraged to share meals, play with their children, read to them and put them to bed. During this time, they are coached by the staff in high structure, high nurture parenting skills that are particularly focused on developing bonding and attachment. These coaches attend family sessions with a clinician to share their observations and reflections as part of the process. They also become home coaches and support persons for the family as part of after-care and transition.
In the Adolescent program, weekly family sessions are an admission requirement, along with attendance at parent support group and multi-family group every other weekend, which coincide with parent visits or visits at home. The program is multi-faceted with a substance abuse track, emotional expressive groups, and interactive groups to develop interpersonal skills. Special mind-body groups address body image and eating disorder issues. Animals care, animal assisted therapy, adventure, and horticulture offer a wide range of life experiences that are both instructive and challenging, designed to develop confidence and responsibility. There is considerable emphasis on creative self-expression through art, pottery, sand tray therapy, and theater as aspects of a multi-faceted learning experience that touches mind, heart, body and spirit.
Adolescents and children attend the Arch Bridge School, a certified special education school on the grounds. Young adults at Angelus House take college courses while in residence, preparing to return to college when they leave. They also obtain part-time jobs in the area from employers known and trusted by the staff to provide a meaningful work experience and honest feedback. Animal care, work therapy and adventure programming are staples of the program that help restore functioning, self-confidence and responsibility. In contrast to the children’s and adolescent programs which restore families and return kids home, Angelus House provides a series of step downs that involve work outside and school as part of a gradual process of transition to independent living.
Each of these three residential programs provide an intensive, multi-modal process that prepares the individual – child, adolescent or adult – for transition back to normal life, whether that life is centered in one’s family or in one’s own apartment. The transition from the residential presents many of the same challenges as transition from the hospital. But much more is now in place that makes this transition more advanced and secure. Primary relationships are usually improved, capacity for healthy peer relationships is more developed, substance abuse is under control, and attachment and bonding for young children is more developed. Residents have had practice making the right choices, and have learned from their experience making wrong choices. If they have slipped, they have learned to re-group, take stock and continue on their way. The elements of successful transition have already occurred in calibrated steps, and the major building blocks are more or less in place. They are prepared academically for return to school and are better prepared to develop new friendships. While residential treatment is not the same as real life, because stability in a supportive structure was provided, there are ways life has been more real in the residential, because relationships built from the experience of shared work and self-disclosure are often more intimate and authentic. Parents have had an opportunity to do their own work, and they are typically grateful for what they have learned, though all will say it hasn’t been easy. Transition home or to independent living presents many of the same problems in different form, but the problems are experienced differently from this angle than before.