Special Programs for Special Families

The Residential Care vs. Community Services DebateIn advocating for community alternatives to residential care, we want to establish some common ground, so initially avoid the negatives. There is nothing inherently positive or negative about any placement, be it institutional, residential center, group home, foster care ,independent living, home based, etc. The quality of care is determined by the staff, the support system, the agencies value system, the referring agencies coordination with the private vendor, equality of funding streams, and a whole range of other variables, most important of which is the youngster's and family's attitude toward the placement. Thus, everything else being equal ,including funding streams (and, of course, they are not equal and remain weighted toward residential), what does residential or community offer in the way of meeting specific needs of kids and families, and which placement has the most potential for meeting needs, and effecting change over the long term?

For example, take a Youth/Family/Team strengths/needs based assessment that identifies the following needs in a 16 year old male with charges of aggravated assault, UUV, probation violations (curfew truancy), possession, and who has a formal diagnosis of PTSD:

  • Increased supervision to prevent further interaction with delinquent peers
  • Someone to talk with about loss of big brother via drive-by shooting 2 years ago
  • Special help with reading - presently reading at a 3rd grade level
  • Closer relationship with mother, who is depressed and on medication
  • Visits with father who is incarcerated on drug and assault charges for next 5 years
  • Organized sports program that will enable him to participate in track and field

Then talk about how both residential community based could address these needs:

Supervision to limit interaction with delinquent peers

  • In residential he would be supervised by the unit child care staff the majority of the time, and he would live in a milieu made up of other kids with problems. How do we determine whether that milieu is somehow therapeutic? Do we evaluate it each time we refer someone there, or do we assume it to be so because the facility's literature advertises the use of a "therapeutic milieu"? At intake does the facility match the kid with other kids and child care staff, or does an empty bed and/or the absence of a waiting list determine the appropriateness of the referral? What input does the family have in determining where the boy lives, and what provisions does the facility make for family interaction?(major points: family often off the hook for involvement; primary interaction on unit is with other kids; referring agency often off the hook re: regular monitoring due to location of facility; background of child care staff may not be relevant re: the unique aspects of the youngster and the neighborhood he comes from. )
  • In home/community based we have the potential to select an appropriate individual to supervise the youngster in the community, and limit his access to delinquent influences. Will we always succeed? Nope. But we have the opportunity to deal with the realities of the home and community that this youngster lives in, will probably live in the majority of his years, and has to learn to deal with. So how much supervision? Whatever it takes - individualized, reviewed, revised, etc. on an as needed basis with the family, local vendor and referring agency. (major points: dealing with the reality based variables that the kid and family must cope with; referring agency able to monitor services; mutual, ongoing accountability possible for kid, family, referring agency, vendor, etc.; possibility that formal resource in neighborhood can continue to provide informal assistance after the program of supervision ends. )

Someone to talk to about loss of big brother

  • The residential center will most likely provide a certified therapist that is part of their staff, and probably has some skills in grief counseling. If conscientious, that individual will seek out the family as part of any counseling with the youngster, will coordinate with mom's therapist or doctor, and will provide an empathic, sensitive, and safe outlet for this youngster to discuss his feelings about his brother's death. (major point: no choice in therapist - by definition it is who is on the staff, and usually who is the assigned therapist for that group of kids. If it happens to be the right match, GREAT! If not, too bad!  Another example of the kid adapting to the world of residential care, which would be fine if that was what we were preparing him to deal with for the rest of his existence!).
  • In the community we have the opportunity to go shopping for an appropriate therapist, to keep the family involved in the decision making process, and to monitor the process. (major point: The brother's death is not a trauma solely experienced by this youngster, but is a total family, and possibly a total community, issue. It demands the utmost sensitivity in searching for a therapist/counselor, and should not be confined to just someone on the staff of the local core service agency. The referring agency, the family, the youth, a local vendor, etc. have the opportunity to go out together and locate the most appropriate helping agent. )

Special reading help

  • Probably the strongest aspect of most residential centers, and that which makes them understandably very appealing to the bench, and referral agencies, is the school program, and the assurance that the youngster will have to attend school. In addition, most residential centers have special ed. curriculums, and the ability to offer special help in areas where the youth demonstrates weakness. A particular youth may also be more willing to admit to reading difficulties in a setting away from his normal peer group, where the embarrassment of being "slow" is often so strong as to lead the youngster away from any help that is offered. (major point: the apparent short term solution lets the local school folks, the referring agency, the family, local education advocates, etc. off the hook, and delays reintegration into whatever special program can be devised to help a youngster with his academic shortcomings. In addition, just as with therapy, appropriate services are dependent upon happening to find the right match - seldom is the school at a residential center looked into (evaluated) to the extent it needs to be - the assumption is that it is certified therefore it is appropriate. It is always easier to buy into the assumption, than to check it out. )
  • In the community, we have the opportunity to individualize the youngster's reading program to whatever extent is necessary in addition to interfacing with the public school that is responsible for either providing the service, or assisting in its funding. (major point: again the issue of mutual accountability and responsibility - family, referring agency, school, legal reps. , etc. all have the opportunity/responsibility to assure the development of an appropriate program. )

Closer relationship with mother

  • If the residential center is close enough, and is so motivated, they certainly can provide help in this area to the extent their staff is able to do so. They will probably have therapists that are certified, and hopefully experienced in working with similar situations. (major point: again, no choice - dependent on who happens to work with that particular agency, their perception of the family dynamics, their skill level in both assessing and providing treatment – all these things are beyond the control of the youth, his family, and, usually, the referring agency. )
  • In the community, again we have the opportunity to shop for the appropriate service, to involve the family in that process (that may include confronting the family if they choose to remain in a passive-victim mode – but then isn’t that part of treatment?), and to establish a level of mutual accountability that is virtually impossible when a youngster’s in residential placement outside of his home community. (major point: as with the other areas, it is mutual accountability, utilization of local resources, dealing with community realities, etc. )

Likewise with visiting dad and participating in track and field, placement away from home just delays the inevitable, allows agency workers to maintain an “out of sight, out of mind” mindset, minimizes the importance of work with the family unit, and does nothing to stimulate the creation of new programming at the community level. So why is it the way it is? – some thoughts:

  1. It’s easier – facility placements are quite seductive – they provide workers, judges, clinicians (and often families) with the illusion of safety and security. Criminal acts that occur in facilities are, more often than not, handled administratively, and the sending Court/Agency is often never aware of them. If the acting out becomes too disruptive, the youngster is discharged, and the Court/Agency is left with the next dilemma – how can we get him placed somewhere else, which essentially means:  “how can we create a referral package that makes this youngster sound as if he is amenable to the particular modality that is practiced at that facility, and minimizes the acting out that just resulted in his discharge. ”
  2. Community work is difficult – the range of variables that one must address in the community are at times overwhelming for workers, especially those workers that come from environments that are at the opposite end of the economic spectrum, or who feel some fear working in those environs. No worker should be expected to put themselves in harms way – however, if we are going to genuinely confront youth, family, and community dynamics, we must hire folks who are not intimidated in that setting. Too often, due to certification requirements, past hiring practices, etc., we bypass quality grassroots resources, and become overly dependent on paper qualifications of staff whose life experiences are not conducive to functioning in the homes and communities of many of our youth. What results are either workers that are overly judgmental and punitive, or workers that become so passive and overwhelmed that they are, in fact, enablers. The ability to reject behavior without rejecting the person(s) is the foundation for all relevant treatment, be it therapy, parenting, teaching, job supervision, whatever. We have done poorly in the selection of appropriate staff, of contracting with appropriate agencies, of holding folks accountable, and of supporting staff in understanding where their particular skills lie, and where they can be most effective.
  3. Young workers (hell, workers in general!) often find family work to be overwhelming – though many workers demonstrate genuine empathy for kids in trouble, those same workers are often incapable of reaching out to parents whose vulnerability, pain, and self destructive acting out, is, more often than not, far more severe than the youngsters. We see the most open and non-judgmental workers with kids, becoming accusatory toward the parents to the point that they often rationalize the youngster’s behavior to the extent that they feed into the kid’s victim self perception. We have done little to help workers with this dilemma, and understand (and hopefully rectify) the counter-transference phenomena that lays at the foundation of these feelings. They either back off from the family altogether out of the understandable frustration that occurs when one is constantly confronted with their limitations, or involve themselves in a rescue fantasy with the kid, which, of course, leads to placement. Obviously, some kid’s home situation necessitates placement – however, that does not mean the discontinuation of family involvement, and usually means even more work is necessary with the family, even if one has to take the difficult step of reporting that family to the local protective services agency to get additional leverage in an attempt to get them to accept assistance. Again, the emphasis on utilizing natural community resources (extended family, church, neighborhood groups, etc. ) tends to get minimized once a placement occurs, and eventually the youngster returns to the same situation that contributed so greatly to his original self destructive behavior.
  4. Judges remain too dependent on clinical assessments conducted in artificial settings, and often provided by less than experienced or competent clinicians. Judges feel safer if they can refer to reports that contain a bunch of initials at the end of the name of the evaluator. However, there exists no scientific evidence whatsoever that 1) these reports are accurate in their predictive capabilities; 2) that the allotted amount of time for the assessment has somehow been proven over time to be the optimum set period (not dissimilar to the 45 minute therapy hour that shrinks so tenaciously embrace); 3) that the psychological tests administered have any genuine ability to predict behavior in the community, in residential treatment centers, 5 years down the road, 15 years down the road, etc. Clinical input has its place, but it has become a crutch for many on the bench, and it is essential that clinicians assist judges in putting their input in the proper perspective. One way for this to occur is for clinicians to participate in family team meetings, and include in their findings their observations from these meetings. Also, observing youngsters and families during visiting hours, observing youth on residential units, shelters, etc. (how ‘bout offices on the units, rather than tucked away safely with other clinicians!?), and finally, being willing to write reports in a language that can be shared with the youth and his family, will often facilitate an alliance with that clinician that may help soften resistance to treatment later on. If clinicians can confine themselves to identifying what they see to be a youngster and family’s genuine needs, rather than making recommendations for specific types of services (residential care, drug treatment, anger management, parenting classes, etc. ), and can participate with the Youth/Family team in a strengths/needs based assessment, they can become a genuine asset in the development of individualized plans for the youngster’s supervision and care. For example, when a judge sees so and so,”…needs a structured environment…” the judge is likely to interpret that as a recommendation for residential care. However, if the clinician is able as part of the Family team to identify ways in which that structure can be implemented in the home, the school, the community, that clinician becomes another effective advocate for the development of more individualized and creative services at the local level. There is no doubt that, for the most part, judges and clinicians have a very real concern for the welfare of the kid, family, and the community – unfortunately they have often unconsciously joined hands in supporting practices that have undermined that concern over the long term, by buying into short term solutions that seem to make the problem go away for awhile.

Finally (sorry for being so long winded) the Interagency efforts initiated in any municipality are the only practical way to begin to address these issues. The super agencies in DC, Chicago, New York, LA, Detroit, etc. (Mental Health, Social services, Education, Probation) are all vulnerable to the pressures of excessive caseloads, limited resources, burnt out employees, lack of vision/commitment, whatever, and have all independently proven over the years their inability to address these issues alone with anything other than expedient, unplanned, and band aide solutions. If we can put aside the turf issues that have historically undermined cooperative efforts, there is a chance we can improve services to our most vulnerable citizens, no matter what agency they happen to initially be assigned to. The leadership in these agencies must be genuinely committed to reform – hopefully government will provide the support and time needed for the enthusiasm of ideas to evolve into practical solutions.