Residential treatment center

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The SOCCSKSARGEN Drug Abuse Treatment and Rehabilitation Center in Alabel, Philippines SOCCSKSARGEN Drug Abuse Treatment and Rehabilitation Center (SDATRC).jpg
The SOCCSKSARGEN Drug Abuse Treatment and Rehabilitation Center in Alabel, Philippines

A residential treatment center (RTC), sometimes called a rehab, is a live-in health care facility providing therapy for substance use disorders, mental illness, or other behavioral problems. Residential treatment may be considered the "last-ditch" approach to treating abnormal psychology or psychopathology.


Historical background in the United States

The Brattleboro Retreat in Vermont Brattleboro Retreat 3.jpg
The Brattleboro Retreat in Vermont

In the 1600s, Great Britain established the Poor Law that allowed poor children to become trained in apprenticeships by removing them from their families and forcing them to live in group homes. [1] In the 1800s, the United States copied this system, but often mentally ill children were placed in jail with adults because society did not know what to do with them. [1] There were no RTCs in place to provide the 24-hour care they needed and they were placed in jail when they could not live in the home. [1] In the 1900s, Anna Freud and her peers were part of the Vienna Psychoanalytic Society and they worked on how to care for children. [2] They worked to create residential treatment centers for children and adolescents with emotional and behavioral disorders.

The year 1944 marked the beginning of Bruno Bettelheim's work at the Orthogenic School in Chicago, and Fritz Redl and David Wineman's work at the Pioneer House in Detroit. [2] Bettelheim helped increase awareness of staff attitudes on children in treatment. [2] He reinforced the idea that a psychiatric hospital was a community, where staff and patients influenced each other and patients were shaped by each other's behaviors. [2] Bettelheim also believed that families should not have frequent contact with their child while he or she was in treatment. [2] This differs from community-based therapy and family therapy of recent years, in which the goal of treatment is for a child to remain in the home. [3] Also, emphasis is placed on the family's role in improving long term outcomes after treatment in a RTC. [3] The Pioneer House created a special-education program to help improve impulse control and sociability in children. [2] After WWII, Bettelheim and the joint efforts of Redl and Wineman were instrumental in establishing residential facilities as therapeutic-treatment alternative for children and adolescents who can not live at home [4]

In the 1960s, the second generation of psychoanalytical RTC was created. These programs continued the work of the Vienna Psychoanalytic Society in order to include families and communities in the child's treatment. [1] One example of this is the Walker Home and School which was established by Dr. Albert Treischman in 1961 for adolescent boys with severe emotional or behavioral disorders. He involved families in order to help them develop relationships with their children within homes, public schools and communities. [2] Family and community involvement made this program different from previous programs.

Beginning in the 1980s, cognitive behavioral therapy was more commonly used in child psychiatry, [2] as a source of intervention for troubled youth, and was applied in RTCs to produce better long-term results. [2] Attachment theory also developed in response to the rise of children admitted to RTCs who were abused or neglected. These children needed specialized care by caretakers who were knowledgeable about trauma. [4]

In the 1990s, the number of children entering RTCs increased dramatically, leading to a policy shift from institution- based services to a family-centered community system of care. [5] This also reflected the lack of appropriate treatment resources. However, residential treatment centers have continued to grow and today house over 50,000 children [6] The number of residential treatment centers in the United States is currently estimated at 28,900 facilities. [7]

Children and teens

RTCs for adolescents, sometimes referred to as teen rehab centers, provide treatment for issues and disorders such as oppositional defiant disorder, conduct disorder, depression, bipolar disorder, attention deficit hyperactivity disorder (ADHD), educational issues, some personality disorders, and phase-of-life issues, as well as substance use disorders. Most use a behavior modification paradigm. Others are relationally oriented. Some utilize a community or positive peer-culture model. Generalist programs are usually large (80-plus clients and as many as 250) and level-focused in their treatment approach. That is, in order to manage clients' behavior, they frequently put systems of rewards and punishments in place. Specialist programs are usually smaller (less than 100 clients and as few as 10 or 12). Specialist programs typically are not as focused on behavior modification as generalist programs are.

Different RTCs work with different types of problems, and the structure and methods of RTCs vary. Some RTCs are lock-down facilities; that is, the residents are locked inside the premises. In a locked residential treatment facility, clients' movements are restricted. By comparison, an unlocked residential treatment facility allows them to move about the facility with relative freedom, but they are only allowed to leave the facility under specific conditions. Residential treatment centers should not be confused with residential education programs, which offer an alternative environment for at-risk children to live and learn together outside their homes.

Residential treatment centers for children and adolescents treat multiple conditions from drug and alcohol addictions to emotional and physical disorders as well as mental illnesses. Various studies of youth in residential treatment centers have found that many have a history of family-related issues, often including physical or sexual abuse. Some facilities address specialized disorders, such as reactive attachment disorder (RAD).

Residential treatment centers generally are clinically focused and primarily provide behavior management and treatment for adolescents with serious issues. In contrast, therapeutic boarding schools provide therapy and academics in a residential boarding school setting, employing staff of social workers, psychologists, and psychiatrists to work with the students on a daily basis. This form of treatment has a goal of academic achievement as well as physical and mental stability in children, adolescents, and young adults. Recent trends have ensured that residential treatment facilities have more input from behavioral psychologists to improve outcomes and lessen unethical practices. [8]

Behavioral interventions

A therapeutic self-help group at the Rehab Center Parus in Moscow Therapeutic group in the Rehabilitation Center for alcohol and drug addicts.jpg
A therapeutic self-help group at the Rehab Center Parus in Moscow

Behavioral interventions have been very helpful in reducing problem behaviors in residential treatment centers. [9] The type of clients receiving services in a facility (children with emotional or behavioral disorders versus mental retardation versus psychiatric disorders) is a factor in the effectiveness of behavior modification. [10] Behavioral intervention has been found to be successful even when medication interventions fail. [11] However, there is evidence that certain populations may benefit more from interventions that fall outside of the behavior-modification paradigm. For instance, positive outcomes have been reported for neurosequential interventions targeting issues of early childhood trauma and attachment. (Perry, 2006). [12] Although the majority of children who receive services in RTCs present emotional and behavioral disorders (EBDs), such as attention deficit hyperactivity disorder (ADHD), Oppositional Defiant Disorder (ODD), and Conduct Disorder (CD), behavior-modification techniques can be an effective way of decreasing the maladaptive behavior of these clients. Interventions such as response cost, token economies, social skills training groups, and the use of positive social reinforcement can be used to increase prosocial behavior in children (Ormrod, 2009). [13]

Behavioral interventions are successful in treating children with behavioral disorders in part because they incorporate two principles that make up the core of how children learn: conceptual understanding and building on their pre-existing knowledge. Research by Resnick (1989) [14] shows that even infants are able to develop basic quantitative frameworks. New information is incorporated into the framework and serves as the basis for the problem-solving skills a child develops as she or he is exposed to different types of stimuli (e.g., new situations, people, or environments). The experiences and environment that a child is exposed to can have either a positive or negative outcome, which, in turn, impacts how he or she remembers, reasons, and adapts when encountering aversive stimuli. Furthermore, when children have acquired extensive knowledge, it affects what they notice and how they organize, represent, and interpret information in their current environment (Bransford, Brown, & Cocking, 2000). [15] Many of the children housed in RTCs have been exposed to negative environmental factors that have contributed to the behavior problems that they are exhibiting.

Many interventions build on children's prior knowledge of how reward works. Reinforcing children for pro-social behaviors (i.e., using token economies, in which children earn tokens for appropriate behaviors; response cost (losing previously earned tokens following inappropriate behavior; and implementing social-skills training groups, where participants observe and participate in modeling appropriate social behaviors help them develop a deeper understanding of the positive results of pro=social behavior.

Wolfe, Dattilo, & Gast (2003) [16] found that using a token economy in concert with cooperative games increased pro-social behaviors (e.g. statements of encouragement, praise, or appreciation, shaking hands, and giving high fives) while decreasing anti-social ones (swearing, threatening peers with physical harm, name-calling, and physical aggression). The use of a response-cost system has been efficacious in reducing problem behaviors. A single-subject withdrawal design employing non-contingent reinforcement with response cost was used to reduce maladaptive verbal and physical behaviors exhibited by a post-institutional student with ADHD (Nolan & Filter, 2012). [17] Wilhite & Bullock (2012) [18] implemented a social-skills training group to increase the social competence of students with EBDs. Results showed significant differences between pre- and post-intervention disciplinary referrals, as well as several other elements of behavioral-ratings scales. Evidence also exists for the usefulness of social reinforcement as a part of behavioral interventions for children with ADHD. A study by Kohls, Herpertz-Dahlmann, & Kerstin (2009) [19] found that both social and monetary rewards increased inhibition control in both the control and experimental groups. However, results showed that children with ADHD benefitted more from social reinforcement than typical children, indicating that social reinforcement can significantly improve cognitive control in ADHD children. The techniques listed are only a few of the many types of behavioral interventions that can be used to treat children with EBDs. Additional information regarding types of behavioral interventions can be found in the 2003 book Behavioral, Social, and Emotional Assessment of Children and Adolescents by Kenneth Merrell.

Types of Family Therapy used in Residential Treatment Center

Narrative Therapy: Narrative therapy has shown an increase in popularity in the field of family therapy. Narrative therapy developed out from the postmodern viewpoint, which is expressed in its principles: (a) not one universal reality exists, but socially constructed reality; (b) reality is created by language; (c) narrative maintains reality (d) not all narratives are equivalent [20] (Freedman and Combs, 1996).

Narrative family therapy views human issues from those roots as emerging and being sustained by dominant stories that control the life of an individual. Problems arise when individual stories do not match with their experience of living. According to the narrative viewpoint, by offering a new and distinct perspective [21]

In a problem-saturated narrative, therapy is a process of rewriting personal narratives. The process of rewriting the narrative of the client involves (a) expressing the problem(s) they are experiencing; (b) breaking down narratives that trigger problems through questioning; (c) recognizing special outcomes or occasions where a person has not been constrained by their situation; (d) connecting specific results to the future and providing an alternate and desired narrative; (e) inviting supports among the community to spectate the new narrative and (f) logging new document [21] Since postmodern viewpoints prioritize concepts rather than techniques, in narrative therapy, formal methods are restricted. However, some researchers have described techniques that are useful in helping an individual rewrite a specific experience, like retelling stories and writing letters.

Children admitted to a residential treatment center have behavior problems so extreme that residential treatment is their last hope. Parents seem to think the child is the problem needed to be fixed, and everything will be okay; on the other hand, the child generally sees him/herself as a victim. Narrative therapy enables these perspectives to be broken down and troubling behaviors of the child to be externalized, which could encourage both the child and the family members to achieve a new perspective no one feels prosecuted or blamed. [22]

Multi Systemic Therapy:

The model has shown success in sustaining long-standing improvements in children's and adolescents' antisocial behaviors. Families in MST have demonstrated improved family stability and post-treatment adaptability and growing support, and reduced conflict- hostility [23]

The method's ultimate objectives include a) eliminating behavior problems, b) enhancing family functioning, c) strengthening the adolescents' ability to perform better at school and other community settings, and d) decreasing out of home placement [24]


Disability rights organizations, such as the Bazelon Center for Mental Health Law, oppose placement in RTC programs, calling into question the appropriateness and efficacy of such placements, noting the failure of such programs to address problems in the child's home and community environment, and calling attention to the limited mental-health services offered and substandard educational programs.[ citation needed ] Concerns [ whose? ]specifically related to a specific type of residential treatment center called therapeutic boarding schools include:

Bazelon promotes community-based services on the basis that they are more effective and less costly than residential placement. [25]

A 2007 Report to Congress by the Government Accountability Office (GAO) found cases involving serious abuse and neglect at some of these programs. [26]

From late 2007 through 2008, a broad coalition of grass-roots efforts, as well as prominent medical and psychological organizations such as the Alliance for the Safe, Therapeutic and Appropriate use of Residential Treatment (ASTART) and the Community Alliance for the Ethical Treatment of Youth (CAFETY), provided testimony and support that led to the creation of the Stop Child Abuse in Residential Programs for Teens Act of 2008 by the United States Congress Committee on Education and Labor. [27]

Jon Martin-Crawford and Kathryn Whitehead of CAFETY testified at a hearing of the United States Congressional Committee on Education and Labor on April 24, 2008, [28] and described abusive practices they had experienced at the Family Foundation School and Mission Mountain School, both therapeutic boarding schools. [29] [30]

Due to the absence of regulation of these programs by the federal government and because many are not subject to state licensing or monitoring, [31] the Federal Trade Commission has issued a guide for parents considering such placement. [32]

Residential treatment programs are often caught in the cross-fire during custody battles, as parents who are denied custody try to discredit the opposing spouse and the treatment program. [33] [34]

Research on effectiveness

Studies of different treatment approaches have found that residential treatment is effective for individuals with a long history of addictive behavior or criminal activity. [35] [36] [37] [38] RTCs offer a variety of structured programs designed to address the specific need of the inmates. Despite the controversy surrounding the efficacy of (RTCs), recent research has revealed that community-based residential treatment programs have positive long-term effects for children and youth with behavioral problems. Participants in a pilot program employing family-driven care and positive peer modeling displayed no incidence of elopement, self-injurious behaviors, or physical aggression, and just one case of property destruction when compared to a control group (Holstead, Dalton, Horne, & Lamond, 2010). [39] The success of treatment for children in RTCs depends heavily on their background i.e., their state, situation, circumstances and behavioral status before commencement of treatment. Children who displayed lower rates of internalizing and externalizing behavior problems at intake and had a lower level of exposure to negative environmental factors (e.g., domestic violence, parental substance use, high crime rates), showed better results than children whose symptoms were more severe (den Dunnen, St. Pierre, Stewart, Johnson, Cook, & Leschied, 2012). [40]

Additional research demonstrates that planned treatment, or knowing the expected duration of treatment, is strongly correlated with positive treatment outcomes. Long-term results for children using planned treatment showed that they are 21% less likely to engage in criminal behavior and 40% less likely to need hospitalization for mental-health problems (Lindqvist, 2010). [41] Further evidence exists supporting the long-term effectiveness of RTCs for children exhibiting severe mental health issues. Preyde, Frensch, Cameron, White, Penny, & Lazure (2011) [42] found that clients showed a statistically significant reduction in symptom severity 12–18 months after leaving an RTC, results which were maintained 36–40 months after their discharge from the facility. However, although there is a great deal of research supporting the validity of RTCs as a way of treating children and youth with behavioral disorders, little is known about the outcomes-monitoring practices of such facilities. Those that track clients after they leave the RTC only do so for an average of six months. In order to continue to provide effective long-term treatment to at-risk populations, further efforts are needed to encourage the monitoring of outcomes after discharge from residential treatment (Brown, Barrett, Ireys, Allen, & Blau, 2011). [43]

One problem that hinders the effectiveness of RTCs is elopement or "running". A study by Kashubeck, Pottebaum, and Read found that runaways from RTCs were "more likely to have a history of elopement, a suspected history of sexual abuse, an affective-disorder diagnosis, and parents whose rights had been terminated." [44] By employing these characteristics of patients in the design of treatment, RTCs may be more successful in reducing elopement and otherwise improving the probability of clients' success.

See also

Related Research Articles

Attention deficit hyperactivity disorder Attention disorder

Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by inattention, or excessive activity and impulsivity, which are otherwise not appropriate for a person's age. Some individuals with ADHD also display difficulty regulating emotions or problems with executive function. For a diagnosis, the symptoms have to be present for more than six months, and cause problems in at least two settings. In children, problems paying attention may result in poor school performance. Additionally, it is associated with other mental disorders and substance use disorders. Although it causes impairment, particularly in modern society, many people with ADHD can have sustained attention for tasks they find interesting or rewarding.

Conduct disorder (CD) is a mental disorder diagnosed in childhood or adolescence that presents itself through a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate norms are violated. These behaviors are often referred to as "antisocial behaviors." It is often seen as the precursor to antisocial personality disorder, which is per definition not diagnosed until the individual is 18 years old. Conduct disorder is estimated to affect 51.1 million people globally as of 2013.

Anti-social behaviours are actions that harm or lack consideration for the well-being of others. It has also been defined as any type of conduct that violates the basic rights of another person and any behaviour that is considered to be disruptive to others in society. This can be carried out in various ways, which includes, but is not limited to, intentional aggression, as well as covert and overt hostility. Anti-social behaviour also develops through social interaction within the family and community. It continuously affects a child's temperament, cognitive ability and their involvement with negative peers, dramatically affecting children's cooperative problem-solving skills. Many people also label behaviour which is deemed contrary to prevailing norms for social conduct as anti-social behaviour. However, researchers have stated that it is a difficult term to define, particularly in the United Kingdom where many acts fall into its category. The term is especially used in British English.

Reactive attachment disorder Psychological disorder that can affect children

Reactive attachment disorder (RAD) is described in clinical literature as a severe and relatively uncommon disorder that can affect children. RAD is characterized by markedly disturbed and developmentally inappropriate ways of relating socially in most contexts. It can take the form of a persistent failure to initiate or respond to most social interactions in a developmentally appropriate way—known as the "inhibited form". In the DSM-5, the "disinhibited form" is considered a separate diagnosis named "disinhibited attachment disorder".

A behavior modification facility is a residential educational and treatment institution enrolling adolescents who are perceived as displaying antisocial behavior, in an attempt to alter their conduct. As of 2008 there were about 650 nongovernmental, residential programs in the United States offering treatment services for adolescents. Some similar institutions are operated as components of governmental education or correctional systems.

Oppositional defiant disorder (ODD) is listed in the DSM-5 under Disruptive, impulse-control, and conduct disorders and defined as "a pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness" in children and adolescents. This behavior is usually targeted toward peers, parents, teachers, and other authority figures. Unlike children with conduct disorder (CD), children with oppositional defiant disorder are not aggressive towards people or animals, do not destroy property, and do not show a pattern of theft or deceit. It has certain links to ADHD and as much as one half of children with ODD will also diagnose as having ADHD as well.

Adventure therapy Type of psychotherapy

Adventure therapy is a form of psychotherapy created as early as the 1960s. It is influenced by a variety of learning and psychological theories. Experiential education is the underlying philosophy. Existing research in adventure therapy reports positive outcomes in improving self-concept and self-esteem, help-seeking behavior, increased mutual aid, pro-social behavior, trust behavior, and more. There is some disagreement about the underlying process that creates these positive outcomes.

Gender dysphoria in children (GD), also known as gender incongruence of childhood, is a formal diagnosis for children who experience significant discontent due to a mismatch between their assigned sex and gender identity. The diagnostic label gender identity disorder in children (GIDC) was used by the Diagnostic and Statistical Manual of Mental Disorders (DSM) until it was renamed gender dysphoria in children in 2013 with the release of the DSM-5. The diagnosis was renamed to remove the stigma associated with the term disorder.

A mental health professional is a health care practitioner or social and human services provider who offers services for the purpose of improving an individual's mental health or to treat mental disorders. This broad category was developed as a name for community personnel who worked in the new community mental health agencies begun in the 1970s to assist individuals moving from state hospitals, to prevent admissions, and to provide support in homes, jobs, education, and community. These individuals were the forefront brigade to develop the community programs, which today may be referred to by names such as supported housing, psychiatric rehabilitation, supported or transitional employment, sheltered workshops, supported education, daily living skills, affirmative industries, dual diagnosis treatment, individual and family psychoeducation, adult day care, foster care, family services and mental health counseling.

Emotional and behavioral disorders refer to a disability classification used in educational settings that allows educational institutions to provide special education and related services to students who have displayed poor social and/or academic progress.

Bipolar disorder in children, or pediatric bipolar disorder (PBD), is a mental disorder in children and adolescents that, like bipolar disorder (BD) in adults, is characterized by extreme changes in mood and behavior accompanying periods of depressed or irritable moods and periods of elevated moods called manic or hypomanic episodes. These shifts are sometimes quick, but usually are gradual. The average age of onset of pediatric bipolar disorder is unclear, but the risk increases with the onset of puberty. Pediatric bipolar disorder is typically more severe and has a poorer prognosis than bipolar disorder with onset in late-adolescence or adulthood.

Child psychotherapy, or mental health interventions for children have developed varied approaches over the last century. Two distinct historic pathways can be identified for present-day provision in Western Europe and in the United States: one through the Child Guidance Movement, the other stemming from Adult psychiatry or Psychological Medicine, which evolved a separate Child psychiatry specialism.

Childhood trauma is often described as serious adverse childhood experiences (ACEs). Children may go through a range of experiences that classify as psychological trauma, these might include neglect, abandonment, sexual abuse, and physical abuse, witnessing abuse of a sibling or parent, or having a mentally ill parent. These events have profound psychological, physiological, and sociological impacts and can have negative, lasting effects on health and well-being. Kaiser Permanente and the Centers for Disease Control and Prevention's 1998 study on adverse childhood experiences determined that traumatic experiences during childhood are a root cause of many social, emotional, and cognitive impairments that lead to increased risk of unhealthy self-destructive behaviors, risk of violence or re-victimization, chronic health conditions, low life potential and premature mortality. As the number of adverse experiences increases, the risk of problems from childhood through adulthood also rises. Nearly 30 years of study following the initial study has confirmed this. Many states, health providers, and other groups now routinely screen parents and children for ACEs.

Child and adolescent psychiatry is a branch of psychiatry that focuses on the diagnosis, treatment, and prevention of mental disorders in children, adolescents, and their families. It investigates the biopsychosocial factors that influence the development and course of psychiatric disorders and treatment responses to various interventions. Child and adolescent psychiatrists primarily use psychotherapy and/or medication to treat mental disorders in the pediatric population.

The wraparound process is an intensive, individualized care management process for youths with serious or complex needs. Wraparound was initially developed in the 1980s as a means for maintaining youth with the most serious emotional and behavioral problems in their home and community. During the wraparound process, a team of individuals who are relevant to the well-being of the child or youth collaboratively develop an individualized plan of care, implement this plan, and evaluate success over time. The wraparound plan typically includes formal services and interventions, together with community services and interpersonal support and assistance provided by friends, kin, and other people drawn from the family's social networks. The team convenes frequently to measure the plan's components against relevant indicators of success. Plan components and strategies are revised when outcomes are not being achieved.

Parent management training (PMT), also known as behavioral parent training (BPT) or simply parent training, is a family of treatment programs that aims to change parenting behaviors, teaching parents positive reinforcement methods for improving pre-school and school-age children's behavior problems.

Multisystemic therapy (MST) is an intense, family-focused and community-based treatment program for juveniles with serious criminal offenses who are possibly abusing substances. It is also a therapy strategy to teach their families how to foster their success in recovery.

Disruptive mood dysregulation disorder Medical condition

Disruptive mood dysregulation disorder (DMDD) is a mental disorder in children and adolescents characterized by a persistently irritable or angry mood and frequent temper outbursts that are disproportionate to the situation and significantly more severe than the typical reaction of same-aged peers. DMDD was added to the DSM-5 as a type of depressive disorder diagnosis for youths. The symptoms of DMDD resemble those of attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), anxiety disorders, and childhood bipolar disorder.

The adolescent community reinforcement approach (A-CRA) is a behavioral treatment for alcohol and other substance use disorders that helps youth, young adults, and families improve access to interpersonal and environmental reinforcers to reduce or stop substance use.

Project Re-ED, the Project on the Re-Education of Emotionally Disturbed Children, is a program to provide effective and affordable mental health services for children. The program focuses on teaching a child effective ways of acting in and responding to the child's social groups and also working with those social groups to help them provide a more supportive environment for the child. It began as a pilot project in the 1960s at two residential facilities in Tennessee and North Carolina. It later expanded to more facilities, and the principles of treatment developed in the project have been replicated and adapted in many other programs.


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Further reading