Residential treatment: A resource for families

Elizabeth Ridgely and William Carty

This article outlines a model of treatment for children, adolescents, and their families who use residential treatment facilities. The authors describe the set-up and operation of a residential program designed to strengthen family competence and examine the implications for programming and staffing. Emphasis is given to the overall integration of residential treatment and family therapy in a way that supports family integrity and responsibility.

The central idea of this paper is that residential treatment is a resource to families. The children belong to the family, not to the residential program. This is a significant paradigm shift in Canada, where the first residential treatment units for children were opened thirty years ago with little involvement from the child's family. The idea at that time was that residential treatment, apart from the family, was therapeutic for the child. Long-term residential treatment, often as long as three years or more, was thought to be curative for disturbed children through milieu, group, activity, and individual therapies. There were no outcome studies and little contact with families throughout the treatment process. The “toxicity" of the family was banished and professional nurturance put in its place.

By the 1970s family therapy was becoming a presence as the voice of Minuchin, Montalvo, Guerney, Rosman, & Schumer (1967), in Families of the Slums, questioned the long-term value of treating children without their families. As more professionals became trained in family therapy, they were less convinced about sending the child away, with the accompanying implicit assumption that the professionals were more competent to raise the child than the family. Throughout this period and into the 1980s, most residential treatment units added family work to the treatment of the child. This was based on a child guidance model with the sharing of information between residential staff and family, maintaining a focus on the child.

As the 1980s proceeded into the 1990s, the length of stay in residential units had decreased significantly. As we approach the year 2000, the issue of treatment in Canada is and will be related to cost of “the bed." The good thing about the cost perspective is that the family will increasingly be seen as the major resource for the child with short-term units resourcing the family.

The George Hull Centre for Children and Families has been operating with such a model for the past fifteen years. Collectively, we have learned from Salvador Minuchin and the faculty of the Philadelphia Child Guidance Clinic, Maurizio Andolfi and the International Practicums in Rome, and the late Carl Whitaker. There are many authors and teachers in the field of children and families but we looked to these three child-centred family therapists to “unlearn" us in pathology and to re-focus our thinking on the strengths of families over time with multiple generations and extended kin, friends, and neighbours. As we explored the resources of the family, it became clear that the logical place for a residential unit was alongside other resources of the family for the family to access as it needed.

There are four main ideas which accompany the resource model. The first two ideas are related specifically to the program. The second two have to do with the families.

Program

Residential treatment is a resource to families, and as such it belongs to the family. The child belongs to the family and not to the program. Families decide admission and discharge to the program.
The primary function is to enhance the competence of families, to facilitate connectedness among family members, and to strengthen the sense of belonging, which is at its most vulnerable at the time of admission.

The program operates an a group format in that it is structured for the whole group of children and adolescents, and each child and staff follow the format on a day-to-day basis. The structures and routines are geared at healthy, normalized expectations that exact cooperation among the children and staff members. With such clarity, it is possible to recognize and respond to individual differences between children. This separates the exceptional from the institutional, and although the rules are for everyone, everyone is different. With recognition of individuals with their own particular talents, skills, and needs, each child is expected to give to and can expect to receive from the group. The format is not pathology-based but strength- and performance based.

Our view is that no matter how damaging a child's experiences have been to his or her development, all children strive toward health. Power struggles between the child and the staff are not seen as productive. The program format lays out the expectations, and the staff assist the child through the program. Although subtle, this idea of assisting children in their difficulties within the program, rather than requiring compliance, is significant.

Much time and energy is spent in planning, through weekly group meetings, shopping, and preparation of food. In all program activities, we find it essential to incorporate the child's family practices and preferences. Discussions with the child and group of children about their families brings out the uniqueness of each child.

The program places the child's contact with his or her family as a right and not a privilege. For example, if a child wants to call her family first thing in the morning, last thing at night, or anytime in between, she is encouraged to do so. The program does not view children wanting to call their families as manipulative. Families and children must be free to call or visit at any time. Dropping in is a good idea. Telephone times are built in at times convenient to the family, not to the program. In fact, there is nothing more important in the program than the family.

Program activities include the family, for example:

Sibling nights and sibling groups that give room for the identified patient of the family to rejoin his or her own generation, away from the scrutiny and concern of the parental generation. By the time there is an admission, the siblings are usually as “fed-up" as the parents with the behaviour of their brother or sister. Work with the sibling group of the family is very important for the future of the family, as this generation outlives the parental generation and will either continue in an integrated fashion or will prematurely develop the beginnings of cut-offs.
Parent groups for feedback about the program and coffee for fellowship with each other and with the staff.
Supper invitations for the family.
Activity invitations (what would you like to invite your family to this week?), discussed at the weekly activity planning meeting.
Father/son events. Mother/daughter events.

The main programming job is to make the residence accessible, welcoming, and supportive to families for their full participation. The more isolated the program becomes from the family, the more “incident" reports are filed as the staff attempt to take over from the family during a period of increased isolation for the child.

Family

Families ask for residential services when all other resources have been exhausted or depleted. They feel helpless, furious, embarrassed, and not able to manage their child. At the time of admission, the family has been like this for a long time, since the birth of the child for some. Most all of the family interactions and thinking have been around the “identified patient." The family becomes totally organized around every move of the child “sleeping, eating, schooling and social life. All other family issues recede and are postponed.
The task of the therapy is to hear the story, find the strengths and the other set-aside issues. The child has become the “field of packaging" for all other issues. These issues are complicated arid have to do with loss, cut-off relationships, immigration, unemployment. For whatever reason, the nuclear family has become the only family and is isolated with few resources.

The importance of the family story leads to the discovery of lost resources. The child is the foremost narrator of the story as she has been trying to help out the family by being the lightning rod. She will lead the therapist to the difficult areas.

As the therapist asks about her grandmother and discovers that she lives in Scotland, she continues to follow the child's view of how her mother does in Canada with her own mother so far away. Does she write or talk to her mother? When did she see her last? Will she see her again? How can she tell when her mother is sad? For how many years has she been sad?

Your grandfather died? How difficult was that for your father? What do you think that he misses the most? How was that relationship with his father? Does he ever talk about this? Who is sadder? Your mother or your father? What is the marriage here? Whose side are you on? Whose side is your sister on? Do you ever trade sides?

Whatever the story: grandparents in Ghana, dead siblings of the parents, miscarriages; there is a bigger story than the child. The work begins with the alternate story “family of origin, loss, gendered power, economics. More people can be added to the sessions as consultants: friends and family creating an enlarged fabric with more flexibility and more possibilities for change. Family members become individuated and not the united mass they presented at admission. The therapy individuates them, divides them, subgroups them, genders them and makes crevices where they were all filled in.

The therapy should not be predictable or it will match the family. It needs to be surprising, confusing, and constantly shifting. The program needs to match this with a strong core of programming that can then be as flexible as the children need in order to to find a new place for themselves in their families.

The culture of the George Hull Centre has been developed by the staff members to include an expanded view of what is normal. Children and adolescents come to the Centre having experienced horrendous abuse, neglect, and inconsistency in their care. Their attachments, behaviours, and view of the world can be seen as quite disturbed. We prefer to view this as normal, given their experiences. This opens up many more possibilities to intervene and provide new experiences from which children will grow.

References

Andolfi, M., Angelo, C., & deNicholo, M. (1989). The myth of Atlas: Families and the therapeutic story. New York: Brunner/Mazel.

Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Press.

Minuchin, S. (1984). Family kaleidoscope. Cambridge, MA: Harvard University Press.

Minuchin, S., Montalvo, B., Guerney Jr., B., Rosman, B., & Schumer, F. (1967). Families of the slums: An exploration of their structure and treatment. New York: Basic Books.

Napier, A., & Whitaker, C. (1978). The family crucible. New York: Harper & Row.

Ridgely, E. (1994). The self of the consultant: “in” or “out”? In M. Andolfi & R. Haber (Eds.), Please help me with this family: Using consultants as resources in family therapy (pp. 53–65). New York: Brunner/Mazel.

This feature: Ridgely, E. and Carty, W. (1998) Residential Treatment: A resource for families. Journal of Child and Youth Care Vol. 11 No. 4 pp77-81