The following interview is part of a “future of mental health” interview series that will be running for 100+ days. This series presents different points of view about what helps a person in distress. I’ve aimed to be ecumenical and included many points of view different from my own. I hope you enjoy it. As with every service and resource in the mental health field, please do your due diligence. If you’d like to learn more about these philosophies, services, and organizations mentioned, follow the links provided.
Interview with Lori Sylvester
Adolescents growing up in chaotic environments are likely to start running out of control. What then? One “result,” welcome or not, is residential treatment. Sometimes the adolescent is admitted voluntarily; more often than not the courts and social services are involved. Here is Lori Sylvester on her work with adolescent girls in residential treatment.
EM: You work as a teacher and group co-leader with adolescent girls in residential treatment. What typically brings girls to your facility?
LS: Girls between the ages of 12 - 18 enter our facility for many reasons. While residential placement is the primary program offered, some girls are referred by area school districts for education only. They live at home, or in other foster care arrangements while they attend our school. Excessive truancy is usually what brings these students to us. The reason for the truancy has many causes: A chaotic home situation that requires therapeutic as well as educational intervention, the student's chronic failure in a typical school setting, excessive fighting or bullying, a last chance effort before placement becomes the only option.
Our residential students are usually referred by the courts or by county departments of social services. Court referrals result when the young person has become involved in criminal activity that is not serious enough for juvenile detention or jail. This may involve theft, assault, prostitution, drugs, gang activity, to name a few. Department of social services referrals usually are the result of family or community inflicted trauma: Neglect, sexual, physical and/or severe emotional abuse, rape, assault, the witnessing of violence, and often a combination of the above. The resulting behaviors can include aggression towards others, self-harm, and a host of DSM-V diagnoses that require intensive therapy and often medication.
At times parents voluntarily file a Person In Need of Supervision (PINS) petition with the courts because their child's unsafe and anti-social behaviors make them ungovernable at home, and the parents are seeking support.
EM: What seems to help the girls who come? What's working?
LS: First and foremost, positive attention and relationships in conjunction with consistently reinforced structure, expectations, support and consequences.
Upon arrival, each girl is assigned to a treatment team that consists of a therapist, case manager, manager of the living unit (if residentially placed) along with a fairly consistent staff of childcare workers. There is also the education team that includes teachers, assistants, crisis intervention workers and administrators. The rationale for this large support team is that out of all of these adults, the girl is likely to make at least one strong, positive connection (although usually it is more than one). The majority of girls have extensive histories of neglect, abuse and abandonment, making trust very difficult. Feeling safe and cared for goes a long way towards helping them develop the ability to care for themselves.
While the majority of the girls resist the rules, the expectation of personal accountability, locked doors, time fully structured, etc., when it is time to leave, many remark that it was care AND the structure that helped them succeed. Therapy and medication are also employed to help stabilize behaviors and ensure safety, however it really is consistency of routine that does the most to promote successful outcomes for the girls.
One of our residents recently turned 18 and, according to her legal right, signed herself out of placement. She was able to remain a student in our day services program, however her life, with reduced structure, became chaotic within a short period of time. After three months of intense struggle, she made the decision to readmit into the residential program last week. She missed the people and the structure. She feels safe again, and with some real world experience, she is ready to build a more solid foundation of life skills for herself.
EM: You are part of a group approach to helping. What are the advantages of a group approach? Any disadvantages?
LS: There are several advantages to the group approach to helping. As stated above, one of the primary benefits is that the girl has a better chance of finding at least one person with whom she feels a close connection. That one connection can be the thing that allows the girl to invest in the rest of the program. Another benefit is that multiple relationships allow members of the treatment team to observe a broad range of the girl's behaviors in various settings.
Members of the team meet regularly to review the girl's progress and challenges. Each brings their own reports of interactions and the entire team is able to see a more full picture of the girl's strengths and needs. It is also important to note that the girl is considered a member of her team and she is invited to participate in the meetings and discussions. She is able to gain insights based on the observations of others, as well as contribute her own perceptions and suggestions for treatment plans. A team approach allows for more thorough consideration for the process of goal planning and implementation.
One disadvantage is the need for up-to-date communication among team members, which can be challenging due to case loads, schedules, departmental bureaucracy and the physical location of offices within the agency's building complex. Email has been making communication easier, however it doesn't solve all the problems. Another disadvantage is individual interpretation of treatment plans and that can result in inconsistent implementation of the plans. The girl is placed in a position where she is able to undermine the plan by playing team members against each other. As long as people on the treatment team are aware of this possibility, they are usually able to communicate the need to reestablish consistency.
EM: What should a parent of a troubled teen think about with respect to residential treatment? What are the pros and cons of residential treatment?
LS: Parents usually don't have much choice in deciding whether or where their child enters residential treatment. What parents need to understand is that their child has probably been placed because life is too chaotic and the child has little to no self control, thus placing them at risk for unsafe situations.
Residential placement will seem to be very restrictive, and at times physical interventions, such as hand on restraint, will be needed to ensure safety. Parents are often angry because they have lost control of their child and the structure of placement can become a lightning rod for their anger, especially if their child is bruised or injured while away from home.
Parents need to know that residential treatment facilities are heavily regulated and all functions are subject to constant oversight and intervention by many agencies. Parents also need to realize that a residential facility will not "cure" their child. In fact, any positive changes will be undermined if the parents are not open to family counseling and willingness to make changes in how the family interacts with the child and each other. Parents who support the residential program usually see their child mature and return home with more adaptive behaviors.
What are the pros and cons of residential treatment? The pros are that the child is removed from a chaotic environment and has a chance to learn safer and more socially effective ways of living in the world. The cons are that the young person is grouped with others who are struggling as much as they are and there are not many positive role models among peers. In fact, at times the child learns new maladaptive behaviors that they never tried before, especially self-harming behaviors and bullying.
EM: If you had a loved one in emotional distress, what would you suggest that he or she do or try?
LS: I would suggest that they identify a support "team," at least a few trusted people they can talk with. I would encourage them to also seek out professional help. Making connections and not being isolated are very important when someone is in distress. The level of professional help would depend on the degree of emotional distress. A coach might be able to help a person focus during a time of stressful transition. Clinical depression might require help from a professional with an advanced degree in the mental health field. The goal is always to help a person identify and use their personal resources to strike a balance between independence and interdependence.
Lori Sylvester has an MS degree in education and has worked with adolescent girls in residential placement for 30 years in her capacity as teacher and group leader. As the chairperson of the facility's Committee on Special Education, she is part of the interdisciplinary treatment team that includes the student, parents, administrative staff, clinical staff and education staff.
Eric Maisel, Ph.D., is the author of 40+ books, among them The Future of Mental Health, Rethinking Depression, Mastering Creative Anxiety, Life Purpose Boot Camp and The Van Gogh Blues. Write Dr. Maisel at email@example.com, visit him at http://www.ericmaisel.com, and learn more about the future of mental health movement at http://www.thefutureofmentalhealth.com
For more information and/or to purchase The Future of Mental Health visit here
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