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Robert Foltz on Adolescent Residential Treatment

On the future of mental health

Eric Maisel
Source: Eric Maisel

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 Robert Foltz

EM: You are the coordinator of the Adolescent Subjective Experience of Treatment study. Can you tell us a little bit about it and its findings?

RF: The Adolescent Subjective Experience Treatment (ASET) study was an effort to understand what works – and what doesn’t – for adolescents placed in residential care.

Eighty-seven youth were interviewed in seven different treatment centers and discussed medications, therapy, milieu approaches, trauma, and resiliency. One strong finding was that youth placed in residential care are extraordinarily trauma-exposed, yet commonly received diagnoses that did not acknowledge the traumatic experiences or their impact.

Receiving medications to subdue dysregulated behaviors will have temporary gains. Until the trauma is addressed, these youth will be slow to recover. Findings also included positive impressions of psychotherapy. Indeed, approximately two-thirds of youth reported positive beliefs about the power of therapy to help them but only about a quarter of youth felt the same way about medications. Approximately half of youth had negative impressions of being medicated. Another common theme from youth was a strong desire for more family contact and support. Overall, over three quarters of youth felt that their lives were better as a result of being in residential care.

EM: What are your thoughts about residential treatment facilities for adolescents? What seems to work?

RF: Having worked in residential treatment centers for over 15 years, I saw the immense challenges, but I also saw the successes. The youth placed in residential care are usually trauma-exposed. That means they come to care scared, untrusting, and vulnerable.

Developmentally-informed, neurologically-aware trauma treatment must be at the forefront of residential models of care. The youth placed in residential treatment can be some of the most challenging youth needing care. Relying on our typical ‘medical model’ of diagnosing and treatment is largely inadequate. The most powerful healing element within residential care is a safe, trusting relational environment. However, not every intervention will work for every child. As a result, treatment offering a range of strategies will likely yield the most robust outcomes. Also, of particular importance, is the training of the direct-care staff. Working with these very challenging youth requires education, support, and self-awareness.

EM: What seems to work less well when it comes to residential treatment?

RF: Unfortunately, there are profound needs for much more research in residential settings to optimize the outcomes of this intervention. Because most agencies do not have the capacity to conduct this level of investigation, many questions remain unanswered. But placing too much expectation on any specific intervention is misguided.

For example, overemphasis on medications is an unfortunate distraction in the well-intentioned effort to control behavior. It reduces the intervention to “containment” rather than “treatment” of a condition. Many youth in residential care are on combinations of medications that do not have an ‘evidence-base’ which further confounds any reliable conclusions of the intervention. This can also be said for the integration of multidisciplinary care such as co-occurring psychotherapies. Rigorous studies have not been able to reliably demonstrate what works for whom, when, and for how long, but these are the essential questions that need to be answered.

EM: What are your thoughts on the current, dominant paradigm of diagnosing and treating mental disorders and the use of drugs to treat mental disorders in children, teens and adults?

RF: Our current model of diagnosing and overemphasis on psychiatric medication has failed our most challenging youth. No doubt, some young people benefit from medication treatments, but as an organized, reliable, scientific strategy, we have a long way to go.

As a psychologist, my field has been infused with “evidence-based treatments,” yet in the use of medications, these standards are not utilized with fidelity. Moreover, regarding diagnoses, we know that young people experience ‘temporal instability’ in their clinical presentation. In other words, their diagnosis (clinical profile) will change over time, yet our current model assumes that these conditions are persistent, if not life-long. The National Institute of Mental Health has determined the DSM model is insufficient. Developmental, interpersonal, trauma-informed, and neurologically-informed perspectives have to be integrated to create a more holistic approach on a person suffering psychological distress, with a deep appreciation for their subjective experience.

EM: If you had a loved one in emotional or mental distress, what would you suggest that he or she do or try?

RF: As a psychologist, I believe that symptoms have meaning. But many troubling experiences may insidiously develop into painful disruptions in one’s life. When this occurs, providing them safety, support, and a holistic approach are essential.

This is important to those caring for them as well. Family and loved ones of an individual struggling with emotional challenges can face tremendous distress. Systemic intervention can create a foundation to support the slow, careful change that is required for sustained progress.

It is also important to listen to the person in pain. While we have many studies to review, an individual may not respond to a treatment considered to be effective, or they may respond to a treatment seen as ineffective. Knowing the swinging pendulum of science, we must appreciate the individual experience in their recovery.


Bob Foltz is a clinical psychologist and Associate Professor at the Chicago School of Professional Psychology. Prior to teaching, he spent over 15 years as a clinician and administrator working in residential treatment settings with severely troubled youth. Towards understanding effective care & outcomes, Dr. Foltz also helped develop the Multi-Dimensional Youth Assessment 360 (MDYA360), available at


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, visit him at, and learn more about the future of mental health movement at

To learn more about and/or to purchase The Future of Mental Health visit here

To see the complete roster of 100 interview guests, please visit here:

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