Who Needs Residential Treatment

For your role as a parent, success in helping your son is dependent on matching your son’s and family’s needs to the fitting specialty of care and level of care. This is accomplished by gaining factual knowledge of what you are up against and understanding of what it takes to overcome. Then you can match your son’s specific needs to both the kind of help he needs and the appropriate level of intensity. Remember these two goals: specialty of care and level of care.

Basically, the short answer to “Who needs residential treatment?” is, if you as the parent(s) have a “reasonable expectation” that your son can turn it around and become healthy and whole without going to a residential program, then don’t take him to one. However, if you have no realistic expectation of that possibility, either because you have already tried the lesser levels of care discussed below, or you just know that the struggle is too big, ask yourself why you are waiting.

We call this the triage process. In a disaster like a train wreck, the first responders will categorize the victims by severity of injury and level of threat to life. They will identify these categories of need by putting a colored tag or light on them. A red tag means an immediate life-or-death threat and action must take place at once. An orange tag means urgent, but you have some time, 15 minutes. Yellow means less urgent, and green means not urgent.

Those triage tags will dictate what kind of medical facility or treatment is needed to match the severity of injury. In this field, it is the same process. You wouldn’t want to take an unconscious person with multiple compound fractures, an obvious concussion, and critical high blood pressure to a walk-in clinic; they must be taken to an emergency room if they are going to have a chance to live, preferably one with a trauma unit. On the other hand, an alert victim with a green tag, who has some scratches, good vital signs and is coherent does not need to be med-flighted to a trauma unit. On one hand, you don’t want to take a BB gun on a grizzly bear hunt, and on the other, you don’t want to take a 12-guage shotgun to kill flies at a cookout. You’ve got to match the level of need to the level of care.

Also, if a person has a broken leg, after the initial first aid stabilization they are sent to an emergency room, stabilized and then seen by an orthopedic MD. They are not seen by a MD in urology! A person with chest pains and shortness of breath is not sent to a podiatrist! Of course not! They are taken to a cardiologist because their medical need, a probable heart attack, demands a specialist in cardiology. These statements are obvious, at least in a medical triage situation. But they are often unnoticed or forgotten in the arena of counseling or treatment.

Often in the field of “counseling” you hear people recommend a counselor who is a “good listener” for all categories of emotional, relational and behavioral needs. While being a good listener is certainly a necessary quality in an effective therapist, by itself it means nothing as far as being an effective triage match for the person in need.

A dad once called me wanting to immediately admit his son to Capstone for our 90-day residential treatment program. I began asking the dad questions to help him determine if we were the appropriate level of care. The only reason for making this decision was that he had found two empty beer cans in the back of his son’s truck. We talked for several minutes, during which I asked him “What else?” in a dozen different ways. And there was nothing else. The dad was very upset at his son for drinking, period, and was in an over-reaction. I understood; I’m a dad, too. It took a pretty long conversation to convince this loving and alarmed dad that his son did not need to go to any treatment, but instead Dad and Mom could handle it at home with maybe some weekly therapy guidance.

I’ve also seen families who would not accept how big the problem was and continued to try to get their son/daughter to “make better choices”. While making better choices was obviously needed in all these situations, the real problem was in why they were making poor choices. What needed triaging was the “retrace-the-vine-to-the-roots core-underlying-issues” that underpinned their bad choices. Many of these situations came back around in a year or so, always in a more difficult and severe situation, but some ended in tragedy before they could come back around.

The mild end of triage could mean that you restructure your boundaries at home to get the change in behavior that you want. That happens sometimes but is a rare occasion for a parent who is on this website.

At the next level up, moderate triage levels, the low end could call for weekly outpatient (OP) sessions with a qualified counselor, or the next rung up the ladder, the high end of moderate, an intensive outpatient program (IOP) of a few hours per week in some kind of therapy group. If your son’s struggles are accurately triaged at a moderate level, outpatient therapy and/or intensive outpatient programming would be your best next steps. I’d suggest that the parents get involved as well because the research shows that family involvement in therapy helps significantly in successful outcomes. If the triage match was on target, these levels will work to achieve the directional turn you are looking for and you don’t need residential.

However, if they don’t work, it is not necessarily a failure or a mistake in triage. It could simply mean that the problem you are facing is bigger than you thought and, although upsetting, it is helpful, even vital, to know more of the already existing facts. This is often the case with a family that becomes a Capstone family. Effective triage is based on knowing enough of the facts to make an accurate match, but it’s hard to get all the facts! If the “iceberg of facts” goes deeper than what you originally detected, it is going to be very difficult to get to that depth in outpatient or intensive outpatient therapy. Weekly outpatient therapy provides one hour per week in session but leaves 167 hours not in session and, thus, back into the same loop of people-places-things. Intensive outpatient means about 12-15 hours a week in therapy and at least 150 back in the loop. When the breaks between sessions are so long that your son gets pulled back down and the time in therapy sessions is too short to last, it is helpful to know, because it will make you wiser for the next step in the triage decision tree.

The severe level of triage means the OP and IOP are not the right intensity match but instead that your son must get out of his loop, away from his peers, and go to a residential program so that he is in an environment that gives him a chance to change.

Here’s a metaphor that helps this process to make sense to a lot of parents. If a sore on a person’s arm is an isolated, stand-alone infection, the triage match is to clean it and treat it with antibiotic ointment. If this procedure heals it and it doesn’t pop up on other parts of the body, the match was indeed correct. But if treating the sore this way only produces a Whack-a-Mole game as other sores continue to pop up on other parts of the body, you must shift seeing the problem as an isolated sore to seeing it as a systemic infection that is running throughout the body. Therefore, the treatment needed would be an antibiotic that addresses the specific strand of infection.

Translation: If you matched your son’s needs to an outpatient therapist or an intensive outpatient program and his life turned in the right direction and that direction was sustained, good call and “Thank you, Father!” In this situation, your son should not have been triaged to a residential program. But if those levels didn’t work, you must move up the level of intensity to “residential,” so he has a safe place to get away from the pressures that keep pulling him down and do the work he needs to do to regain his life.

  • It is very rare that a young adult or an adolescent will ask for help. The old-adages that a person must hit bottom, want help or ask for help for therapy or treatment to work do not apply to the ages we work with, 14-26. Their prefrontal cortex is too immature, their resiliency from testosterone is too strong, and their lives are too short to have accumulated enough consequences to be able to experience those things.
  • If your son hasn’t asked for help, don’t be alarmed. It is not a requirement for him to be helped. As a matter of fact, he is normal. It’s just the nature of their brains to not realize the gravity of their situation. Most of our clients, over 1300 since 2001, did not ask for help nor want to come to Capstone in the beginning. That’s normal with this age. Our goal is that they are glad they did when they graduate, which happens with almost all of them. However, in the rare times a young person does ask for help, it is vital to get him the right match as soon as possible. Asking for help at the ages up to 25 or 26 usually means that the situation is very serious, and you need to take immediate action. It would be a rare opportunity that I would be thankful for.