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News & Views - Dec, 1995 Issue #37 

COMMUNITY-BASED VS GEOGRAPHICALLY DISTANT TREATMENT 
by: W. Kimball DeLaMare, 
Clinical Director 
Island View RTC 
Layton, Utah 
801-773-0200 

During the last decade a number of mental health professionals have opted to treat adolescents in residential settings "close to home." This philosophy is primarily based on the central belief that troubled youth should be treated within the close context of his/her family system, as it is there that etiology and maintenance of maladaptive behavior occurs. In addition, it is often assumed that the adolescent may be rehabilitated away from the family but, once returned to the home setting, he/she may quickly regress to former states of dysfunctional behavior. 

Such reasoning is based on the assumption that contextual family therapy is the major and overriding curative factor in the entire treatment/rehabilitation process of adolescents, posing the following pertinent questions regarding geographically distant residential treatment. 

1.) Can contextual family therapy be effective when the adolescent is treated away from home? 

2.) Is relapse a foregone conclusion for youth treated away from home? 

3.) Can it be assumed that those treated "close to home" have a lower rate of recidivism? 

4.) Is intense family involvement/therapy always indicated in the treatment of adolescents? 

5.) Are there other curative factors that are equally or more important than community based residential treatment? 

Such important questions demand a closer look at the efficacy of residential care away from the home community. 

Length of Stay
Short vs Longer - Time in treatment is often a major curative factor. Most parents and many professionals would agree that a troubled adolescent is better served, and has a better chance for not relapsing, if he/she is two months in therapy vs one month only. Most adolescents reject personal responsibility for maladaptive behavior and are thus disposed to go through a "honeymoon" period during the early phases of treatment, thereby misleading parents and professionals into believing that substantive change has occurred. 

Cost Effectiveness
Low vs Higher - Cost for residential care in Utah is often significantly less than comparable care in large metropolitan areas on the West Coast, East Coast and in other locations. In fact, cost can be as little as 1/3 of "close to home" treatment, thus allowing families to use the same health care benefits for up to three times the length of stay in an "away from home" setting and still maintain residual benefit for "home" based transition care.

Recidivism
Home Based vs Away from Home - Are recidivism rates of adolescents treated "close to home" vs those treated "away from home" really lower? Most parents and professionals working with adolescents, would argue that length of stay, program intensity and discharge and aftercare planning are likely far better predictors for recidivism than locale of treatment. 

Treatment Efficiency
Environment & Treatment - An adolescent who is treated in the "home setting" is often exposed and can easily maintain continued negative peer interactions via visits, phone calls, interaction while on outings, etc. Such distractions diminish the therapeutic focus and make less use of the dollars spent for treatment. In addition, the temporary removal of a troubled adolescent from the home community may allow for a more rapid "healing process" of chronic family conflict. Thus, in many cases, "away from home" residential treatment may be equally or more efficient than community based treatment. 

Family Therapy
Home Based vs Away from Home - Sometimes it is effective to create a little distance between a troubled adolescent and his or her family. Not having very frequent personal (visual) contact with them allows the adolescent to "grow fond again" of a family system that he has rejected, ignored, abused and even hated. In addition, other forms of communication other than verbal face-to-face interaction become meaningful such as letter writing and phone calls. Conversely, enmeshed parents are not as easily allowed to maintain unhealthy parent/child relationships, allowing the child to individuate. As a result, face to face family therapy is often more eagerly awaited by the adolescent and when it occurs is frequently more intense, focused and meaningful. Even the impact of routine family interaction patterns become more significant in the therapeutic process. Weekly phone therapy via conference calls with family, patient and therapist allows them to work on pertinent therapy issues. Conference call phone therapy can particularly be helpful where the natural parents and/or significant others do not reside together and have transportation difficulties. 

Emancipation
Community Based vs Away from Home - In certain situations, due to chronic parental disfunction, older adolescents may be best served by profiting from a treatment program away from home which also focuses on emancipation issues including vocational training, independent living skills, etc. 

Conclusion
Considering the above discussed issues, one could incorrectly conclude that "away from home" residential treatment is superior to community-based treatment in all cases. Conversely, it would be incorrect to conclude that in all cases, community-based treatment is always superior to "away from home" care. There are clinical cases where community-based treatment is clearly indicated and there are cases where "away from home" treatment is indicated. To universally reject geographically distant residential treatment as second best to community based care, however, is over zealous. 

Therefore, it may be in the best interest of the patient and his/her family to consider geographically distant residential care on an individual case basis. 

Copyright 1995, Woodbury Reports, Inc. (This article may be reproduced without prior approval if the copyright notice and proper publication and author attribution accompanies the copy.)

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