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Extended Insights
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Posted:
Sep 1, 2006
15:17
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Transition Of Teenagers Between Programs
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Communication and Planning Between Institutions
By: Dustin Tibbitts, LMFTI, Executive Director
New Haven Femal RTC, Inc.,
Provo, Utah
801-794-1218
www.newhavenrtc.com
Introduction:
Paula Rudy recently posted an "Extended Insight" on August 1, 2006 concerning the "conversation that should be," a poetic phrase she coined to describe the absence of good communication between programs when those programs transition students from one placement to the next, such as from wilderness to residential treatment. I appreciate Paula's thoughts and her article, which opened the door for discussion on this critical issue.
The Problem:
In February of 2004 Dr. Paul Goddard, Dr. Janet Greenwood, Becky Schofield, LCSW, and I presented at the National NATSAP Conference in Clearwater, FL on how poor transitions between programs negatively affect the ability and desire of students to attach in healthy ways. We surveyed 98 students in four different treatment centers/wilderness programs. What we found shocked me:
Of those 98 students, 63% had been through a Wilderness Program before going to treatment, 24% had been in three placements, 15% had been in four placements, 10% had been in five placements, 10% had been in six or more placements, and the average number of placements was three! Fully 60% had been in three or more placements, and more than half of those had been in four or more placements. The really disturbing number was that the average time spent in treatment was 12 months!! Even worse, 30% of the students surveyed said that their previous placement had done nothing to help with transition.
When we look at the research, the picture Paula Rudy painted for us gets even more drab: "Multiple placement is the characteristic most associated with negative outcomes for youths in out-of-home care, two to five years following emancipation" (Penzerro, 1995). Adolescents who are emotionally disturbed in treatment centers or foster care are more likely to have histories of placement disruption (Penzerro, 1995). As a result, admissions procedures, treatment modalities, continuum of care decisions, and discharge (transition) planning become major issues for facilities and other out-of-home programs serving youth.
As attachments become more and more tenuous, children become less selective regarding relationships, so they are "likely to drift into harmful relationships or to repeat the pattern that has already been established of drifting through relationships" (Penzerro, 1995). This causes numerous negative outcomes in adolescents. Some worthy of note are: "Unemployment, school dropout, relationship troubles and teen parenthood. . . . Multiple placements and emancipation from group care, rather than family situations, are associated with incarceration in young adulthood" (Penzerro, 1995).
Cautions And Solutions:
So, what can be done? Simply getting the placement right the first time is always best. And yet, we can never be absolutely sure that it will be all that the student needs. Transition is inevitable in a majority of the cases we see. We must remember the internal worlds our clients live in, and be sure to acknowledge that no matter what we try to do, it may not be beneficial, depending upon how it is received. Bowlby, the great champion of attachment, agrees: "I have always held the view that the internal world is a reflection of the external world and there is a constant interaction--you can't understand one without the other" (Bowlby, 1985, p. 20).
Involve The Family:
Gunderson (1996) cautions that while we may want to make our centers, programs, and systems so good that adolescents bond to us and attach, we must always realize that the "relationships that do not involve mental health caregivers, such as increased reliance on family members, friends, or pets, can diminish separation anxieties" more effectively than can we, as professional caregivers. This highlights the critical need for involvement of the family in the transition. Of the students surveyed in the study I mentioned above, only 43% kept in touch with line-staff, 27% kept in touch with therapists, and 11% kept in touch with teachers. Guess what? One-hundred percent kept in touch with their families through each transition! We must involve families better in the transition process.
Involve The Line Staff:
Yet these percentages highlight an interesting point: Students formed more important attachments to line staff than to therapists. How often do we, as program leaders, allow or encourage line staff to be a part of our aftercare and transition plans? Erdman (2003) explains further:
"End-stage caseworkers in out-of-home care have a special role to play in transitions. If caseworkers and providers understand the relationship between the internal processes of conduct-disordered teenagers and their alienating behaviors during termination of services, they can begin to intervene on several levels. The goal is to reduce feelings of abandonment and the need to act out. When placement disruption must occur, as it does at the point of emancipation, acting-out behaviors should be anticipated for these youths. Helping the young person understand his or her own relationship pattern is a primary clinical goal during the termination process. Learning to label feelings of loss and uncovering feelings and other expressions of abandonment should be central themes in therapeutic work with these youngsters."
Who better to assist students in what Erdman describes than the staff with whom they associate 24 hours each day, 7 days each week? We must do better at training and involving our line staff in all phases of treatment, including transition and aftercare.
Involve the Educational Consultants:
Educational Consultants often have a unique perspective on the subject of transition. In late 2003, I hired an independent company to survey 27 Educational Consultants. In the survey, I asked this question: "Regarding transition, what concerns do you have with transitions between programs or programs and home?" This is the distribution of their answers:
Communication between programs 9 33%
Timing of the transition 6 22%
Complete plan in place 4 15%
Wished for more services to aid in transition 4 15%
More gradual transition 4 15%
You can see from the numbers listed above that these 27 Educational Consultants share the concerns Paula Rudy outlined in her article. Communication and its related issues (planning and timing) make up 70% of the concerns of Consultants when they assist in the transition of a child from place to place. In an effort to respond to these concerns, Dr. Janet Greenwood posed these crucial questions to the NATSAP National Conference in 2004. It would be well for us all to answer them:
- How do we decide what is best for a child in transition? What information do we need to have to make that decision?
- Do we develop a process that all kids go through or will there need to be a more individualized approach? What procedures will we formally put into place?
- Will this process differ when going from program to program, wilderness to longer-term program, or program to home?
- What will be the educational consultant's role during that transition? What will that interface look like?
We must do better as program leaders, at tapping Educational Consultants' expertise
during transition.
Involve the Students:
The 98 students who were surveyed had some advice of their own for us. They said they wanted "closure" and to be told about the transition. They said they wanted someone to "listen" and to "care." One student said he/she appreciated the survey, but not to "try to save the world." Amusing, but true! The solutions to transition are more simple than we sometimes make them. We need to return to fundamentals - to calling a student periodically after she leaves our program just to "check in." We need to have the courtesy and common sense to allow, even expect, our therapists and staff to contact the admitting program's therapist and staff personally. As Paula Rudy notes, it's not good enough to just send a Discharge Summary. Isn't the child important enough for us to make a ten-minute phone call to the people who will be treating her, living with her and nurturing her for the next few months of her life? Don't we owe it to her family? We must be better at anticipating and responding to the needs of our students throughout the transition process.
Conclusion:
As we face becoming more of a society that institutionalizes children, the solution is for us to focus more intently upon the proper admission, adequate continuum of care, and then only when absolutely necessary institute a well-researched, carefully thought-out, intensely monitored, transition of that child to another institution. We need to remember that "moving children from placement to placement should be seen as more damaging than allowing the children to grow up in a stable institution" (Erdman, 2003). We should focus more of our efforts, more of our monies and more of our time, around the transition process. "It's the transition that allows for the success" (Van Fleet, 2001). We must be better at incorporating the family into the transition process, at utilizing the relationships students build with line staff, at involving the Educational Consultants, and above all, we must be better at truly serving the needs of the students we are transitioning.
Bibliography:
- Bowlby, John (1985); Interview with John Bowlby. Bethlem and Maudsley Gazette, 32, 4, 20-23, 1985.
- Erdman, Phyllis (2003)Conceptualizing Attachment Theory From a Systemic Framework: Implications for Family Therapists, Journal of Systemic Therapies, Summer 2003, Vol. 22, Iss. 2, Pg. 1. Guilford Publications, Inc.; New York. Journal of Systemic Therapies. New York: Summer 2003. Vol. 22, Iss. 2; pg. 1.
- Gunderson, John G. (1996); The Borderline Patient's Intolerance of Aloneness: Insecure Attachments and Therapist Availability. The American Journal of Psychiatry, Washington: June 1996, Vol. 153, Iss. 6; Pg. 752, 6 pages.
- Penzerro, Rose Marie; Lein, Laura (1995); Burning Their Bridges: Disordered Attachment and Foster Care Discharge, Child Welfare, New York: Mar 1995. Vol. 74, Iss. 2, Pg. 351.
- Van Fleet, Russ; University of Utah School of Social Work, KUER's Radio West radio address, August 3, 2001.
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