This blog is my place to vent and share resources with other parents of children of trauma. I try to be open and honest about my feelings in order to help others know they are not alone. Therapeutic parenting of adopted teenagers with RAD and other severe mental illnesses and issues (plus "neurotypical" teens) , is not easy, and there are time when I say what I feel... at the moment. We're all human!

Saturday, December 8, 2018

RTC/ RTF Residential Psychiatric Care

What is Psychiatric residential treatment?

When an individual’s mental health treatment needs exceed the type of treatment that is available in inpatient care (such as psychiatric hospitalization), then residential treatment might be the recommended "next step up." 

RTC - Residential Treatment Center
RTF - Residential Treatment Facility
PRTF - Private Residential Treatment Facility
...
Whatever you call it, they all mean the same thing. 

What is the difference between RTC and inpatient treatment?

Inpatient treatment in a hospital unit is an extremely intensive treatment that offers strict 24-hour care and round-the-clock medical monitoring for individuals who may not be safe to be left alone. The goal of inpatient treatment is to stabilize acute symptoms, develop a treatment plan, and then hopefully get the individual into a long-term program. For instance, inpatient treatment programs and psychiatric wards are more likely to handle issues with acute suicidality than residential treatment programs. Once it is believed that the individual’s issues with potential suicidal ideation have been resolved, they can be transferred to a different environment, such as a residential treatment.

Residential treatment programs are typically not located in the psychiatric wings of hospitals but in more homelike settings.  The level of supervision is a step down from inpatient treatment in a psychiatric unit. 


  • Short-term residential treatment programs -  Short-term residential treatment programs provide very intensive but brief interventions. Often, these programs last several days to six weeks, depending on the intervention and the client's needs.
  • Long-term residential treatment programs - Long-term residential treatment programs may last 6-12 months. Individuals in these programs often have very severe issues, including significant psychological/psychiatric issues, substance abuse issues, and tendencies toward self-harm or harming others, etc.

    Treatment is highly structured, depending on the needs of the individual and the particular type of issues the program specializes in treating. For instance, some of these programs cater to individuals involved in the criminal justice system; some cater to individuals with psychotic disorders; some cater to those with personality disorders, etc.

    Comprehensive interventions are delivered in these environments that can include the use of medications and therapy as well as support services aimed at job-training, tutoring, speech therapy, etc. By their very nature, these programs must have modifications to treat individuals who have special needs. In some cases, clients may stay extremely long periods of time, or their stay may be permanent, depending on their level of disability.

    Therapeutic communities: Therapeutic communities are long-term residential treatment programs where clients and treatment providers live within the residence. These programs typically focus on re-socializing individuals as the major form of intervention and are designed to help clients develop attitudes, self-concepts, and behaviors that are constructive, allowing them to accept responsibility for themselves and lead productive lives. 



What do they do in an RTC?
Residential treatment programs provide a variety of different services, including medical management (medications from a physician and treatments from other medical professionals like nurses), group therapy, individual therapy, social support group participation, and other types of specific treatment interventions. For children, RTCs often have onsite school programs although some bus their clients to local public schools.

Residential treatment programs may specialize in the type of treatment they provide. Some facilities are basically "holding pens," some focus on diagnostics and medication, others are focused on DBT therapy or other types of therapy, job training... 

Most residential treatment facilities are not just for mental health treatment. Some also treat chemical dependency, substance abuse, and co-occurring mental health conditions. There are some that focus exclusively on neuropsychiatric treatment and a few specialize in children with reactive attachment disorder or other trauma issues. 

Most facilities either work with either children or adults, not both, some focus exclusively on adolescents.



Am I A Failure For Placing My Child in Residential Treatment? 
"We once told a person, who questioned our decision to place our son in residential treatment, that if he had a terrible illness or disease and we were told the only cure for him was to drain our savings account, fly to Australia, and see a specialist who could give us a cure, we would. In a heartbeat, no questions asked!
Why? Because we love our son. Our heart to help him heal, leads us to fight tooth and nail for him. We envision a day where he leads others, helps others, and gives back to the world in some amazing way. In order to help him get to that place tomorrow, we must fight today.
I’ve seen it in the eyes of a thousand parents I’ve talked to over the past few years- passion for their child. A belief that their current choices are not the end of their story. We’ve read it in the millions of words some of you have written in the comments on our blog or on our Facebook Page- a hopeless, empty, even terrified feeling over your child’s extreme behavior. But a willingness to fight. A belief in tomorrow. An “I’m not quitting” mentality.
Was the choice to take our son to residential treatment difficult? Absolutely! Did his choices lead him there? You bet! Does it mean we are failures for making that choice? Not in a million years! ~ Mike Berry


Is Residential Psychiatric Treatment (RTC) what your child needs? 

This is a great post about what RTC can't do (I don't necessarily agree with all of it. I do believe RTC can provide some solutions, but in general it is NOT going to solve all your child's problems). http://fletcherclan.blogspot.com/2012/03/myths-about-residential-treatment.html


How Do I Find Residential Treatment?

We've had quite a bit of experience with RTC's for our two children who are severely mentally ill and adopted with lots of trauma issues. The main thing to remember is that you have the right to "shop around."  for a provider and you have the right to work closely with them.  Here's what we do:

Prequel: Before you start the RTC process, you need to have documentation showing that your child NEEDS this level of care. For us, this meant repeated psych hospitalization, psychiatrist recommendations, therapist recommendations... The best thing you can do is Document! Document! Document! and keep it organized and easy to access.


  1. Check with your insurance to see what they'll cover and their requirements. Our kids were on state Medicaid and our state doesn't cover RTC, but we were able to get funding from the state we adopted through (because a friend had warned me to have it written into our adoptions subsidy). We had private insurance at one point and they had a bunch of hoops to jump through first (getting our child declared to have an SMI - serious mental illness; repeated psych hospitalizations and other outpatient stuff first... they would only pay for 4 days of RTC for my son because we didn't do all their steps.
  2. RECOMMENDATIONS! Ask your therapists, psych hospital social worker, psychiatrist, post on places like this... every RTC is different in what they provide and what they're good at, and of course your child's needs are individual too. Insurance companies will sometimes give you a list, but be sure to check it out yourself.
  3. Check the REVIEWS Check the State Licensing Board. In our state, it's called the Department of Family, Protective and Regulatory Services (or something like that). They have an ONLINE evaluation of ALL places they regulate (I use it for childcare facilities too). They record ALL deficiencies (this can be injury or even death of a child, cleanliness of the facility, record keeping...). I also enter the name of the facility online with the word review. I've found some things that way that didn't make it to the licensing reports.
  4. Have a written list of questions to ask of each facility.
    Some of our questions:
  • Do you take our insurance?
  • What age children do you take?
  • What is the average length of stay?
  • What does the typical client there look like (aggressive, mostly male, most of the kids are there for substance abuse, kids with primarily behavior problems....)?
  • What type of therapy do you provide?
  • How familiar are the therapists/ psychiatrists/ staff with trauma issues (PTSD, RAD/ attachment issues, Borderline Personality Disorder...)  Will they try to facilitate attachment to the family, or to themselves?
  • My child has unusual or special modifications/ accommodations _________ (blind, uses a wheelchair, sexually reactive, afraid of the dark, intellectually disabled, needs to be in small groups...), how would you handle these?
  • What are the education/ experience/ training requirements for staff?  What is the staff turn-over rate?
  • What happens if my child becomes violent or non-compliant?
  • How will you protect my child from other children's behaviors?
  • What happens if my child's behavior, health, or other issues change or escalate?
  • Do the kids attend the local public school or is there a charter school on campus?
  • How receptive are the therapist, staff psychiatrist to communicating with me?
  • How do you keep us (family) informed about what's going on with my child?
  • What type of communication and visitation policy do you have?  What does that look like?
  • In what areas are family expected to be involved (family therapy, part of the treatment team, staffings... ?)  In what areas are parents allowed to be involved?  
  • What kind of testing/ evaluations do you do?
  • What type of health care providers do you have on staff?  (psychiatrists, therapists, nurses, doctors...) 
  • Is the psychiatrist conservative or progressive with medications?
  • Can you accommodate my child's food/ seasonal allergies or other health issues?
  • What happens if my child gets sick or injured?  Where do they go if they need medical care not provided by the facility?
  • Can you get me a copy of the manual about how things work there (usually has info on visitation, dress code, level systems...) before we commit?
5) Check out the facility yourself. 
I went to a facility that during the interview process actually asked me these questions: 

First question:  
Random caseworker - "Our facility has a large minority population. Are you OK with that?" Me - "Yes, my son prefers this." 

SECOND Question (I kid you not!) CW: "Your son will be on a ward for aggressive boys (Bear was very aggressive due to his undiagnosed bipolar disorder among other severe issues). Are you OK with him getting beaten up every day?  My answer was NO!! by the way, and we did NOT take him to this facility, which has since closed its doors. 



Find a Residential Treatment Center (RTC)
A free resource to match RTC's with funding options and children's needs. I have not used their services but it came from a good source http://www.kidlinktreatmentservices.com/
Texas-based - Youth for Tomorrow http://www.yft.org/

Info about what makes an RTC a good place.





Getting Funding for RTC

Where is your child adopted from? (International, Private Adoption, Domestic Foster Care, Out of State Foster Care...). This can affect your options/ resources.


Some Tips:
  • Be prepared for a fight. 
  • Your child's School District may help. If a child is in a residential program, the school system must pay the cost to educate them, but this is expensive, so getting them to admit your child needs care they cannot provide is often a battle that requires a special education advocate/ attorney.  
  • Private health insurance generally covers residential treatment, as long as you meet their requirements. For this, I highly recommend you document, document, document. Generally, your child must have a diagnosed Severe Mental Illness (SMI), and have stepped up through repeated psychiatric hospitalizations, intensive outpatient (IOP) aka partial day hospitalization(PDH), and of course have an RTC recommendation from a psychiatrist. Don't be surprised if insurance will only pay for a short period of hospitalization
    {We had a child hospitalized 6 times in a 3 month period, did 2 months in an IOP (Intensive Outpatient Program/ Partial Day Hospitalization), and had 2 psychiatrist recommend RTC, but was only covered for 8 days of RTC - even though she was still suicidal and the extensive neuropsychiatric testing (which this RTC specialized in) took 2 weeks!
    Luckily, in our case, the RTC actually covered the remaining week it took to get the testing finished. I know the RTC hoped to win an appeal to the insurance to be reimbursed, but they lost. Luckily for us (although unluckily for them), we were not required to reimburse them.}
     
  • Medicaid. If your child has Medicaid, some state's Medicaid covers RTC - many do not. In Texas, RTC is covered for children in foster care, but not for children who have been adopted from foster care, even if they are still on Medicaid. This is why many families are forced to do Joint Conservatorship.
  • Joint Conservatorship. Putting a child into foster care so the state will pay for mental health services. Second Time Foster Child by Toni Hoy gives a little more info on this. -  It is not an easy road, but a lot of states are working on improving the legislation that makes it legal. (Ex. currently, many states might pursue you for child abandonment if you refuse to pick up an unsafe child from the hospital). You may be responsible for paying for the child to be in foster care (ex. if you receive an adoption subsidy from that state, this may be suspended while the child is receiving support outside your home).
  • Other Programs. Every state is different. Ask around. Start making phone calls. Get online. Talk to your school district, adoption support groups, National Alliance on Mental Illness (NAMI), your government representatives, psychiatric hospitals, community support programs...  
  • State Representatives. Try contacting your state representative for help.
  • Private pay. Unfortunately, sometimes this is the only option. If you work directly with the RTC, they may be willing to work with you on discounted rates and/or financing for out-of-pocket treatment.
Foster Care Adoption:
  •  Adoption Agreement. When drafting an adoption agreement, you can request adding a clause to cover RTC if you are unable to find alternate funding. {We adopted children from another state's foster care and went this route.}
  •  Post Adoption Services.  Contact your adoption caseworker and keep calling up the chain until you get someone who can help you. Sometimes saying you have no choice but to relinquish (even if untrue) might help get someone to listen.



What happens if you don't pick up your child from RTC?
Sometimes our child is unsafe, to himself or others. Bringing the child home could endanger you and/or other members of the household but your funding is running out and they or the courts or some professional is telling you that you must take your child home or be charged with child abandonment.

Child Abandonment Laws
Laws regarding child safety and welfare, abandonment, and abuse vary from state to state, though in most states child abuse and child abandonment laws go hand-in-hand. In many states, child abandonment is considered a felony, even if the child has not been physically harmed by the abandonment. Other states classify child abandonment as a misdemeanor unless specifics of the crime suggest it should be raised to the level of a felony.

Criminal child abandonment is often defined as physically leaving a child somewhere, though it may also include failing to provide for the child’s basic needs, such as shelter, food, clothing, and medical care. 


Some things to think about if you're thinking about refusing to pick up your child from the hospital/ residential treatment facility (RTC/ RTF):
  • If insurance or other funding will only pay for a certain number of days and then their plan is to send the child home ready or not. I'd take what I could get and hope that the child showed his/ her "true colors" during the time he or she is there (you can also "poke the bear" - aka deliberately trigger the child while the child is in care so that others see what's going on at home where the child is no longer "honeymooning"). Acting Differently with Others
  • This also provides important documentation from an outside source that might help confirm that the child is unsafe to be back in the home. Document, Document, Document!
  • Can you refuse to take the child home until they have a working crisis plan/ viable option for how to keep everyone safe?
  •  Will he/ she be all sweetness and light and deny everything at an intake or when it comes time to discharge from the facility? Documentation might be able to counteract some of this. 
  • Do you have other children who will be in danger of being removed if you take the abandonment charges? 
  • Do you have careers that will be damaged if you take abandonment charges? (social worker, childcare provider, police officer, or other helping services)
  • Pick the child up and go straight to an acute care facility. This could potentially buy you 4-10 days - more time to find an alternate solution.
  • Are there other possible living alternatives? Group home, boarding school, with a friend or family member, staying with one parent while the other parent is with the other children (not ideal at all, but it works for some families)... try thinking outside the box.
  • Is therapeutic foster care an option? 
  • Look into Joint conservatorship with the state? Joint conservatorship is a little like placing your child into state foster care so your child will have access to mental health services but unlike fostercare, you have a lot more say in your child's life - like being able to work together with the state to find a facility that will work for the child.
  • What about facilities like Methodist Children's Home? https://www.mch.org/ 
  • Look for places that can help you find and access community resources. Unfortunately, finding programs can be difficult now that they're more decentralized.
    MHMR (Mental Health Mental Retardation) There used to be MHMRs in every state and most counties, but to be more politically correct or something, each one chose a new name. The advantage of the internet is that if you enter "MHMR and your county and state name" you will usually get the new name of your local MHMR. These programs offer sliding-scale mental health services including case management, therapists, psychiatrists.
    Many times national programs will have state and local branches.
    Parent to Parent (https://fndusa.org/contact-us/programs/parent-to-parent/) Provides emotional & informational support for families of children who have special needs.
    NAMI (National Alliance on Mental Illness - https://www.nami.org/ An association of hundreds of local affiliates, state organizations and volunteers who work in communities to raise awareness and provide support and education that was not previously available to those in need.


If you have any suggestions or clarifications for funding sources - please comment and I'll add them to the list!


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