Insider’s Guide: Educational Consulting and Therapeutic Placement

It was warm, breezy day in the little cove where the treatment center was located where my client and her parents were standing. We were all on the back deck of the main building and the parents and I had just arrived. The client smiled after a few minutes of small talk and said, “Um, not to be rude or anything, but who are you?” Her parents looked mortified and embarrassed that she didn’t know who I was.

“My name is Rob Danzman and we’ve met several times before you came to treatment. I helped your parents find a healthy place for you.”

The client, after pausing for a second smiled again and said “I think I was so high I don’t even remember you. Thank you.” She started crying. Her parents started crying and they hugged.

There is a deep and broad gap between what families need and all of the treatment options available. There are a ton of variables to consider when your son or daughter need treatment, whether its outpatient therapy or residential treatment. Insurance, location, modality, diagnosis, and housing options are just a few things families need to consider when figuring out what’s best.

There is a dramatic range in expertise and costs and they are not often aligned. Some of the most expensive consultants with whom I’ve worked have minimal understanding of psychological conditions and the evidence-based approaches that best treat them. The goal of treatment is either assessment, intervention or maintenance of a behavioral health issue. If a consultant does not have a combination of academic and experiential background they may not serve clients well. In fact, my agency has worked with clients who were given terrible advice on what types of service to use. You would never have a mechanic give advice on spinal surgery because, while the mechanic may be really well-intentioned and personable, they may due considerable harm. The same is true when dealing with behavioral issues, many of which either in the short or long term may have life and death implications.

Evidence-based interventions need to be well understood and require clinical expertise. Therapeutic placements do a great job of presenting themselves as comfortable, safe and a good value yet many do not provide evidence-based treatments. Evidence based treatments are not for broad spectrum of psychological issues.

Another confusing aspect is the terminology. Decades ago, educational consultants did a few things and did them well – they focused on private school and college prep admissions. They provided deep advice on testing strategy, applications, and how to write a great essay. They coached clients through interviewing and often the whole education process. But over the years, ECs expanded their service offerings, often outside of their area of expertise. ECs without credentials or appropriate degrees started advising parents on treatment recommendations, presumably assuming that applying to a treatment center is similar if not the same as applying to college. Since those wild-west days of ECs pushing kids into cookie-cutter programs and charging a fortune, more clinicians with actual therapeutic experience have entered the EC world. Granted, there is still the old guard of older, white women who had their own children placed in a treatment center and saw an opportunity to help other families while making good money in an unregulated field. There are essentially only one entity that oversee ECs – the Independent Educational Consultants Association. The division continues to widen between those serving families

EC should not receive gifts from treatment centers though it’s not unusual for them to have travel expenses covered when they are touring programs.

There is a symbiotic relationship between treatment centers and ECs. Treatment centers count on ECs for referrals. ECs count on treatment programs to cover travel expenses and, sometimes, provide referrals back to the ECs when a client needs a different placement or the family needs advice on treatment options.  

Where to Find These Magical Beings

First thing to do is just google the terms “educational consultant” and “treatment.” You should get plenty of options that pop up. You could also just contact my agency but I’m a bit biased since I believe we do great work for a fair price.

Next way to find a placement consultant is to go to the Independent Educational Consultants Association (IECA) website (below in the Resources section) and look for the ‘Search’ option under the Parents tab. All of the people listed in this resource are paying members of IECA and met the IECA’s criteria. If you are going this route, I encourage you to, at a minimum, look for a consultant who has a graduate degree in a behavioral health discipline like counseling, psychology or marriage and family. Pastoral counselors or ‘Qualified Mental Health Practioners’ are not nearly qualified enough. It’s even better if they are a licensed professional (eg. Licensed Professional Counselor, Licensed Marriage and Family Therapist, Licensed Clinical Social Worker).

Do Your Homework

A great EC can support your family through the most difficult times while a bad EC can cost your valuable time and money and have nothing to show for it or set things back even further with a terrible placement.

Consult: If you can’t meet them face to face, then schedule a call with them. Before you go into any details, dig into the business end of their service first. Do they offer therapeutic placement consulting or do they focus on prep school and college? What are ALL the costs associated with what they do. What is their degree in and what active licenses do they hold. Ask if they are a member of any associations and if they have any disciplinary actions against them. Ask when and how they got into educational consulting. Ask what the scope of their work is – Do they meet clients at treatment centers for admissions? Do they continue to work with families while the client is in treatment? Do they assist with discharge planning?

Payment: Another thing to consider is how the ED gets paid. It’s important to understand whether the EC sends you an invoice and bills as they go along or do they receive a retainer upfront. Though not a deal breaker, I don’t like asking for retainers from clients for the same reason I don’t like attorneys collecting a retainer from me. They have my money and pull from it as they do work. I’d prefer to pay for things as we go along through a project. We only accept credit cards so that a) there is protection for the client and b) we don’t need to run after clients to pay an invoice. We also itemize every time we charge a client’s card so that everything is 100% transparent. Ask about how folks get paid before you agree to work with them. If they can’t agree to provide itemized billing or seem too focused on money upfront, you may want to consider working with someone else.

Guarantee: It’s unlikely anyone is going to offer you a guarantee for their services but it doesn’t mean you can’t ask about their responsibility if a treatment option doesn’t work or a treatment option can’t be found in a reasonable amount of time.

Cost

Take a deep breath for this section. Expect to pay between $10,000 – $300. Yes, I know that’s a ridiculously large range but there are no regulations on what an EC can charge. The spectrum of fees is truly that big. Some charge as much as $10,000 for a placement. They may put in 5-10 hrs but their rate doesn’t change. Other ECs charge a lower rate but most have a basic flat fee which covers support and advice through the admissions process. In my humble opinion, a lower flat fee or hourly rate is more fare. For instance, my agency has a free consultation to determine if someone really needs an EC. If we determine the client really can’t find an appropriate treatment option on their own, we charge $179 per hour and use as few hours as possible. We’ve had client come to us after spending $25,000 on placement services only to realize the ECs they were using had no clue about severe clinical issues like substance abuse and schizophrenia. Fortunately, we quickly found them services and billed them less than $500.

FAQ

Q: I know how to do internet researching. Why can’t I just find a treatment program on my own?

A: You could totally do this own your own. There are three easy steps. First – get a graduate degree in some counseling or psychological discipline to learn the clinical aspects of behavioral health and intervention. Next – work in the behavioral health industry for about five years so you can see what makes a program great and what makes a program terrible. Finally – go and visit 50 treatment programs. Granted, that will take a few years, and by the time you’re finished visiting, staff at each program will likely have changed (so start over). Ultimately, this experience  will be very helpful in determining which programs are good and which ones you would not trust to take care of your house plants. After all these steps, you should totally do some internet searching to decide which program is most effective at serving your loved one.

Resources

Independent Educational Consultants Association – https://www.iecaonline.com/

Insider’s Guide: Getting Insurance to Pay for Residential Treatment

imagesThis is our second installment on how to get insurance to pay for residential treatment and therapeutic programs. Below is some great information to help you beat the insurance companies at their own game. Insurance companies count on your ignorance, laziness and distractibility to avoid paying for services they are legally obligated to cover. 

With the Affordable Healthcare Act and the Mental Health Parity Act in full swing it’s time to learn how to get the most out of the insurance you pay for. We’ve included some tricks, strategies and how-to’s to help you out. Though we’re focusing on Residential Treatment for our discussion here, this info is applicable to therapeutic programs like wilderness programs, therapeutic boarding schools and intensive outpatient programs.

Ok, let’s get started with some basics… 

What If I Need Additional Help?

First, read through everything below. These strategies are time consuming and require steady attention but they are not impossible. If you still don’t feel confident in holding your insurer accountable, contact us for a free consult and we’ll help you figure out how to move forward. 

What is the Insurance Company’s Criteria for Residential Treatment?

…Or more importantly, how does an insurer define residential treatment? Each insurer has their own definition but most have virtually identical criteria. For our purposes, residential treatment is defined as specialized mental, behavioral health or substance abuse treatment that occurs in a residential (overnight) treatment center where the provider is responsible for clinical service, safety, shelter, and food.

Licensure differs by state, but these facilities are typically designated either as residential, subacute, or intermediate care facilities and may occur in care systems that provide multiple levels of care. Residential treatment is 24 hours per day and often requires a minimum of one physician (or psychiatrist) visit per week in a facility based setting. 

What Specific Criteria Do They Look For?

Now, let’s drill down a bit more and look at some of the more common criteria requirements insurance companies are looking for when determining whether to pay for residential treatment to a struggling teen or young adult. 

  • Was there a sincere attempt to first use evidence-based outpatient therapy in the home community by a licensed professional before residential treatment was requested and outpatient therapy did not work? Basically, they want evidence that you tried outpatient therapy with weekly sessions (or more often) and because it was not effective, a more intensive level of care like residential treatment was justified.
  • Prior to admission, did you contact your health plan for list of in-network residential treatment options? More on this later – what to do if you can not find a good option.
  • Is there uncontrollable risk-taking to self or others or other dangerous behavior?
  • Has there been a documentable and rapid decrease in level of functioning in one or more life domains. Another way to describe it is a decline in functioning resulting in the ability to perform self-care. 
  • Is there a likelihood of no improvement in current environment (ie. home or college)
  • Is there a reasonable expectation that patient will improve in residential setting and be able to return to outpatient therapy for aftercare? 

How to Request this Higher Level of Care?

Now that you understand the criteria, let’s talk about how to actually request residential treatment. 

  • Write a letter strongly recommending admission to residential treatment 
  • Provide copies of assessments and testing performed by a licensed professional that indicate 1) a formal diagnosis and 2) specific recommendations that list residential treatment.
  • Explain how outpatient therapy has not been successful
  • Explain why current circumstances make it unlikely that patient will show improvement (ie. Improvement is not likely in home setting due to social stressors such as negative peers that sell drugs but remain in the environment)
  • Document unsafe, declining behaviors – show symptoms and behaviors that represent a decline from usual state and include either self-injurious or risk-taking behavior that cannot be managed outside of 24 hr care. Can your kid maintain abstinence outside of 24 hr care? 
  • Explain that the residential treatment program uses evidence-based clinical interventions.
  • Request the residential treatment program directly contact your insurer for pre-authorization. Pre-authorization is the insurance company’s way of giving formal permission to use a higher (and more expensive) level of care. Make sure to obtain the tracking number and verification of the call from the residential treatment program. If approved, obtain written authorization confirming admission approval.

After you send off your request, your insurer should should respond in 5 days. Don’t wait that long – call them every day to find out the status of your request. Yes, seriously – call every day. 

Accepted! Now Some Additional Insurance Mandates

The insurance company accepted your request (more below on what happens when they do not accept it) and a wave of relief comes over you planning for some quiet time once your kid is safely transitioned. But before you get too comfy, there are a few things you want to make sure the residential treatment program will do to ensure insurance covers as much as possible. It’s easier to ask these questions during the admissions process rather than at discharge. Here’s a list of what to look for or ask for:

  • A basic physical during admission (urine screening for drug facility)
  • Onsite nursing and 24hr access to med care
  • Multidisciplinary assessment (also called a Biopsychosocial Intake) performed within 72 hr of admission, including information obtained from patient’s previous providers (ie. therapist, primary care physician)
  • Individual therapy with a licensed therapist (ie. LPC, LCSW, LMFT) at least one time per week
  • Weekly meetings with doctor for medication management
  • Weekly family therapy
  • Discharge plan created one week after admission which acts as a set of exit criteria
  • Licensed in the state in which they are located. Some facilities are owned by huge companies in another state. Make sure they are credentialed and licensed.

Denied. Now on to The Appeal Process

Denials are just a way of life in the therapeutic treatment world but it’s certainly not the end. Here are some information on what to do when you experience a denial.

  • First Thing – Do not let the denial get you mad and do not attempt to use logic, common sense or science to understand why. Insurance is a business and their business model is take in money and pay for as little service as possible – period. 
  • If residential treatment is verbally denied, request written denial. They must deny in writing and often will send the residential treatment program as well as the insured person a copy. 
  • Do not just ignore the denial and send your kid off unless you are willing to pay out of pocket and work your tail off at discharge to get the insurer to pay for it.
  • How to appeal depends upon the reason for denial. The insurance company will likely list specific criteria either your kid or the residential treatment program did not meet.
  • If the insurer states that residential treatment is not a covered benefit but they offer  other mental/behavioral health benefits, they are required by law to pay. In Harlick v Blue Cross of California – On August 26, 2011 the court confirmed that California’s Mental Health Parity Act requires health plans to provide coverage of “all medically necessary treatment” for “severe mental illnesses” under “the same financial terms as those applied to physical illnesses,” and are obligated to pay for residential treatment for people with eating disorders even if the policy excludes residential treatment.

And It’s Still Denied – What Next?

If you submit an appeal with additional information and site the law but still are denied or hear nothing, you can request an independent review from your state’s regulatory body that oversees insurance compliance. It’s amazing how quickly insurance companies can ‘find missing paperwork’ or reverse a denial when regulators and attorney’s get involved. 

  • Send a certified-mail cover letter describing the dispute
  • Provide all relevant evaluations, assessments and testing you already sent to the insurer
  • Submit a doctor’s letter stating care is medically necessary
  • You can also hire an attorney that specializes in insurance issues like this. They are often worth their specialist price tag.

Plan B – If You Can Afford It

If residential is denied and you don’t want to push the insurer for whatever reason, you can pay out of pocket for room and board and try to get the clinical services covered. This approach is often what is equivalent to out-of-network coverage. The insurer is more likely to cover outpatient therapy, group therapy and medication management (virtually the same as if client was living at home and going to therapy).

You can also request that the residential treatment primary therapist get a single case agreement which forces the insurer to pay at in-network rate and you only owe the copay, as usual. 

What if Our Family Member is at Therapeutic Boarding School?

With the growth of therapeutic boarding schools, we’ve received a ton of questions about how insurance pays for the clinical aspects of these hybrid programs. Here are some tricks we’ve picked up over the years:

  • Think like the insurance company – they want to hear your son or daughter is being referred to as a patient and not a student.
  • Make sure to request a physical assessment is done at admissions. This promotes the perspective that he/she is a patient and not a student. Remember – we want the insurer to understand this is a therapeutic program, not as much an academic program.
  • We also want to ensure the program is keeping daily records such as treatment plan updates, nursing and medical notes and service notes – health plans will want copies. We want to be documenting progress as well as setbacks. 

When we conduct placement services, we always request the therapeutic program develop a treatment plan with some specific exit criteria. The first day of treatment is the first day of discharge planning. Some plans will want exit criteria so err on the side of having the program provide it early on. It’s also a good clinical practice to give the providers a clear target. 

In Which State Should Insurance Regulators Be Notified if Insurance Refuses to Cooperate?

The state in which treatment is being provided is where insurance regulators should be contacted if your insurance company refuses to play nicely. The state in which you live may be where your insurance is attached, but legal oversight for provision of service and insurance regulation is in the treatment state. 

Can Insurance Pay for Services Retroactively?

Theoretically, yes. Practically, it’s pretty difficult and will require regular attention and contact with the insurer. They will likely ‘lose’ applications, claim forms and anything else you send. If you get insurance to agree to pay for residential treatment or other therapeutic services after treatment has started, you can request for retroactive coverage. It’s best to write a letter (and send it certified mail and keep a copy for your records) stating why you didn’t understand or it was not stated clearly in a policy that treatment was covered. 

Will Insurance Cover Partial Hospitalization Programs (PHP)?

Partial Hospitalization Programs or PHPs is typically a level of care designed for individuals who need structured mental health, behavioral health or substance abuse programming but do not need 24-hour supervision (ie. inpatient or hosplitalization). Many hospitals and residential treatment programs offer partial hospitalization or day treatment services. Good PHPs are designed to provide support, education, medical monitoring and accountability during the hours of the day often identified as most troublesome for patients. Patients participate in therapeutic groups, structured activities and discharge planning similar to those offered in the inpatient and residential programs. Many patients who have been in an inpatient or residential program can “step down” to this level of care because it continues to provide a high amount of structure and support. 

Insurance generally covers PHP at a per diem rate (daily rate) but will not cover overnight which the hospital or treatment program may charge extra for. Make sure to clearly understand how the treatment center charges for PHP before signing up. Also make sure insurance covers it and what portion it covers. 

So we covered several of the topics and tricks that can help you navigate the insurance company maze when it comes to paying for residential treatment. If you need additional help, contact us today – help@fonthillbehavioralhealth.com 

Program Review: The Renfrew Center

Renfrew PicMany years ago I had the pleasure of visiting The Renfrew Center just outside of Philadelphia, PA. At first, I wasn’t sure if this was a gigantic private residence with it’s ancient stone farm house, stables, and quintessential barn. Definitely one of the more beautiful suburban locations for a treatment center I’ve seen. I had my tour of the grounds which look more like an upscale farm (in a good way), talked with the Executive Director about mental health under a giant oak tree, and got to know the program schedule as young women shuffled in and out of the various buildings. Below are more details on Renfrew with my Final Thoughts at the end. 

Background

The Renfrew Center is headquartered in has been serving women with eating disorders and behavioral health issues since 1985. As one of the nation’s first residential eating disorder facility, with 16 locations throughout the country, Renfrew claims to have worked with more than 65,000 women since their founding. The Renfrew Center has experienced it’s most significant growth in the last decade and a half have with the additional of programs across the country. 

Services

The Renfrew Center offers a full continuum of care that supports patients well beyond a residential stay. This comprehensive range of services available at most of their locations, includes day treatment, intensive outpatient and outpatient programs. The services are tailored for each patient and with her referring therapist to develop treatment plans and goals based on her unique needs.

Renfrew maintains continuity in philosophy and approach throughout the individual’s treatment, while facilitating timely transitions from one level of care to another in order to maximize treatment and insurance benefits. 

Residential services are only offered in their Philadelphia, Pa and Coconut Creek, Fl locations. 

Clients

Renfrew works with women over the age of 14 suffering from anorexia nervosa, bulimia nervosa, binge eating disorder, eating disorder not otherwise specified (EDNOS) and related mental health problems.

Locations

Cost
Residential – $8050 per week
They work with most insurers so a significant portion of services may be covered. 

Reviews
Employees on multiple sites give Renfrew some terrible grades for working conditions, diversity of the work force, and work-life balance. Most notably were many comments on Renfew’s seeming focus on profit and not much focus on treatment. They also described poor, untrained supervisors that did little to organize chaotic situations. 

Clients on the other hand often report having a positive experience and feeling somewhat nurtured. There were dozens of reports from clients going back to Renfrew multiple times for support. This could be viewed as good or bad. 
The New York location stood out with many, many negative reviews which highlights an ongoing theme among larger providers like Renfrew – when it comes down to actual effectiveness of a program, everything has to do with the clinicians at specific locations and very little to do with the corporate handlers up above. 

Contact

Here is a link to their online contact form which is probably the best way to get ahold of them. 

Final Thoughts
Oh how I wish programs like Renfrew could just slow down and focus more on quality. I’ve known too many therapists over the years who think poorly of Renfrew’s clinical integrity to feel comfortable referring clients that come to Fonthill. That said, it doesn’t mean women struggling with an ED should avoid Renfrew. I think programs like this have a place in the menu of options, especially if you want treatment close to a major metro area like Philadelphia. Just make sure to make a decision on more than what the admissions folks at Renfrew tell you. Look up reviews, talk with outpatient eating disorder specialists (like Dr. Joanna Marino in Washington, DC) or placement specialists (…like Fonthill ) and do your homework. It’s expensive and takes a huge amount of time to go to Renfrew so don’t rush in. 

Program Review: Timberline Knolls Residential Treatment Center

You may have recently heard of Timberline Knolls for the high-profile admission of Ke$ha on Friday, January 3, 2014. Or maybe you heard of Timberline Knolls when Demi Lovato was raving about it to MTV when she was discharged several years earlier. Both of these and many other celebs are drawn to Timberline Knolls for their quiet, discrete environment with a good reputation for getting young women healthy.  imgres

Reviews

We take reviews from the internet lightly since they could have been written by competitors (yes, that really happens), written by staff posing as program alums or written by actual alums. Unfortunately – there’s just no way to know for sure so be cautious when considering the reviews. Most of the negative reviews for Timberline Knolls across these sites indicates pretty good clinical program, really nice setting, but super high pricing which may not be very transparent (not currently listed on their site) and significant problems with the Timberline Knolls administration for various issues. 

Google Reviews: 2.8/10 (10 Reviews)
Yelp Reviews: 5/5 (2 Reviews)
EdTreatmentReviews.com: Mixed
BBB.com: 8 Complaints
ComplaintsBoard.com: 6 Complaints 

Who They Serve

They admit women ages 12 – 60’s to extremely discrete care (lots of celebrities). Timberline Knolls recognizes that recovery from eating disorders, addiction and the other conditions is a lifelong process for women. Women require different tools as they move through different phases of life. Their customized program addresses the unique treatment needs of women at various stages of life. 

Many adult women come to Timberline Knolls after having been in recovery for many years. They offer programming tailored to the specific needs of mature women, including those of mothers with children at home. Many clients come to them having been triggered by complicated life events like a death in the family, divorce or significant career challenges.

Residents live in separate lodge settings based upon their age. Adolescent girls attend school at the state-approved Timberline Knolls Academy. They benefit from the tight integration between the classroom and a therapeutic living environment that supports their social, developmental and clinical needs. Check out their video here

Location

timberline-knolls-campusTimberline Knolls (40 Timberline Drive Lemont, Illinois 60439) is located on 43 wooded acres just a few miles southwest of Chicago, less than a half-hour’s drive from either O’Hare or Midway Airport. An interesting side-note: The campus received recognition for its beauty from the American Institute of Landscape Architects. The tranquil grounds contain a lake and reflecting ponds, an historic art studio, comfortable contemporary residential facilities, and outdoor activity fields.

Residents are housed in one of four residential lodges, (Oak, Maple, Pine and Willow), which are staffed 24 hours a day with nursing and clinical support staff. Timberline Knolls also employs on-campus security staff 24 hours a day to protect the safety and privacy of both residents and staff.


Fees, Insurance and Financing 

$875 per day. The daily rate is inclusive for all clinical, educational, psychiatric, behavioral/milieu, nursing, and expressive therapeutic services on a 24 hour, 7 days a week basis. Individual, family, and group therapies are included. It also includes all meals and lodging. The daily rate is based on a tuition model of monthly billing. Non-included services are off-site medical services such as pediatrics, gynecology, dentistry, dermatology, hospitalization, urgent care, emergency care, urine/blood/lab work, etc., and medications. If any of these services are required, the specific provider of those services will directly invoice the parent(s)/guardian(s) or their insurance. 

If applicable Timberline Knolls works with a client’s insurance company (some in-network, some out-of-network) to get as much of the fees covered. Admissions counselors will help clients investigate their benefits.

If insurance is not an option and out-of-pocket is out-of-reach, contact Timberline Knolls and ask about financing.

Final Thoughts

Timberline Knolls had a bumpy start when they started in 2005. The original founders were two pretty shady characters who have since been replaced by reputable investors that seem to be focused on providing a good quality program to upper and middle class women. Most of the feedback we gathered from online and colleagues was that they do a descent job working with the clinical issues but could be a lot more upfront about expenses. They also received several negative marks for having difficult admin staff. These issues could be more about personality (clients as well as the staff) and less about policies that impact every client.

Overall, we encourage perspective clients to take a tour and consider the program. It’s best to higher an educational consultant or case manager to go with you. They will ask detailed questions you may not think to ask or just feel way too uncomfortable to ask. This is a decision you should not make alone. 

Virginia Senator Deeds Stabbed by Son (…And How it Could Have Been Avoided)

Virginia Senator Creigh Deeds was Stabbed by his 24 year old son Austin (Gus) Deeds  who then killed himself with a shotgun at their rural home just West of Charlottesville, Va.. Austin Deeds had just been ‘psychologically’ evaluated just hours before at Bath Community Hospital under an Emergency Custody Order (ECO). The ECO is only good for 4 hours with a possible 2 hour extension if ordered by the magistrate.  Hospital staff stated, working within the maximum 4 hour window, they were unable to find a treatment facility to address Austin Deeds’ psychiatric needs despite several hospitals reporting they did in fact have availability.

Here is some analysis/questions from someone (me) that’s been in this profession for years. I also provide some ideas of solutions if you know of someone struggling with a similar situation:

1. Diagnoses: If the hospital was looking for a treatment facility this means that something the evaluator found indicated Austin was either a threat to himself or others or needed a a level of medical intervention not available at the current hospital. I’m also thinking about the type of evaluation that was conducted and why it was even done at BCH, what the evaluator’s credentials are, and how it was reviewed with Austin and his family. 

2. Discharge: If there were no options (which there clearly were), I wonder if and how the hospital communicated their findings from the evaluation as well as their concerns about safety to the parents and authorities. I’m also wondering what kind of discharge meeting took place. When a client is stepping down from a hospital or residential setting, we always facilitate a comprehensive treatment team meeting to talk about discharge so everyone leaves understanding what the next steps are – action steps. When we work with families struggling with similar issues, we don’t wait for the hospital to give updates. But as mental health professionals, we are able to navigate the bureaucracy much easier and get clear answers much faster. 

3. Responsibility: Providers, whether big hospitals or little, ole’ therapists, have an ethical and legal responsibility to communicate to authorities if a patient is in eminent danger. So who is responsible here? If you ask the hospital, they’ll probably point fingers until the next news cycle. If you ask an attorney, they’ll go through the policy and procedures for the hospital regarding intake, evaluations, referrals, discharge, etc. and anyone of making decisions in that chain could be liable.

4. Intervention (Placement Options): The hospital staff at BCH clearly did not consider referring outside of the traditional placement list (psych beds at hospitals). It’s unlikely that it was due to financial constraints and certainly not due to a lack of treatment centers as some have speculated (Yes, there are certainly a lack of medicaid-funded psych units in VA). There are facilities all over the country that are extremely well-equipped to accept, stabilize and work with patients just like Austin. Most hospitals, though, follow a tired, out-dated protocol of calling three near-by psych hospitals to find out if they have a bed avail. If they here no at all three, patient is discharged with a list of therapists to contact to set up an appointment. Sound ridiculous? You’re right. 

5. Solutions: In my humble opinion, Austin would be alive today if earlier intervention had been provided by a treatment team including a psychologist, psychiatrist, therapist, and case manager. The psychologist provides the initial psychological evaluation to identify the issues, what is causing them, and create a specific list of interventions for the rest of the team. The psychiatrist (though in limited supply in Bath Co, VA) performs an initial psychiatric (medical/medication) evaluation and identify what, if any, medication is necessary to compliment any individual counseling being performed. The therapist provides weekly counseling either in-office or in the family’s home to address areas identified within the psychological evaluation. The case manager is the project manager for everyone and is on-call 24/7. This person also facilitates regular treatment team meetings to ensure updates are provided to the family and all professionals. For instance, if the therapist starts seeing signs of bizarre thinking patterns which are historically correlated with dangerous behavior, the case manager can alert the rest of the team and monitor the client more closely while also increasing the frequency of support. If a higher level of care (ie. psychiatric hospitalization) is recommended by any member of the team, the case manager not only identifies a placement but completes all intake paperwork. The case manager also provides psychoeducation to the family to help them understand the client’s diagnoses and what they can do to most effectively support him. 

If you or someone you know is in a similar mess, do not assume your local hospital has the expertise to handle the situation. Contact a mental health professional to find services that can manage the entire project from assessment to placement to discharge and aftercare. 

Treatment 101: Therapeutic Boarding Schools and Residential Treatment Centers

Today we examine some of the basic differences and similarities between therapeutic boarding schools and residential treatment centers (or programs).

 

THERAPEUTIC BOARDING SCHOOLS

Also known as Emotional Growth Boarding School (not used so much any more), is a boarding school based on the therapeutic community model that offers an educational program together with specialized structure and supervision for students with psychological, behavioral, substance abuse, or learning difficulties. Another newer term is Academy which lends some gravitas and impressions of legacy. Basically, it sounds fancier. 

In contrast with Residential Treatment Centers, which are more clinically focused and primarily provide Behavior therapy and treatment for adolescents with serious issues, the focus of a TBS is toward emotional and academic realignment involving clinical and academic oversight for physical, emotional, behavioral, family, social, intellectual and academic development. Therapeutic and educational approaches vary greatly; with the approaches best described as a combination of interventions often based on the founders’ perspective. The typical duration of student enrollment in a TBS range from one to two years with many schools mandating a minimum stay of at least 1 year. Students may receive either high school diplomas or credits for transfer to other secondary schools. Some therapeutic boarding schools hold educational accreditation within their respective states. TBS’s may be for-profit or non-profit entities and might also be owned by a much larger company (eg. Aspen Education Group, Red Cliff Ascent, Universal Health Services to name a few). 

Therapeutic boarding schools are generally middle schools and high schools that have comprehensive therapeutic interventions (medication management, individual/group counseling, life skills) for the students and a program to help them with self-esteem and problem behaviors. Some are more therapeutic than others while some boarding schools are actually therapeutic but will not list themselves in that category to avoid any negative connotation. 

Most of the therapeutic boarding schools do not have a medical plan for bipolar disorder, and do not provide psychiatrists on staff. If you want your child to attend a therapeutic boarding school he or she needs to be stable enough to attend school with therapy support (typically includes individual counseling 1-2x/wk, group counseling 1-2x/wk and 1 weekly phone conference with parents/therapist), while maintaining a relationship with an outside psychiatrist. Additionally, some schools do not wish to administer psychotropic meds. Ask the admissions folks if this is something important for you. 

 

RESIDENTIAL TREATMENT CENTERS

Sometimes the school that best meets the child’s needs just doesn’t exist anywhere near home, or the child may become too unstable to stay at home and attend school. It may become painfully obvious that a change in environment with a twenty-four-hour peer group and non-parental authority figures may help the child grow and mature in a safe environment. Maybe they are a danger to themselves or others and they need to be in a setting that can monitor their illness and behavior, as well as provide them with tools to understand and deal with their illness while not losing ground in school.

Residential Treatment Centers (RTCs) are medical facilities (most of the time). They should have psychiatrists and nurses on staff. They administer medications, make medication adjustments, and provide therapy and schooling. They are required to follow a student’s IEP.

Residential schools can cost anywhere from $56,000 to over $125,00 per year. A school district may pay part or most of the fee of such a placement, but typically only after a due process hearing. This process is not recommended for parents – Definitely bring in professional support for this (yes, a case manager or educational consultant with expertise in IEP/504 process and laws within your state). 

If you have not noticed the theme, here it is – Parents should ask for help from a clinical case manager or educational consultant. While the vetting and application may seem like an easy project for accomplished parents, the timing, financial and clinical complexities can create significant challenges. The case manager should have any professionals working with your child contribute to the discussion on placement strategies and options. Leave this to the professionals. It costs money on the front end but will save you thousands of dollars over months and years and also help you to understand your child, family and the education/psychological process much better. 

Here are some additional resources: