The young adult treatment world is expanding fast and furiously. The average age emerging adults are entering treatment is getting higher, and the levels of care are more customized, and therefore harder for a young adult or family member to discern and digest. This became incredibly apparent as Mona Treadway, Ph.D. and I had a conversation about the various types of options for Young Adult Treatment.
This blog dissects the young adult mostly residential treatment levels of care, and concepts for families to review, should you need your family need or be considering treatment help. In order to consolidate types of treatment, All Kinds of Therapy has grouped them by programmatic levels of support - how they staff or provide therapy or psychiatric support. Like all levels of care, there are exceptions to these five buckets of residential young adult treatment.
Note: This blog does not include Intensive Outpatient Therapy (IOP) and Partial Hospitalization Programs (PHP), however, many residential treatment programs offer these levels of care too.
1. Young Adult (and Older) Residential Treatment: This is the highest level of care and should have a psychiatrist on staff and part of the treatment team to treat mood disorders. Much like teen RTC, the staff are highly trained in a particular treatment model, programs may have round the clock nursing, and clients may have co-occurring disorders or a severe mental illness* that may have been masked by substance use. Once the recovery process begins, the presenting issue evolves into a mental illness or the trauma history and the recovery piece is part of the equation. Young adults who need this level of care might have entered residential treatment from hospital, treatment failure at a lower level of care or wilderness therapy settings.
Questions to ask if you are looking for a young adult residential treatment program:
- Was this level of care recommended from short term hospital stay for stabilization?
- Has the young adult had multiple, short term hospital stays?
- Is a clinician recommending the level of placement?
- What behaviors does the client want to address?
- Is there a specific evidenced-based treatment component t to address the clinical needs of the patient (DBT, CBT, etc)?
- Has a lower level of care been unsuccessful already? (If so, how does this program address earlier clinical concerns, gaps?)
- Are clients allowed to come and go as they please? What is the structure? Do they list them on their Ethics Page of their website? There are a lot of shady treatment facilities that participate in patient brokering. Cumberland Heights' (TN) website lists 12 insightful questions to ask before entering addiction treatment.
- Is the treatment program capable/prepared to treat a mood disorder diagnosis?
- What standards/accreditation is the residential treatment center following? Some states license these programs and others do not. Are they Joint Commision Accredited? JCAHO Accreditation, CARF Accreditation? This is where it gets REALLY confusing, so if a state does not license, then be sure that there is an outside accrediting body by JCAHO Accreditation or CARF Accreditation.
- If the treatment program is covered by insurance, what do they have to do for that?
2. Integrated Therapy with Residential Housing: Similar to the RTC level 24/7 staffing, the client needs a treatment setting that is more contained to build success, an integrated community in terms of housing and managed peer dynamics, licensed therapists are part of the treatment team, consulting psychiatrists are also on the treatment team, and more individual support is available/provided on a daily basis. Staff to student ratios are high. This level of care can taper off as the young adult moves through the treatment program. Emerging Adults at this level may have started treatment in another setting, such as a Wilderness Therapy program or hospital or intensive outpatient program (IOP) and their improvements are such that they do not need the psychiatric care or nursing staff but can succeed with an intentional community/relationship based treatment with licensed clinicians onsite.
Questions to think about if you are entraining an integrated therapeutic program with residential support:
- Does the client need more support initially to build skills, resilience and reduce behaviors?
- Does the young adult buy-in to the idea of a longer term approach to treatment?
3. Outpatient Model, Transitional Young Adult with Housing: A key piece distinction between RTC and Transitional programming is that licensed therapy happens outside the community’s living space. There may be live-in supervision in the apartment/housing, but there also may be less structured supervision. These programs are generally tied to a specific need of the client -- adjusting to college life with therapeutic and/or academic support life skills, larger community, getting a job and the program’s community may play less of a roll in that process.
Questions to ask if your emerging adult would be successful in a transitional young adult with outpatient therapy:
- Can the family handle if the emerging adult is struggling and allow the struggle to occur? (In other words, is the direct family able to allow the young adult and the program to manage logical consequences of impulsive or unfortunate decisions, without interfering directly with learning?)
- What is the worst behavior the client has exhibited? What if that happened again?
- Does the program allow direct community involvement? Does the program require Service in the community?
- Does the client have a history of substance abuse? If so, what is the model for dealing with relapse, maintaining a Recovery milieu or harm reduction?
4. Mentoring Support/Apartment Living: This is the newer type of young adult service (not really a treatment) that is available. Perhaps the young adults have made significant gains in treatment already, have little to no real dangerous behaviors or psychiatric needs and are looking to gain a skill, go to college and primarily need mentoring and not the processing groups/ individual therapy needs that other levels provide. The goals of these Mentoring programs are to integrate previously sheltered clients into a city, assist them in developing professional or, vocational occupations, and develop independent, academic supports. Clients who are successful in these options are internally-motivated to connect with their mentors and other external support options; they have an intrinsic desire for community integration, and are long-term capable of independent living.
Questions to think about for a mentoring support is the correct level of care:
- Has the young adult been to a previous treatment program and found success?
- What experience does the client show, regarding previous behaviors that would prevent success?
- Does the young adult want to explore life in a city or suburban area?
- Does the young adult want to experience a coaching model in a community?
- Does the young adult need assistance with learning disabilities as he/she moves forward?
- What is the young adult’s level of motivation?
- Does the young adult need gender specific programming? If so, how does the treatment program provide this?
- If the 18+ year old wants this type of option, but is not ready, is the program structured to evolve through this treatment stage?
- Is the young adult able to take their medication without prompting or oversight?
Note: Several higher levels of residential treatment programs offer this level of support for their clients to transition into & the services are sometimes tied to insurance billing too. Do your homework on options!
5. Gap Year with Supports, Collegiate Experience: These options are not treatment options, instead these programs focus on mentoring, defining goals and assisting the young adult to obtain the goals. This option may have clients on meds who only needs med checks. If a client has a therapist, it can be a licensed clinician in the community who may or may not have regular communication with the program, but is not a formal part of a treatment team. Few of these clients have a therapist in the community. The program/client focus is assistance with goal creation, goal execution, community social skills, academic matriculation and more support than a traditional college could provide (even with a learning disability support program), because the community is a huge piece of the student’s social life.
Questions to think about for a Gap Year with Support:
- Does the high school graduate (college postponed) want to be in a community of peers?
- Is there a question that the 18+ year old will be successful out of the home without the structure of high school and family?
- Does the 18+ year old need assistance with integrating into a larger community because of an Autism Spectrum Diagnosis?
- Does the 18+ year old have a history of learning disabilities that have delayed emotional development?
- Would this high school graduate benefit from a year of finding success and supportively learning to create goals and executing upon those goals?
- Will the student benefit from the level of support which includes (literal and metaphorical) knocking on a dorm or apt door in order to ensure engagement, progress, and success? (Insider Tip: Even the most supportive LD college does not offer this level of service.)
- If substance abuse and recovery are relevant issues, what structures are already in place to help create success?
6. Gap Year with International Travel/Community Service: requires more independent motivation and drive, tremendous flexibility and patience, along with historical and social curiosity and is vastly different from a Gap Year with Supports/Collegiate Experience. I was recently told that the rate international GAP Programs have sent students home prematurely is between 33 - 40%. The main difference is travel, and international travel on top of that requires a level of daily functioning, self control and self awareness that not high school graduates are not ready for.
So what are some of the reasons that participants are being sent home from International Gap Year programming at such high numbers?
- Rule infractions
- Not having the mental grit needed to handle the novelty of a new culture or social conflict
- Refusal to attend programing or participate in programming
- Being on medications for mental illness that were not disclosed or asked about during admissions
- Clients not having the recovery skills to support personal needs
- Little to no screening of all of the above during the application/admissions process
- This is a deadline driven process vs. the previous 4 levels of treatment/mentoring have rolling admissions
Buyer beware! Parents are on the hook to pay the entire tuition for a Gap Year. As a consumer of Gap year option, be sure to completely understand and question the contracts, student engagement requirements and policies pertaining to a breach of expectations. Do not entertain gap year options if you question the 18+ year old’s ability to manage any meds, an understanding of what he needs for success or if he or she struggled to finish high school or make it to school on time.
Another conversation is college readiness in general. I will leave you with results of a 2015 US News & World Reports study: at 1800 surveyed colleges and universities, 1 out of 3 college freshmen did not return for their sophomore year.
This blog was read and reread by many program directors, owners at all levels, therapeutic consultants and professionals who have experience with all the levels of care. I would like to thank all of them all for taking the time.
And to the young adult who may be reading this, your 20’s may be harder than your teenage years. There is no hurry to get through these steps, trust me, it is just work, loans, and your family raising the bar in terms of what their expectations are of you. Take your time, find your path and your recovery.