Original Publication: October 28th, 2014 – Last Updated — February 9th, 2018
The short answer is: it depends on the state and how the state licenses residential programming. There is no national standard and each of our fifty states have the responsibility to set their own licensure requirements for private-pay residential programming; many states divide up the enforcement between numerous governmental departments and some states do not even regulate private-pay residential care. The scope and specifics of state regulations vary greatly, and some states do not require independent licensure at all.
What these programs all have in common is that they are all addressing physical, emotional, behavioral, familial, social, and intellectual/academic development; it is how that is addressed which differentiates between the TBS or RTC.
Many of the associations like National Association of Therapeutic Schools and Programs (NATSAP) and Wilderness Therapy’s OBH Council require their members to be licensed by their state, but not all states provide the license. Most associations do not require the additional accreditation like, Joint Commission or Council on Accreditation (COA) certification or CARF, however, many treatment options choose to achieve the higher accrediting bodies standards to gain an additional type of oversight..
The label “Therapeutic Boarding School” might be a license provided by a state or might just be a way of a program differentiating itself in the marketplace. This is why the labels do not exist except in definition on www.allkindsoftherapy.com – because a TBS or RTC in Montana or New Hampshire or Utah has different requirements by the state, so when you examine options look beyond what you see in the marketing material or in the name. You may – or may not – be comparing apples to apples — there are very many variations. Yes, it is exhausting.
Let’s start off with a couple of definitions:
Residential Treatment Centers can generally be described as behavioral and emotional support, but to end with that is to limit the breadth and depth of their programming to reach either the population (diagnosis(es) they serve) or minimize how they effect change for teens and families. In lay terms, residential treatment programs serve clients who are clinically more complex than a TBS. There are varying levels of RTC’s around the United States and a family can see the difference based on how the RTC secures their setting — ie locked vs. staff secure, suburban vs. rural and so on. (Hint: these are some of the questions/facts that are asked of advertisers on this website so the user can being parse out differences.) Additionally, most RTC’s today have accredited high schools as a major part of the client’s day in treatment, while the client is also receiving physical, emotional, behavioral, familial and social supports 24/7.
Therapeutic Boarding School generally denotes an educationally focused milieu, where therapy (individual, group and family) is more focused on intellectual/academic development, while the student is receiving integrated physical, emotional, behavioral, familial, social supports.
(Previously, the term “Emotional Growth Boarding School,” which started in the 1980’s, was used in parallel to Therapeutic Boarding School for decades. That has changed in recent years. Most of the Emotional Growth Schools have either closed or rebranded to reflect major programmatic changes to reflect therapy, because the industry best practices have evolved past their original model – that is a blog for another day).
The key for parents who are reading this blog is that the delineation between RTC’s and TBS’s may be as simple as a state regulation, or as complex as describing the varying approaches to emotional development and behavioral needs of clients. Ideally, they each have admissions approaches that can assist families in evaluating the alignment between client needs and programmatic supports – and can clearly articulate their unique level of care.
The following chart can serve as a starting point for understanding the varying levels of support among therapeutic options. Not every program fits cleanly into a specific category, but this can serve as a starting point for understanding key differences. Asking questions of specific programs is the best way to understand their level of care.
Residential Treatment Center (RTC – locked)
Residential Treatment Center (RTC – staff-secured)
Therapeutic Boarding School (TBS)
Contracted & part of the treatment team
Contracted, not always part of treatment team
Length of Stay (months)
weeks to about
9 -12+ months
12 to 24 months
Average Caseload for licensed therapist
8 – 18+
30 – 40
20 – 60
Group/Individual/Family/ Experiential Therapy Hours per week (facilitated by licensed therapist)
12 – 18
4 – 6+
Clients come into treatment from
Home, Acute hospital
Home, Acute hospital, wilderness therapy
Where clients graduate to
Matriculate to home, some or additional therapeutic placements
Many graduate to home or traditional schools (with supports), or additional lower level treatment placements placements
Most graduate to home or traditional schools (with supports), or additional lower level treatment placements placements
Clients with emotional or physical behavior necessitating direct oversight/intervention
Staff to Student Ratio
1:4 or less
1:6 or more
(*General guidelines because this is state regulations and program treatment approaches vary widely)
How do I decide what level of residential care that my child needs?
Short answer: Ask a professional.
If you are investigating online and comparing treatment options look at the following which the advertisers on this website have to answer.
Therapist to student ratio
Staff to student ratio
Visit the location,
Compare the model and your child
Inquire about the approach when it is not a perfect fit. Ask for specifics and examples.
Here are a bunch of questions from a previous blog.
How do you compare treatment programs between states?
Communicate with the state licensing body, if one exists.
Ask the state for their latest review and if the program has ever had a violation or restriction against its license.
Ask what the state requires in terms of communication with parents. Different states require different types of communication with family. Some states grant parents the right to enroll a teen until they are 18 years old and other states require teens participate voluntarily after their 14 or 16th birthday. Most state licensing agencies will direct you to the actual form their auditors use (for example, here’s Utah’s “Residential Treatment Rules Checklist)
To Visit or Not To Visit? Not Even a Question!
Making a placement for a child or teen can be an incredibly wrenching, significant decision for a parent to make, and usually feels extremely urgent, as well. When you are making this decision ask questions, visit, and verify for yourself.
Many families use therapeutic consultants for their process and even if you do, you are missing an opportunity by not visiting yourself. In the end of a day there is no perfect program – and if your teen is struggling then knowing who the person is on the other end of the phone a time zone or two away is invaluable (even when you have a consultant). You are making a decision that will impact your whole family and you have to trust the people who you have entrusted your teen to. You have to know that the staff, teachers, therapists, and administrators care for your teen and want what is best for him/her. If you do not trust the program you should keep your kiddo at home; your distrust will undermine the process and waste your money. Websites are pretty interactive these days (this one included), but they do not take the place of a visit. You should see with your own eyes the features that you think are important and meet the staff or therapist.
Generally, programs will allow you time with their students without a staff or therapist in the room, as long as you respect program obligations to their current families’ privacy and do not seek information about the students directly. If you meet with current students find out how long each student has been in the program. You must not ask the students why they are at the program, or inquire about potentially identifiable information (last names, home town, etc.). You may ask if they completed a therapeutic wilderness program as this gives you some context for their answers and also provides some ability to understand an appropriate placement.
Different programs have different “feels” to them – they have different types of populations, they have different features (horses, gardening, recreation therapy, community service – ask how many students participate in these events, and with what regularity, to differentiate between “programming” and “marketing”). The usual routine and how they interact with kiddos is different. It can be quite helpful to have a therapeutic consultant guiding you through the exploration process. Ask them questions – and then visit. You are about to entrust your child/teen to someone outside the home, for a significant amount of time. Didn’t you visit your college or university before you went? Just because you are in the crisis does not mean you skip the most important step.