Beyond Weekly Therapy: Options for a Teenager in Crisis
It still makes me anxious to think about that day. I think it was a Wednesday afternoon, fall, 2018 in our hometown of Greenville, SC.
Something sent my 17-year-old son into a tailspin. His anxiety and depression was so bad at that point it could have been anything
While his dad and I stood at his bedroom door, he picked up a heavy wood-framed chair and threw it against his bedroom wall, knocking a huge chunk of plaster out and onto his bed. And without hesitation he then picked up his golf bag full of clubs and threw it -followed by the X-box controller he hurled in our general direction
The next thing I remember happening was him yelling and screaming and heaving the free-standing kitchen island, with a 4-inch-thick heart-pine top, over on its side.
My husband and I knew we had to make a decision that day – one we’d been dreading and putting off. We had to do something to get him more serious psychiatric help.
That’s what I want to talk to you about today – what to do when you know your child needs serious psychiatric intervention.
Unfortunately, since 2020, it’s even more likely that you may need this information - our kids are suffering – they were before the pandemic but it’s so much worse now.
So, in this episode I’ll explain the most common options for adolescent treatment programs and services, why one option might be considered over another, how to choose the specific program or facility - all the things I had no clue about when I began that journey. Stay with me.
You’re listening to Speaking of Teens, a weekly show to help you better understand and parent your teen or tween.
I’m Ann Coleman, and after surviving a couple of difficult years with my teenage son, I decided to make the leap from practicing law into the science of parenting teens and tweens. I want to make sure you have the skills I was sorely lacking.
That day certainly wasn’t the first time he’d been out of control. He’d knocked holes in every solid wood door in the house, in the walls, dinged in the hardwood floors - but that day was next level - his intensity and desperation were scary.
His anxiety and depression had been off the charts for months, he’d talked of “not wanting to be here anymore”, he’d acted out in all sorts of risky ways and all attempts at counseling and medication had failed.
Just days before, his psychiatrist and counselor had thrown up their hands and said there was nothing more they could do. He needed intensive in-patient help.
So, on that beautiful sunny day in September, my husband and I both walked out of the house, leaving him behind to rant and scream at the walls. And through tears, my husband gave me the go-ahead to call 911. We were terrified.
We didn’t want to do it, but we’d learned, after taking him to the ER before (when he felt like the “world was ending”) and they hadn’t admitted him, there are particular words and phrases they look for.
So, I now knew that if I called the police and convinced them he was “a danger to himself or others” he’d have a much better chance at being admitted – at least in our area.
A couple of understanding officers went into the house alone, talked to him, and walked him outside to a waiting ambulance. They told us he’d be taken to the ER, where the staff there would evaluate him and decide how to help (in other words, determine if he should be placed in an adolescent psychiatric hospital).
It was too late to change our minds now. We both had mixed feelings about taking such a drastic step, but we knew we had no other choice. We’d run out of options.
Hours later, in the ER, once they’d decided to admit him to a psychiatric hospital, they told us there was not a spot available for him in Greenville, nor in the entire 10-county area of the “Upstate of South Carolina”.
Unfortunately, this is the case in most areas of the US and around the world. There’s literally a global shortage of both mental health clinicians (psychiatrists and psychologists) and beds for adolescent psychiatric care. I’ll get into this more in a later episode, but the situation is truly dire. You likely already know this if you’ve needed to make an appointment with a psychiatrist or psychologist and had to wait 6, 9 or 18 months or more to get in.
So, anyway, after a night in the ER, they sent our son to an adolescent psychiatric hospital in Columbia, South Carolina, (an hour and a half away) where he stayed for around 5 days, while I desperately tried to figure out what residential treatment center he would enter when he was released. I guess you could say I learned to swim by being thrown in the deep end.
Well, today, I hope to save you from the near-drowning experience I had. I want you to be familiar with the lingo and timelines and potential roadblocks - the things you need to know if you ever need to make the decisions I had to make.
What if your child needs more help than typical outpatient counseling can provide? I hope that never happens, but as I learned the hard way, it’s better to be prepared and not need it… than need it and not be prepared.
Let me be clear now - I’m not a mental health professional. I’m an attorney and the mother of a 21-year-old who experienced some issues with his mental health and substance abuse in his teen years. I’ve researched it, I’ve lived it, I learned A LOT and we not only got through it, but my son is doing really well now.
So, let’s get to it - how do you even know if your child needs more than counseling or therapy with an individual provider? This is probably one of the hardest parts. I think it’s easy to be in denial - to keep hoping and praying and delaying the inevitable. But I also think we know in our heart when it’s time – it can be pretty obvious.
If your kid’s not making any progress or they’re spiraling out of control after weeks or months of therapy, it’s time to talk to the counselor, (and the psychiatrist if they’re seeing one). You may even consider having them evaluated by a psychologist if that’s possible. Let these professionals know what’s going on at home, at school, with friends.
If their emotions are out of control, if they’re getting in trouble at school, at home, with the police, they’re being aggressive, belligerent, doing drugs - whatever it is, tell them your concerns and get their advice.
Here’s the bottom line: none of these people live with your child. They see them and talk to them for a snippet of time. So, even if they haven’t recommended more serious help, remember, they don’t have the advantage of seeing what you see, of knowing your child like you do. If your gut tells you it’s time to for some intensive help - if you’re afraid for them - then it probably is.
On the other hand, your child’s clinician or counselor may even suggest before you do, that they’ve done all they can do and that your teen or tween needs more help than they can give.
And then again, you may be in the situation where your child is struggling but they refuse to see a counselor or speak with anyone…or they’re suddenly in crisis mode with no warning at all.
Regardless of the exact situation, you’re going to have to accept a few things:
- your child needs more advanced care than they’re getting
- it’s going to stressful but it’s also going to be a relief that they’re getting the help they need
- your kid is probably not going to be happy about any of this – prepare to listen to them, acknowledge their feelings and let them know that you understand how they feel but that they need more help to get better and to feel better…that you love them more than anything and that you’re doing what you can to help them.
- Keep reminding yourself that you’re doing this to insure your child’s safety and wellbeing…and that despite their protests, it must be done.
So, what are your options for a higher level of care than weekly counseling? Heck, what does “level of care” even mean? And what other terms do you need to be familiar with?
“Level of care” simply refers to the intensity of the services or treatment provided to the patient. The level of care is meant to match the patient’s needs. For example, you wouldn’t need to hospitalize a kid who’s having minor issues with social anxiety - you’d likely send them to a counselor once a week. Likewise, you wouldn’t send a kid to weekly counseling who’s experiencing so much anxiety that they’ve refused to leave the house for 5 days and have spent every day in the bathroom crying and throwing up.
Generally speaking, basic talk-therapy, weekly counseling, group therapy alone or combined with psychiatric oversight and medication are the lowest levels of care provided by mental healthcare professionals.
Also, before discussing these potential options, a couple of other terms commonly used are inpatient and outpatient. Inpatient simply means somewhere a patient stays overnight and outpatient is when you go back and forth for treatment and stay at home.
So, let’s start with the highest level of care – that’s hospitalization, which may mean an adolescent psychiatric unit of a regular hospital or a stand-alone facility. Now, these separate facilities aren’t always associated with your local hospital, and most don’t even use the term “hospital”. They may be called “behavioral health inpatient facility”, “inpatient psychiatry” and have a name like Smith Center for Behavioral Health.
But if you Google something like “adolescent inpatient psychiatric hospital”, these facilities will come up. And to make sure you have the right place, look for terms like “crisis” and “stabilization” and “short-term”.
If you have time (and a cooperative teenager), you could actually call these local centers first and see if they have a bed available and many will allow you to bring them directly there for an evaluation and if they decide they need to be admitted they will do so right then.
But in most situations, the ER of any hospital is probably the safest way. And because spots are so rarely available, it appears to be the best way to make sure your child is cared for and is prioritized for admission.
And there are at least 3 situations that you can’t hesitate to get them to the ER or call 911:
- If they’re considering, talking about, or threatening suicide,
- If they’re threatening to hurt you or someone else, or
- they’re in a state of psychosis, hallucinating, delusional
For example, in our son’s case, he was in a fit of rage, being destructive and aggressive. And besides that, it had reached the point where we felt he was going to end up hurting himself, someone else, going to jail or ruining his life in some way.
We couldn’t communicate anymore, he was miserable, we were miserable, the outpatient professionals couldn’t do anything else, and we felt we had no other choice…even though, in that moment he was not literally threatening to kill himself or hurt us and was not in a state of psychosis.
Now, if you can get your child to go to the ER with you, that’s great. But, if you can’t, you’ll need to call 911, tell them the situation and ask for an ambulance or the police (if they require that first). If you see this possibly on the horizon then go ahead and speak with a mental health professional, or the police station or someone who works in the ER and ask them the best way to insure admission.
I’m certainly not giving you mental health or legal advice here, but in my own personal experience, getting the assistance you need may require you using language that clearly indicates that your child is “a threat to themselves or others”…you may even be able to use those words without ever being any more specific.
I’ll also mention again, that because of the shortage of beds in facilities for adolescents, there may be a very long wait for admission…days or even weeks in some areas of the US is the norm…and even then, they could be sent to stay in a facility miles from home.
This is another good reason to reach out and talk to people in your community in advance of an emergency. Find out about the availability of beds, where they are, how long the wait could be, what route you should take to secure one for your child.
Let me tell you what you should and shouldn’t expect from your child’s stay. First of all, the hospital is really just a band-aid. It’s a short-term crisis intervention meant to stabilize your child, check, or prescribe new medication, get them through the crisis and discharge them. That’s it.
A typical stay is anywhere from 3 to 7 days but they could be there 1 night or for several weeks depending on staff recommendations and your insurance provider determining that there’s continuing medical necessity for the stay.
Insurance is always crucial - and that’s a whole other episode - but your insurance company is another call you should make as soon as you have an inkling that hospitalization could happen in the future.
Now, while your child is there – again for probably just a handful of days – they are very unlikely to receive a full-scale psychological evaluation. The facility’s psychiatrist will meet with them and do their own clinical evaluation (even if your child is currently seeing another psychiatrist). They’ll take a look at the medication they’re on, make adjustments or prescribe a new medications.
The kids in most facilities attend group therapy or support groups - they may even have one-on-one counseling. And, if time allows, you may receive family counseling.
Also, know the facility will be secure (or locked) and there will be strict rules about what your kid can have there with them - even what they can wear (for example, they’re not allowed to wear anything with strings or have belts because they could be used to hurt themselves). There will be rules about when you talk to them, when you can visit, how long you can stay. It’s a lot to wrap your head around – but just remember, all of this is to protect your child, and you’ll have plenty of opportunities to talk to the staff there to have your questions answered.
(I have some links in the show notes that go into more detail about hospitalization like what questions to ask and how you can deal with it all. That’s neurogility.com/7).
So, probably after a few days, when your child is deemed stable, they’ll be discharged. Again, remember, this is crisis stabilization – a short-term solution to get them over the hump and move them on to a step down or lower level of care where they can continue their treatment. It can feel really rushed but the staff usually starts talking to you almost immediately upon admission about their discharge and what happens next. A seamless transition to the next step in treatment is critical. Any lag time in between could be a disaster for your child.
Now you may also be coordinating with your child’s therapist, or other clinicians as well so you could be receiving all sorts of advice and recommendations for further treatment. And the problem is having the time to weigh your options, get other opinions and do the research. Which is why I think it’s important to at least be aware of these issues in advance.
So, let’s look at a few of these lower levels of care your teen might transition to after discharge from the hospital.
Technically, your child could be discharged with recommendations for any number of lower levels of care, including just regular weekly counseling or therapy, but that wouldn’t be typical. And if the child’s therapist was involved in the decision to hospitalize, then they’re probably not going to suggest that either.
If an adolescent is experiencing major issues with their mental health, like suicidal thinking or a suicide attempt, or they’ve been diagnosed with a severe mental illness like schizophrenia, has an eating disorder or substance use disorder, then most therapists I’ve spoken to recommend they go directly into a Residential Treatment Center or “RTC”.
An RTC is also an inpatient treatment facility but differs from a psychiatric hospital in many ways. An RTC is normally set up more like a residence than a hospital (hence, the name). They’re often literally in a house. Most RTC’s offer individual therapy, group therapy and even experiential therapy for the kids (like yoga, art, music) and family therapy.
It's also not necessarily always the case that an adolescent must come directly from a psychiatric hospital to be admitted to an RTC. It’s possible to have them admitted without having been hospitalized first and can hinge on whether you’re using your insurance to pay the RTC and whether the RTC is contracted with insurance company.
If you’re using insurance, then you’ll need to start coordinating between the insurance company and the RTC and before making any solid plans. If the RTC accepts insurance, they’ll have an entire department that can work on this for you and figure out medical necessity. Insurance is one huge area in which hospitals and RTCs differ – hospitals almost universally accept insurance and many if not the majority of RTCs do not.
The insurance issue alone is really complicated so I’ll not get into the weeds with it today – but if there’s enough interest, we could discuss it – along with mental health parity laws - in a future episode. Let me know what you think.
So, one of the main issues critics have with RTCs is that unlike hospitals, there are no federal laws or regulations that govern the programs they operate. They are required to adhere to HIPAA and payer rules if they accept payment from the federal government. But as far as how they operate, who they employ, the rules for how they treat your kids - that’s all governed by state law - and these laws couldn’t be more diverse.
Now, there are national quality programs like the Joint Commission, that will accredit an RTC if it meets their set standards. But not all of them do (not all of them even apply)…which does not mean they can’t operate and call themselves an RTC as long as they follow state law.
And state law includes licensing by a state agency, which would require the RTC to jump through certain hoops…but it’s those hoops and the oversight and enforcement provided for these hoops that make it really difficult for parents to fully trust they’re choosing the right RTC.
And many groups, including the American Academy of Child and Adolescent Psychiatry have a real problem with this and would like to see all RTC’s not only be accredited by the Joint Commission but to adopt additional standards they published back in 2010.
Now, there’s no doubt there are many residential treatment centers that are not even accredited by the Joint Commission, so they certainly don’t meet AACAP’s proposed standards. As a matter of fact, most wilderness programs are not accredited by The Joint Commission, but you will see various other “accreditations” on their websites. It’s up to you to understand those accreditations and what they really mean. By the way, a “boot camp” is not the same as a wilderness program – many psychologists and counselors endorse wilderness programs but do not feel the same about boot camps.
But because it is a bit of the wild west out there, you have to do your homework. There have been plenty of lawsuits and state and federal investigations launched into RTCs, boot camps and wilderness programs across the country. The fact is you can find negative information online about almost any program you look into for your child. Again, do your homework as far in advance as possible. I know it’s difficult but if the thought has crossed your mind and you’ve made it this far in this episode, then it’s not too early to research.
I suggest contacting every mental health professional, school counselor, or pediatrician you know to get recommendations. The only thing is, in my experience, most of these folks know very little about specific facilities or programs. But they may be able to put you in touch with another parent or professional that can help. Of course, if you already know someone who had a child in an RTC or wilderness program, talk to them about their own experience.
And, here again, we hit the issue of insurance. One of the biggest deciding factors for you may be whether the RTC program accepts your insurance. It certainly was for us. Many residential treatment centers don’t accept insurance…so it’s all self-pay. They’ll give you ideas on where to borrow the money and they’ll give you a bill you can submit to your insurance company to try and get reimbursement but that’s about it.
There are also some really well-regarded RTCs that do accept insurance though. And, by the way, they do not have to be in your state of residence to accept your insurance. My son was in California, we had South Carolina insurance and they paid $2,000 a day for his stay – we owed less than $1,500.00 at the end of 2 months. So, don’t assume – pick up the phone.
Not surprisingly, wilderness programs are not even covered by insurance. They generally deny coverage based on the experimental or unproven nature of the programs. But there are many people and organizations working to change this.
Now, be careful out there Googling these RTCs and wilderness programs they are very predatory in their advertising and will stalk you like crazy all over the web. If you’re going to search, the best place to start is All Kinds of Therapy.com. It’s founder Jenney Wilder was an educational consultant and doesn’t take ad money or kickbacks from the residential treatment centers and allows you to search and compare them according to different factors like what disorders they treat or whether or not they take insurance. So, you can check that out for sure.
And, speaking of educational consultants, that may also be an option for you if you can afford it. You may also hear them referred to as therapeutic consultants or behavioral health consultants. They’re really sort of a branch of consultants that used to just help parents find the right schools for their kids (like boarding schools, prep schools and colleges) but these guys focus on just RTCs, and other treatment programs and even therapeutic boarding schools.
So, if you can find an independent consultant (one with no ties or kickbacks from the RTC) then they can be well worth the money because they work for you to sort through and find the right fit for your teen. They’ve been to many of these places and toured them, met the staff there, spoken to parents and can be a wealth of knowledge. Again, ask other parents and professionals for a referral for an educational consultant.
One thing I can tell you is that if your child goes into an RTC, no matter where they end up, there will be things that frustrate you, things the he or she despises, things they get wrong. You just have to stay on top of everyone and educate yourself, stay in constant communication with the clinicians and staff. You are still your child’s best advocate. Trust your instincts.
Not long at all into my son’s stay at the RTC the psychiatrist called me to tell me she had diagnosed him with bi-polar disorder. Now, as far as I understood at the time, she had met with him maybe twice for 30 minutes at most. He’d been evaluated by an adolescent psychologist and had been seen by 2 adolescent psychiatrists before going to the RTC and had never been diagnosed bi-polar or even suspected to be bi-polar. So, I was a bit skeptical - but then again, I’m not a psychiatrist.
So, I got online and started reading scientific studies on adolescent bipolar disorder and realized there was one particular scientist who’d been involved in most all of them. He’d actually written on the subject, (which has been translated in 8 languages), so I read that. I still wasn’t thoroughly convinced about this diagnosis. This fellow was a professor at very highly regarded university in California, which was an easy drive from where my son was in treatment. So, I found his number and called this world-famous psychiatrist and begged him for an evaluation. Several weeks later my son was sitting in his office. Long story short - he does not have bipolar disorder.
Now, the point of that story is not to say, “don’t trust RTCs or psychiatrists at RTCs”. My point again, is that you are still going to need to advocate for your son or daughter even when they are in the care of professionals. Everyone makes mistakes and everyone can be questioned and challenged if necessary. You just can’t take anything for granted – that’s all.
But even with that misdiagnosis and having him furious with us for most of his stay - sending him to that RTC did change everything. He was removed from the kids he was doing bad stuff with. He was removed from the house where we’d been embroiled in stress and anxiety and arguments and negativity for so long. He was in California, where he’d never been before. We had a wonderful family therapist, he had an individual therapist, a drug counselor, attended group therapy daily, did online school. And bonded with a bunch of boys with many of the same issues from all over the country.
And as much as he claimed to hate it there, when he got back home (which was now AL instead of SC – we moved while he was there!), he talked about it all the time. You know so and so from the RTC, he made this great cornbread muffin… Yeah, we did that at the RTC, this guy would… That was 2 months at the end of 2018 and he’s still in touch with some of those kids.
So, I think the sudden change in scenery, people, activities was enough to knock him off the course he was on and throw in the therapy and guidance at the RTC, combined with the new parenting skills we learned through self-study - it all just coalesced in the right way to lead him to a much healthier place thank goodness
So, I could do an entire episode on Residential Treatment Centers and probably will in the future, but that should give you a good idea of their place in the continuum of care, what you need to consider and how well you need to do your homework.
So, let me review so far:
If your child is in imminent danger of harming themselves or others or experiencing a severe psychological crisis – a psychiatric hospital or psychiatric unit of a hospital via the ER is the best bet.
If they’re in crisis but not to that extent, then you may choose to skip the hospital and have them admitted to an RTC.
But there are several other options for lower levels of care that might be an alternative for your teen if, even though they’re in crisis, you and their counselor or psychiatrist (whomever you consult with) decide they’ll be staying at home – the 2 most common are:
- A partial hospitalization program or “PHP” or
- An intensive outpatient program or “IOP”.
If your child does end up in the hospital or an RTC you will no doubt hear these terms thrown around during their stay because they’re both also considered “step-down” programs from inpatient stays at the hospital or RTC. In other words, less intensive – mainly because they’re outpatient.
A PHP (partial hospitalization) is the higher level of care of the two (the more intensive). PHP is sometimes referred to as “day treatment” or “therapeutic day program”, depending on the facility offering the program. That’s because all these programs aren’t necessarily affiliated with a hospital. As a matter of fact, some residential treatment centers offer PHPs and IOPs as well.
In a PHP your child would be at home – it’s outpatient – but they would be at the facility all day, which depending on the facility, is generally around 5 to 7 hours, and they go 5 days a week - it’s basically like going to school. And school or academics is one thing these programs do address. Some may coordinate with the school, but others could do more of an online substitution. After COVID, there may even be better options.
Every PHP is going to be different but in general you can also expect medication management, group and individual counseling, experiential activities like art, music, yoga…there may even been parent support groups.
A PHP is considered a short-term treatment program, but the actual length of time spent in the program could be just a few weeks to several months depending on the child and their particular needs and progression. Of course, staying in a program is not mandated by anyone so it’s very much up to the family after getting any recommendations. Some facilities even have various levels of PHP. All of this is very facility-specific so, again, your homework is crucial to finding the right program.
And I’ll just keep emphasizing that if you’re using any program where you’re dependent upon insurance benefits, then everything is going to hinge on their decision about medical necessity and whether they’ll pay. So, always pick up that phone first. And actually, I say pick up the phone because I’ve found that these facilities and programs don’t do a very good job of discussing insurance on their website. If they don’t mention insurance at all, you can probably bet they don’t accept it.
The other most common option for a lower level of care than the hospital or an RTC is the Intensive Outpatient Program or IOP (you may also hear this referred to as IOT for intensive outpatient treatment)
The IOP is considered a step down from the PHP and is obviously also a step-down from the hospital or RTC. Your teen may also be a good fit for an IOP if they simply need to step up from traditional weekly therapy or counseling.
Often so much is lost between weekly sessions, and an hour a week is not much if your teen is really struggling – they may benefit by ramping up the frequency or intensity a bit. There are IOPs for issues like gaming and technology, anxiety, depression, mood disorders, attachment issues, and for even substance use disorder if detox isn’t necessary – if they’ve already been through detox at a higher level of care. IOPs are outpatient, so your kid would be at home. And generally, treatment is in the afternoon after school, usually around 3 hours a day, 3 days a week. Depending on the program there could be group, individual and family therapy, support groups, classes on life or social skills, medication consulting and even parent support or coaching. And since COVID, many places are still conducting virtual IOPs.
But here’s the problem with PHPs and IOPs; they’re pretty easy to find for adults but not so easy to find for adolescents. They mostly seem to be located in larger cities and metropolitan areas. If you do a Google search, all the ads you see will say they “serve your area” but that doesn’t mean they’re actually IN your area. The same goes for the Psychology Today website. For each listing, over to the right, it will say “We serve” and name your town or one near you. But when you go to their individual listing, look at their address, they’re likely at least a state away.
This is one of the main reasons we ended up with our son just in weekly counseling after leaving residential treatment. There were absolutely no options for IOP or PHP where we had lived in South Carolina or where we moved in Alabama.
If you can afford to somehow make it work financially and logistically, you could rent a place near an IOP or PHP and stay for weeks or months on end…and I’ve actually known people to do just that. But jobs, other kids and money make it impossible for most of us…it was certainly not feasible for us.
So, we just hoped that by moving to Alabama and staying away from the memory-triggering environment he’d been in, that he stood a better chance. And as it turns out, it was the right decision.
Keep PHPs and IOPs in mind for stepping up from regular weekly therapy or for stepping down from hospitalization or an RTC. Talk to your child’s therapist, psychiatrist, psychologist to determine the level of care your child needs. Then talk to them about where you should go, get input from other parents if you can. Do your homework on your insurance and if you can’t figure something out, let me know, I’m happy to point you in the right direction.
Trying to make a decision about whether to put your child in the hospital, residential treatment or to just bump up from counseling - it can be brutal - and on top of that, trying to figure out which one - it’s confusing, and it can feel completely overwhelming.
But remember why you’re doing this; your child needs you and you’re stepping up to the plate. You’ll figure it all out if you need to - because you’re a fabulous mom and you you’re your kids more than anything. And I know you can do it. But please, don’t go through it alone. Find someone who’ll support you, who won’t judge or shame you (and steer clear of anyone who does judge or shame). Find your own counselor or coach or even an educational consultant - someone who gets it. And you can always reach out to me if you need anything.
Speaking of Teens is the official podcast of neurogility.com, an organization I started to educate other moms and adolescents about emotional intelligence.
You can go to neurogility.com (SPELL IT OUT)/7 for this episode’s show notes (with lots of links and resources).
Thank you SO much for listening – I hope I helped you in some way!
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Thanks again – see you same time next week!