Alternatives to Long-Term Residential Care Programs

MDFT is a family-based treatment for adolescent substance use, delinquency, and other behavioral and emotional problems. Therapists work simultaneously in four interdependent domains: the adolescent, parent, family, and community. Therapy sessions are held alone with the youth, alone with the parents, and with youth and parents together. Once a therapeutic alliance is established and youth and parent motivation is enhanced, the MDFT therapist focuses on facilitating behavioral and interactional change. The final stage of MDFT works to solidify behavioral and relational changes and launch the family successfully so that treatment gains are maintained.

Multisystemic Therapy (MST) is an intensive family and community-based treatment for serious juvenile offenders with possible substance abuse issues and their families. The primary goals of MST are to decrease youth criminal behavior and out-of-home placements. Critical features of MST include: (a) integration of empirically based treatment approaches to address a comprehensive range of risk factors across family, peer, school, and community contexts; (b) promotion of behavior change in the youth's natural environment, with the overriding goal of empowering caregivers; and (c) rigorous quality assurance mechanisms that focus on achieving outcomes through maintaining treatment fidelity and developing strategies to overcome barriers to behavior change.

TFCO-A (previously referred to as Multidimensional Treatment Foster Care - Adolescents) provides foster care treatment for children 12-17 years old with severe emotional and behavioral disorders and/or severe delinquency. TFCO-A aims to create opportunities for youths to successfully live in families rather than in group or institutional settings, and to simultaneously prepare their parents (or other long-term placement) to provide them with effective parenting. Four key elements of treatment are (1) providing youths with a consistent reinforcing environment where they are mentored and encouraged to develop academic and positive living skills, (2) providing daily structure with clear expectations and limits, with well-specified consequences delivered in a teaching-oriented manner, (3) providing close supervision of youths' whereabouts, and (4) helping youth to avoid deviant peer associations while providing them with the support and assistance needed to establish pro-social peer relationships. TFCO also has versions for preschoolers and children. Treatment Foster Care Oregon for Preschoolers (TFCO-P) is rated separately on this website. Treatment Foster Care Oregon for Children (TFCO-C) has not been tested separately, but has the same elements as TFCO-A except it includes materials more developmentally appropriate for younger children.

FFT is a family intervention program for dysfunctional youth with disruptive, externalizing problems. FFT has been applied to a wide range of problem youth and their families in various multi-ethnic, multicultural contexts. Target populations range from at-risk pre-adolescents to youth with moderate to severe problems such as conduct disorder, violent acting-out, and substance abuse. While FFT targets youth aged 11-18, younger siblings of referred adolescents often become part of the intervention process. Intervention ranges from, on average, 12 to 14 one-hour sessions. The number of sessions may be as few as 8 sessions for mild cases and up to 30 sessions for more difficult situations. In most programs, sessions are spread over a three-month period. FFT has been conducted both in clinic settings as an outpatient therapy and as a home-based model. The FFT clinical model offers clear identification of specific phases which organizes the intervention in a coherent manner, thereby allowing clinicians to maintain focus in the context of considerable family and individual disruption. Each phase includes specific goals, assessment foci, specific techniques of intervention, and therapist skills necessary for success.

RRFT is an integrative, ecologically informed, and exposure-based approach to addressing co-occurring symptoms of PTSD (and other mental health problems), substance use problems, and other risk behaviors often experienced by trauma-exposed adolescents. RRFT is novel in its integration of these components, given that standard care for trauma-exposed youth often entails treatment of substance use problems separate from treatment of other trauma-related psychopathology. RRFT is individualized to the needs, strengths, developmental factors, and cultural background of each adolescent and family. The pacing and ordering of RRFT components are flexible and determined by the needs of each family and symptom severity in each domain. Substance use (as relevant) and posttraumatic stress (PTS) symptoms are monitored throughout treatment to help track progress and guide clinical decision making. The average frequency and duration of RRFT depends on the symptom level of each youth, but typically involves 18-24 weekly, 60-90 minute sessions with periodic check-ins between scheduled appointments.

TFCO-P (previously referred to as Multidimensional Treatment Foster Care for Preschoolers) is a foster care treatment model specifically tailored to the needs of 3 to 6-year-old foster children. TFCO-P is designed to promote secure attachments in foster care and facilitate successful permanent placements. TFCO-P is delivered through a treatment team approach in which treatment foster parents receive training and ongoing consultation and support. Children receive individual skills training and participate in a therapeutic playgroup, and family of origin (or other permanent placement caregivers) receive family therapy. TFCO-P emphasizes the use of concrete encouragement for prosocial behavior; consistent, nonabusive limit-setting to address disruptive behavior; and close supervision of the child. In addition, the TFCO-P intervention employs a developmental framework in which the challenges of foster preschoolers are viewed from the perspective of delayed maturation.

CARE: Creating Conditions for Change (3rd edition) is a principle-based program designed to enhance the social dynamics in residential care settings through targeted staff development, ongoing reflective practice, and data-informed decision-making. Using an ecological approach, CARE aims to engage all staff at a residential care agency in a systematic effort to orient practices in order to provide trauma-informed and developmentally enriched living environments and to create a sense of normality for children and young people. CARE is organized around six principles related to attachment, trauma, resiliency, and ecological theory. The principles state that child care practices must be:

• Relationship-based
• Trauma-informed
• Developmentally focused
• Competence-centered
• Family-involved
• Ecologically oriented

Cornell University CARE consultants follow a standardized set of steps to train and support staff over the 4-year implementation period. An essential activity is the formation of a local Implementation Team with multilevel representation that provides support, modeling, and mentoring to staff at all levels as they incorporate CARE principles into their work. This approach is designed to cultivate personal investment and ownership among all staff levels at the agency

Dialectical Behavior Therapy (DBT) is a cognitive-behavioral treatment that was originally developed to treat chronically suicidal individuals diagnosed with borderline personality disorder (BPD). The four skills modules include two sets of acceptance-oriented skills (mindfulness and distress tolerance) and two sets of change-oriented skills (emotion regulation and interpersonal effectiveness).

Components of DBT:

• There are four components of comprehensive DBT: skills training group, individual treatment, DBT phone coaching, and consultation team.
• DBT skills training group is focused on enhancing clients' capabilities by teaching them behavioral skills. The group is run like a class where the group leader teaches the skills and assigns homework for clients to practice using the skills in their everyday lives. Groups meet on a weekly basis for approximately 2.5 hours and it takes 24 weeks to get through the full skills curriculum, which is often repeated to create a 1-year program. Briefer schedules that teach only a subset of the skills have also been developed for specific populations and settings.
• DBT individual therapy is focused on enhancing client motivation and helping clients to apply the skills to specific challenges and events in their lives. In the standard DBT model, individual therapy takes place once a week for approximately 60 minutes and runs concurrently with skills groups.
• DBT phone coaching is focused on providing clients with in-the-moment coaching on how to use skills to effectively cope with difficult situations that arise in their everyday lives. Clients can call their individual therapist between sessions to receive coaching at the times when they need help the most.
• DBT therapist consultation team is intended to be therapy for the therapists and to support DBT providers in their work with people who often have severe, complex, difficult-to-treat disorders. The consultation team is designed to help therapists stay motivated and competent so they can provide the best treatment possible. Teams typically meet weekly and are composed of individual therapists and group leaders who share responsibility for each client's care.

The Sanctuary Model® is a blueprint for clinical and organizational change which, at its core, promotes safety and recovery from adversity through the active creation of a trauma-informed community. A recognition that trauma is pervasive in the experience of human beings forms the basis for the Sanctuary Model's focus not only on the people who seek services, but equally on the people and systems who provide those services. Sanctuary has been used in organizations that provide residential treatment for youth, juvenile justice programs, homeless and domestic violence shelters as well as a range of community-based, school-based and mental health programs.

The Stop-Gap model uses a multi-component approach (i.e., environment-based, intensive, and discharge-related) to service delivery for residential treatment settings. The two-fold goal of the Stop-Gap model is to interrupt the youth's downward spiral imposed by increasingly disruptive behavior and prepare the post-discharge environment for the youth's timely re-integration. Youths enter the model at Tier I, where they receive environment-based and discharge-related services. The focus at tier I is on the immediate reduction of "barrier" behaviors (i.e., problem behaviors that prevent re-integration) through intensive ecological and skill teaching interventions (e.g., token economy, social and academic skill teaching). Simultaneously, discharge-related interventions commence. To the extent that problem behaviors are not reduced at Tier I, intensive Tier II interventions that include function-based behavior support planning are implemented. The Stop-Gap model recognizes the importance of community-based service delivery while providing intensive and short-term support for youths with the most challenging behaviors.

TFM is a unique approach to human services characterized by clearly defined goals, integrated support systems, and a set of essential elements. TFM has been applied in residential group homes, home-based services, foster care and treatment foster care, schools, and psychiatric institutions. The model uses a married couple or other "teaching parents" to offer a family-like environment in the residence. The teaching parents help with learning living skills and positive interpersonal interaction skills. They are also involved with children's parents, teachers, and other support network to help maintain progress.