RileyDMFT6104-8

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Dec 6, 2023

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Week 8: Reflection on Community Mental Health Center Tour Danae Riley School of Social and Behavioral Sciences, Northcentral University MFT-6104 v2: Family Therapy with Children Dr. Chisato Hotta December 27, 2022

Agency Tour Reflection For my assignment last week, I toured Aurora Behavioral Health Care in San Diego. I interviewed Susan Writer who has worn many hats while working with Aurora over the last 10 years. She currently works in Psychoeducation and Public Affairs for the center. I had a difficult time finding a facility during the holidays that was open to touring and had the staffing to provide an interview/tour at this time. Aurora offers care to children, adolescents, and adults, so although my trip was focused on the children and adolescent experience, I felt like it was great exposure to see the entire facility and the differentiation between care options for all clients coming in. Aurora offers 101 beds and 20 of those beds are dedicated to children and adolescents ages 5-17. The rooming is split between children ages 5-12 and adolescents ages 13-17. These patients are brought for a few different reasons. Their parents may bring them in due to concerns about not being able to properly care for their children who are dealing with disorders, or they may have been referred by their child’s therapist or school. The other way kids end up at Aurora is via a 5150 hold, meaning that law enforcement or a medical professional is involuntarily bringing them into the facility as a life-threatening risk to themselves or others. The most common diagnoses for these patients are anxiety, depression, suicidal ideation, self-injurious behavior, and drug/alcohol dependency. 50-80% of these kids are brought in with dual diagnosis. Aurora offers inpatient and outpatient services and takes most health insurance plans. They offer 24/7 assessment, detox, stabilization, and treatment services while using a multi- disciplinary approach comprehensive of psychotherapy and counseling, psychiatry, and social work for all inpatient treatment. For outpatient programs, they offer two programs and numerous other helpful resources to families. Partial Hospitalization Programs (PHP) include 6 hours a day,

5 days a week for 2-4 weeks for kids who do not need a permanent hold but need more support and hand on tools before fully re-entering “normal life” again. Intensive Outpatient Programs (IOP) are 3 hours a day 3 days a week for 8 weeks and the kids can choose to either do this during or after school hours dependent upon their needs. The IOP program is a perfect bridge from PHP back into typical schooling and once a week therapy session to continue to refine the skills learned through inpatient and outpatient services at Aurora. One important callout to note is that the Outpatient Programs are not covered by Medical, so kids under these plans do not have the option to move throughout a phased approach from inpatient to normal life like those who are more financially stable with increased insurance coverage. This is a major disadvantage that is harmful for these children due to them going from an intensive 24/7 care approach to a very hands-off, weekly meeting with a therapist which is too drastic of a change to be effective for these kids. The methodology used for psychotherapy at Aurora depends on the age and needs of each patient. For younger children, attachment theory is primarily used as the lens by which therapy is approached, and for the older adolescents, a few approaches are used including Cognitive Behavioral Therapy, Dialectical Behavioral Therapy and Acceptance Commitment Therapy. There is a strong focus on building a series of skills like mindfulness, affect regulation and interpersonal skills to help them tolerate and navigate the stressors that will face in their future. Parental Perspective As a parent coming into Aurora, I can imagine I would be scared about the idea of potentially being told my child needs inpatient care. I would imagine there would be waves of guilt, shame, blame, frustration, anger, confusion, and maybe more. I would feel a need to deeply trust the staff to not only keep my child safe but to also do what it takes to stabilize and

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rehabilitate them while also offering me the skills to effectively merge them back into our home post-care. What I would be looking for in this beginning phase of assessment and treatment planning is not only reassurance of stability, but also a discussion about the phases of care following this inpatient care. Many parents in this situation have succumbed to negative patterns that are continuing to worsen the existing problem at hand, so teaching the parents the skills to have conversations encouraging their children to articulate their fears and communicate through the changing of negative patterns of behavior as a whole family will be essential to the success of the outcomes post inpatient care (Cooklin, 2001). “At first glance, I am a bit uneasy about the facility due to its run down, minimalistic appearance along with the fact that there are primarily adults throughout much of the facility being treated. The staff seem kind, helpful and willing to talk through all concerns about the intake, assessment, and housing but I am surprised to hear the inpatient care is typically only 3-6 days for my child to receive initial stabilization and psychiatric assessment/treatment. I expected that based on the severity of my child’s behavior and potential risk of safety that the facility would be keeping them longer than that. The informational brochures and organization of the program from initial phone call to assessment, admittance and start of the program made me feel assured that this program is well managed, and the staff seemed very competent and willing to address my concerns. I am worried about whether my insurance will cover a PHP or IOP program following this initial inpatient stay, because if it doesn’t then I don’t know that I have the skills to take my child back into my home after only a couple days here at Aurora. I would like to know more about resources for my family after my child is released. I am nervous to talk to my child’s school about getting their curriculum sent over to Aurora due to the stigma I may face but I don’t want my child to be too far behind when they return to school either. I know

there will likely be a lot of communication needed between myself and the school, therapists, and psychiatrists which I am glad to know Aurora will assist me with after this period.” Client Perspective As a child coming into this facility, I can imagine that there have been numerous attempts to correct my behavior and/or solve the psychological challenges I am facing which have been unsuccessful requiring an intensive treatment option like this. That being said, I would assume that similar to the feelings of my parents, I would be scared and maybe angry but also, for some of the older children, maybe relieved that it has come to a point where my parents have finally recognized the severity of the symptoms I am facing which require specialized care that they are unable to offer me themselves. If I were a younger child, dependent upon the level of attachment to my current guardian or parent, I may feel rejected, scared, or simply compliant to another change in my environment which I already cannot seem to trust or rely on. One impactful stat that Susan shared with me was that there has been a dramatic increase in LGBTQIA youth coming into this facility causing the team to develop targeted care and therapy designed to help families adapt to any challenges that come alongside having an LGBTQIA child. This care is gender affirming and strengths based, helping families to embrace their children as they are. True impact can be seen when these children are not only given the opportunity to speak about their feelings and identity but more so when they sense that their opinions matter to their therapist and family (Cooklin, 2001). “My impression of the facility is that it seems a bit dark and older but there are holiday decorations all over and paintings on the walls that it appears other kids have drawn. The staff seem to really care about me and my family and they seem like they want to help but I don’t know if I believe they can yet. I am scared that my parents may be leaving me here and I don’t

know if I trust these people enough to tell them how I am really feeling yet. My parents and I spent 2 hours being asked a lot of questions by a therapist about how I have been behaving and about why my parents are worried about me, and I like the therapist, so I have been feeling better about talking with her about my transition. I am happy because the therapist said that this facility offers affirmative care for me as a trans kid, and I hope that maybe they can help my family to understand why I have chosen to transition and how hard it has been for me to deal with. I think that is why I have been so sad and I know my mom and dad want to protect me but it doesn’t feel like they like me anymore now that I am asking them to call me by my new name and wearing different clothes and stuff. Maybe these doctors can help my parents learn to love me again.” Clinician Perspective As a clinician in this agency, I would have a strong sense of purpose and commitment to bettering the lives of the clients who come through these doors, however, I would feel constantly roadblocked by major impacts to the success of a client’s future like lack of funding, lack of necessary insurance coverage for clients, and lack of proper staffing levels. Susan mentioned to me that she is rewarded by the positive impact she has made on the lives of her former clients, however she has felt burned out and has watched numerous other colleagues burn out and occasionally leave the profession due to the stress of limited resources and the emotional impact of seeing lower income families facing inadequate care accommodations due to lack of coverage through Medical. As a clinician coming into this facility, I would want to ensure that my case load were reasonable enough to allow for adequate time to log clinical notes and help clients to manage multi-modal care options versus being scheduled with back to back sessions. This was one large callout Susan made which she feels is what has made many therapists leave. Not only is the workload at times overbearing, but that in addition to clients in a severe state of

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psychological distress may increase symptomology inclusive of anxiety, depression, and burnout in clinicians (Macchi et al., 2014). Another piece of information I would be curious to better understand is what the statistics are like for percentages of families who not only begin family therapy together, but also who remain consistently committed to developing the skills necessary to bring their child home from this type of care facility. Commonly, 40% to 60% of families who begin services terminate prematurely that early termination, so I would be curious to know how we could increase engagement and retention strategies to ensure the families have the best outcomes (Thompson et al., 2009). I would hope that in this kind of an environment there would be benefits offered to clinicians inclusive of supervision or group discussion with other therapists to talk through challenges being faced and possible solutions to increase client outcomes (Macchi et al., 2014).

References Cooklin, A. (2001). Eliciting children's thinking in families and family therapy. Family Process , 40, 293-312. Macchi, C. R., Johnson, M. D., & Durtschi, J. A. (2014). Predictors and processes associated with home-based family therapists’ professional quality of life. Journal of Marital and Family Therapy, 40(3), 380–390. https://doi.org/10.1111/jmft.12016 Thompson, S. J., Bender, K., Windsor, L. C., & Flynn, P. M. (2009). Keeping Families Engaged: The Effects of Home-Based Family Therapy Enhanced with Experiential Activities. Social Work Research , 33(2), 121–126. https://doi.org/10.1093/swr/33.2.121

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