Located on 260 acres of farmland in Saco, Maine, Sweetser’s residential treatment program offers extensive treatment, education, and recreation services amid a quiet, natural setting. Sweetser’s roots in residential care for children date back to the opening of the state’s first orphanage in 1828 in Portland, which is just north of Saco. Over the years, Sweetser’s commitment to behavioral health evolved into a system of care that includes family-focused and community-integrated services for children with severe emotional or behavior problems, or learning disabilities. Today, Sweetser provides a network of mental health, recovery, developmental, and education services for children, families, and adults throughout the state of Maine.¹

Sweetser’s residential treatment program always has sought to provide a short-term, focused therapeutic intervention and to reunify children who have been removed from their families as soon as possible. Sweetser’s Saco campus serves about 40 children between the ages of 8 and 18, with about two-thirds of the residents being male.

About 10% of Sweetser’s resident children have been removed from their homes by Maine’s Child and Family Services, but the majority have been voluntarily placed by their parents through the behavioral health system as a result of a crisis. Families come to Sweetser seeking a short-term residential intervention to address their child’s severe emotional and behavioral health needs after they have exhausted other intensive, home-based interventions. The average stay at Sweetser is between six and eight months.

Until the 1990’s, however, Sweetser was serving children in isolation of their families. Children were removed from home and admitted to Sweetser to get “fixed,” and then returned home without any parental involvement in treatment.

“At that time, the primary family engagement happened at the bus stop as parents were dropping their child off or picking them up from their residential stays,” recalls Gail Howlett-Brown, director of intake. Upon returning home, many children resumed their old behavior patterns and family dynamics did not change. But following the emergence of a new body of research demonstrating the importance of actively engaging parents in their child’s treatment, the Sweetser leadership team came to understand that without parent engagement, it was unlikely that therapeutic changes achieved in the residential setting could be transferred to a home setting. Sweetser made a shift in its business model: residential intervention should be oriented not around removing the problems that children bring to Sweetser, but toward creating the strategies and conditions that will ultimately help the family system function more effectively together.

Practice shift

A family engagement and inclusion approach was first piloted in 1994 at the agency’s Saco campus. Called Family Focus, this short-term program worked closely with family members and involved a brief residential stay for children of three months followed by up to three months of intensive community-based treatment. Parents were invited into the program to practice various skills to support their child, with staff providing the training. They were asked to spend at least twice a week at Saco. Parents attended treatment sessions focused on repairing relationships and reconnecting with their child. They also worked on developing new parenting techniques to help them better manage their child’s behaviors. Families were trained in the same strategies that direct care staff were taught, such as crisis prevention, verbal de-escalation, and self-calming/soothing techniques. “It was not just about the child’s behavior, it was about the parent’s response to that behavior that we chose to focus on,” says Dr. Andrea LeMoal, director of clinical services.

The pilot’s tremendous success led to improved outcomes once the child returned home. As a result, Sweetser changed its traditional practice approach and developed a framework to promote and integrate family-centered treatment into every program. The agency maximized contact between children and families, actively involved and supported families in treatment, and provided ongoing support and aftercare once children returned home. As a result, family engagement and inclusion has been a core value of Sweetser’s residential care model for the past 20 years. Sweetser’s leadership team identified a number of key elements that have been integral to actively engaging and including families.

Philosophical commitment to families as valued partners

Sweetser leadership adopted a clear philosophy, communicated across the organization, that emphasizes the facilitation of healing through evidence-based interventions and the involvement of family. The importance of family engagement and inclusion at all levels is discussed in depth with children and families at intake. Families are welcomed and encouraged to be involved in treatment, and staff are expected to provide services to the entire family in the home as much as possible. To overtly support this shift, Sweetser updated institutional vernacular. For example, a “home visit” is now called “family time.” and the position of “child counselor” is now “youth and family counselor” – much truer reflections of the work and the job.

The switch to a family-centered model did not happen overnight. It took considerable investment in the current staff, as well as recruiting new staff committed to a more holistic model of family treatment. Although the majority of staff were on board and supportive of family-focused work, many of them, particularly the direct care staff, did not have previous experience working with families. As a result, Sweetser had to retool staff training and supervision to infuse practices consistent with family-driven care. All staff now are trained on Structural Family Therapy and receive two hours of clinical supervision on each family per week in the form of a team meeting run by the clinician and attended by the residential services director and clinical services director.

Active engagement

The vast majority of the parents who admit their children to Sweetser bring with them one of two types of experiences: They either are new to treatment programs and feeling frightened and ashamed to leave their children in the care of strangers, or they have exhausted their efforts trying other interventions that have not worked — often involving multiple hospitalizations — and are feeling frustrated and distrustful. Each has its own set of family engagement challenges. But in both cases, parents are eager to do whatever it takes to reunify with their children.

At Sweetser, parents are viewed as a valued partner with an active role in their child’s treatment. From the initial phone screening, parents are welcomed, listened to, and asked about their child’s background and previous treatment experiences. Parents must attend the intake interview with the child and commit to involvement throughout the stay. Staff inquire about their goals for the child, set clear expectations about the parental role during the residential treatment stay, and design a treatment plan in partnership with the parents. Parents also are asked how often they would like to be communicated with, how they would like to receive feedback, and who from the family unit should be involved. During the child’s stay, parents remain the primary decision-maker so that the child continues to view them in a parental role.

“If staff members have any issues with the child, they immediately call the parents to ask them how they would handle the situation,” LeMoal says. “It is not about what we are doing, it is about what the parents can do. We teach the youth that they should be carrying their parents’ voice in their head.”

Staff also communicate with parents about positive experiences and celebrate milestones. For parents who have struggled with extreme negative behavior patterns from their children for years, small gestures can go a long way in giving them hope. On weekends, staff take youth and families on fun outings that offer respite from the heavy work of healing from trauma and repairing relationships. “Parents comment on how wonderful it is see their children acting like kids again,” says Laurie Raymond, senior director of residential services. “We know this is a difficult time for families, so we work hard to create moments of joy and happiness.”

Transparency

Direct care staff initially expressed some concern over parents being invited to spend unlimited time at treatment sessions and in the campus cottages. “Certain team members were nervous at first to have families watching them all of the time,” Howlett-Brown recalls. However, even the most resistant staff members warmed to the approach in fairly short order as they saw firsthand how much family contact benefitted the youth. An open-door policy was created for parents —there are no visiting hours or telephone restrictions. Parents are welcomed in the cottages at any time and are invited to partake in activities and therapy sessions with their children. Staff build trust with parents by encouraging them to express their fears and concerns, and by not judging them.

Addressing barriers to engagement

Even when families are committed to be fully engaged, obstacles sometimes are in place that prevent them from participating at the level they would like to be involved. Transportation, child care, and competing priorities can stand in the way of a parent’s engagement. Sweetser staff ask parents about potential barriers to participation and then brainstorm potential solutions with them.

Since family engagement and inclusion is a core value of Sweetser, staff go above and beyond to ensure that parents are able to participate. They drive long distances to bring children home for a weekend visit, provide child care, pay for taxis, and provide gas cards so parents can visit the campus. Technology – including video chats, FaceTime, and text messaging – has also proved extremely helpful for maintaining family involvement.

While staff does their best to help repair familial relationships and promote healing, some of the children may not be able to return to their homes. In those situations, as well as instances when children have been placed at Sweetser due to abuse and neglect, Sweetser is committed to finding a family for every child, no matter the circumstances. Staff employ Family Search and Engagement strategies to ensure that each and every child has family members involved in the treatment. “It is a core value of Sweetser to never give up on finding a family for every child,” Raymond says.

Permanency and after-care support

As soon as a child enters Sweetser’s short-term residential treatment program, the planning begins for that child’s return home. Sweetser staff work closely with the case management unit, making referrals to home-based services in the community and ensuring a soft handoff to community providers. For most programs, a 30-day overlap in services is allowed, and that is extended for more complex cases. This allows Sweetser and community providers to coordinate care and ensure a solid plan for clinical follow up. A system is in place between Sweetser and providers involving the release and sharing of records in order to ease the transition. 

Transitions into and out of the residential program are among the most difficult times for children and families. To ease anxieties about the return home, there is a significant amount of “rehearsal” in the home setting, with youth and family counselors providing support during scheduled “family time” visits and offering to solve problems in between over the phone. A family apartment is available on campus to allow for practice in a supported setting.

Impact

Over the past three years, Sweetser has adopted and implemented the evidence-based Children and Residential Experiences (CARE) treatment model, which revolves around family involvement. After 90 days on the job, each staff member receives 40 hours of training on CARE. Developing a reflective practice is a vital component of the model, which has helped to decrease the number of critical incidents, such as verbal abuse, runaways, and physical interventions. The CARE model incorporates intermittent surveys for children that ask about the culture and climate at Sweetser — for example, whether they feel listened to and understood by staff, whether they trust staff, and whether they feel connected and safe. CARE also surveys staff about their core competencies. All areas have been trending in a positive direction since the implementation of CARE. Children also have reported improved self-esteem, as well as improved social and emotional adjustment. Sweetser will continue to evaluate the CARE model and measure the impact of CARE principles on child outcomes.

1 Information for this brief was obtained through interviews with Sweetser staff: Laurie Raymond, senior director of residential services; Dr. Andrea Le Moal, director of clinical services; Gail Howlett-Brown, director of intake; and Liz Kingsley, clinical supervisor. June 5, 2019.