Advances in Applied Sociology
2013. Vol.3, No.2, 102-105
Published Online June 2013 in SciRes (
Copyright © 2013 SciRe s .
Rural Adolescent Residential Treatment Facilities as Centers of
Clinical Support and Excellence*
Kenneth M. Coll1, Robin Haas2
1College of Education, Bo ise State University, Boise, Idaho
2Cathedral Home for Children, Laramie, USA
Email:, r hass@cathedralhome .org
Received January 31st, 2013; revised March 2nd, 2013; accepted March 10th, 2013
Copyright © 2013 Kenneth M. Coll, Robin Haas. This is an open access article distributed under the Creative
Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly cited.
In rural western states (e.g., Wyoming, Idaho, Montana, Utah) that are large geographically and small in
population, it is unrealistic to expect to have comprehensive mental health and substance abuse profes-
sional support in most rural communities. One viable idea is for mature and distinguished treatment facili-
ties in those geographic areas to expand their delivery system.
Keywords: Rural; Residential Treatment; Adolescents; Clinical Support; Best practices
This article’s concepts, recommendations, and suggestions
are directly tied to the recently released Guidelines for Cultural
Competence in Rural Child Welfare (2009). The problems en-
countered at Cathedral Home for Children (CHC) (a residential
adolescent treatment facility in Wyoming) are typical of many
rural treatment services. For example, youth represents a high
poverty rate, elevated parental substance abuse, and poor access
to mental health and substance abuse services (CWLA, 2009).
CHC is a rural residential treatment center in the Rocky
Mountain Region of the United States. The agency is a nation-
ally recognized Joint Commission accredited residential treat-
ment facility that offers specialized educational, psychological,
and therapeutic services for adolescents. Youth are referred to
this facility for one or more of the following reasons: 1) non-
compliance in school, 2) history of criminal activity, or 3) hav-
ing been a referral to Child Protective Services. The youth at
CHC range in age from 12 - 17, with approximately 57% male
and 43% female. Typically 75% - 85% of the participants iden-
tify their ethnicity as European American, with 10% - 15%
Hispanic, and 5% - 10% American Indian/Alaska Native. 40%
to 50% of the youth comes from families below the poverty line,
and about 55% report parental substance abuse/addiction.
This article includes ways in which unique rural challenges
are faced, particularly related to what happens to youth aging
out if residential care back to rural settings and innovations for
support and professional education for rural child welfare staff.
CHC uses service delivery methods that have been tested and
are evidence-informed, but adapted for rural settings. How are
those methods are different from urban ones will be described
and a rural model for a “Center of Clinical Support and Excel-
lence” will be explained.
What Happens to Youth Aging out of
Residential Care in Rural Areas?
Rural settings present a unique challenge in terms of avail-
ability, accessibility and acceptability of services. CHC is no
exception to these challenges. For example transportation in
Wyoming is extremely challenging with some in-state rural
youth coming from communities over 10 hours away by car.
Accessibility of coordinated services for family members are
also quite challenging, with many youth coming from commu-
nities of less than 1000 in population and larger communities
perhaps a 5 hours car drive away. Stigma in Wyoming commu-
nities is also quite high, and consistent with CWLA findings for
rural communities (2009), such stigma is tied to the perception
that confidentiality for accessing services cannot be maintained.
For youth aging out and returning to a rural setting, such ser-
vices are severely limited compared to what metropolitan areas
offer. As youth age out of the child welfare system, unprotected
by the social welfare system they once relied on for their sur-
vival, they must quickly adapt to becoming independent adults.
For example, leaving a recovery environment like CHC, which
provides both instrumental support (medical, dental, food,
clothing, shelter) and psychosocial support (academic, recrea-
tional, mental health) to a rural community that offers few if
any of those services is quite daunting. As challenging as tran-
sitioning may be for youth returning to metropolitan settings,
going from the full slate of services to very few if any is typi-
cally not their reality. Therefore youth returning to rural set-
tings need to be prepared to creatively access transitional ser-
CHC has recently become more intentional in educating
youth about their transitional needs for rural environments.
Inspired in part by a recent article, Preparing Youth for the
Transition into Adulthood: A Process Description that specifi-
cally addresses rural issues (Ringle, Ingram, & Newman, 2007),
CHC is adapting a process in which youth returning to rural
*Note: copies of pertinent national refereed journal articles and summaries
(CHC Research Briefs) are available on CHC’s web-site (www.cathedral-
settings complete an educational experience over a 6-month
period immediately before their transition through a series of
structured real-life activities and lessons. These activities in-
clude a workbook that provides real life rural situations, and
possible solutions for accessing services in such setting (e.g.,
skyping, phone conferencing, on-line resources). The “class”
incorporates independent living curriculum (e.g., job searching
is a rural area, budgeting, time management, dealing with rural
transportation costs), an alumni program (that matches youth
with others in the community or within 50 - 100 miles), and
aftercare services provided by CHC that includes a once per
month face-to-face visit and regular phone calls from a CHC
professional that extend their current services and ‘trouble-
shoots’ with them related to specific problems and accessible
Results from the Ringle, et al., (2007) 5-year follow-up study
indicates that those who completed this process reported more
positive functional outcomes than those who did not. This
process and effective after-care services helped these young
adults maintain the gains established during treatment. As
adapted at CHC, key interventions include online, pre-place-
ment and post care arrangements; all recommended by
CWLA’a Guidelines for Cultural Competence in Rural Child
Welfare (2009).
Similarly, CHC transitional services have drawn from an-
other rural based article, called Transitioning Behaviorally Dis-
ordered Young Adults from a Structured Residential Treatment
Center into Independent Living in a Small, Rural Community,
by Conrad (1991), The program consisted of three levels, each
offering more independence, while providing support, guidance,
and direction to the transitioning youth. Each level encourages
greater personal, economic, and emotional responsibility and
independence related to returning to his/her rural setting. For
example, each youth works with child welfare professionals to
think through the challenges of their particular rural setting in
terms of relapse potential and the recovery environment, then
incorporate these insights into the transitional plan. CHC has
built in this level system to help youth determine the level of
independence often needed in rural environments to be suc-
cessful and how crucial planning and decision-making are keys
in environments where more formal social supports are not
present. CHC accents the value of developing informal supports
during this process, encouraging participation in church groups,
community clubs, volunteerism, and on-line connections as part
of the planning.
Rural Child Welfare Staff
Development-Challenges and Recommendations
CHC specifically has been recently aggressively addressing
the CWLA Rural Cultural Competency of 1f:
Rural child welfare staff and administration should receive
additional support to develop child welfare competencies and
professional education”.
Child welfare staff and administration in rural settings are
faced with many professional challenges (Smith, 2003). Profes-
sionals tend to lag in training for diagnosing, intervening and
treating mental illness, while the need for such competence
grows (DeLeon, 2000). For example, “in the United States, at
least 15 million rural residents struggle with significant sub-
stance dependence, mental illness, and medical-psychiatric co
morbid conditions” (Roberts, Battaglia, & Epstein, 1999: p.
497). Compared to urban and suburban settings, rural settings
consistently report higher incidences of abusive drinking, sui-
cides, mood and anxiety disorders, and chronic illness (Roberts
et al., 1999).
There are many benefits to child welfare staff and admini-
stration in a rural setting, such as lifestyle (clear skies, slower
pace, clean air, and close social networks), lower overhead and
cost of living, greater autonomy, more collegial relationships,
varied tasks and functions, and community identity and recog-
nition. However, rural child welfare staff and administration
often face role overload, heightened stress and burnout, rela-
tionship/role/boundary challenges, professional isolation, eco-
nomic issues (e.g., scarcity of resources), lack of social/cultural
opportunities, and lack of privacy (DeLeon, 2000). This reality
in rural areas is often exacerbated by “a constant search for
balance between professional and ethical issues” as helping
professionals in rural areas are very identifiable (Smith, 2003).
These assertions are supported by a major study, in which
Weigel and Brown (1999) discovered that the chief challenges
indicated by rural child welfare staff and administration were
limited resources, few staff members with large caseloads, var-
ied presenting client issues, geographic isolation, limited su-
pervision and consultation options, and high employee turnover.
Weigel and Brown concluded that there are potential problems
with stigma and local credibility due to the “close-knit” nature
of rural communities, [where] child welfare success or failures
are often visible and public. In addition, Brownlee (1996) noted
that the rural child welfare professional who participates ac-
tively in community life will eventually encounter this particu-
lar dilemma, often further contributing to a sense of isolation.
The solution to such challenges is additional support.
Rural Residential Treatment Facilities as
Centers of Clinical Support and Excellence
In rural states (e.g., Wyoming, Idaho, Montana, Utah), it is
unrealistic to expect to have comprehensive mental health and
substance abuse professional support in rural communities. One
viable idea is for mature and distinguished treatment facilities
in those areas to expand their delivery system. For example, a
rural Residential Treatment Center (RTC) can act as a regional
hub- providing outreach to rural regional needs. This idea is
related directly to several CWLA Guidelines for Rural Cultural
Competence (2001), especially Standard 5: “Child welfare pro-
fessionals in rural communities should deliver services in a
culturally competent manner, be knowledgeable about services,
and be able to marshal existing resources to best serve their
clients”. One such example of this model is now being imple-
mented by Cathedral Home for Children (CHC), located in
Laramie, Wyoming. Located in the least populated state in the
US, CHC provides regional outreach in crisis center cervices,
group home options, prevention, aftercare, tutoring, psycho-
logical testing, and coordinate home health care for a large
geographic region (120 square mile radius ), and to rural com-
munities that would not be able to access these services any
other way. In that RTCs have trained professional and resources,
this “center of excellence” model for rural communities is
highly feasible, and will help in transitioning CHC youth to
independent living.
The Alliance for the Safe Therapeutic and Appropriate use of
Copyright © 2013 SciRe s . 103
Copyright © 2013 SciRe s .
Residential Treatment (ASTART) (co-sponsored by the De-
partment of Child and Family Studies of the University of
South Florida and the Bazelon Center for Mental Health) re-
cently developed a Parent’s Checklist—called “Warnings for
Parents Considering a Residential Placement for their Child and
Adolescent”—that was supported and co-sponsored by a num-
ber of agencies (e.g., Child Welfare League of America,
American Psychological Association). A RTC can take such
recommendation and develop an outreach function to turn per-
ceived weaknesse s into strengths, and improve communicate to
parents and other key informants, as outlined below.
The Table 1 lists points on ASTART’s Parent Checklist with
information about how and RTC can address each point per the
Center of Clinical Support and Excellence” Model.
Funding for this kind of initiative can come from cultivating
partnerships with the state, private grants and counties. This
model could also effectively address another CWLA rural
competence standard (1g).
1g. Supports for increasing competence and professional
education should include: compensation for tuition, compensa-
tion, for travel time to courses, development and access to
online education, and reduction in workload to accommodate
the special needs of rural employees accessing education.
For example, the RTC as a Center of Clinical Support and
Excellence can provide the services needed in rural settings; as
described below:
1) Consultation and clinical supervision are essential to pre-
vent isolation and redundancy of ineffective techniques. The
rural child welfare professional can create an interdisciplinary
consultation group by collaborating with teachers, clergy, po-
lice officers, judges, and paraprofessionals all of which bring
specific expertise and appropriate care to child welfare (Smith,
2) Continuing education is another large component to keep-
Table 1.
Cross Referencing ASTART, RTC, CWLA Guidelines.
Astart RTC as a center of clinical suppo r t and excellence Examples of CWLA Corresponding
Guideline(s) for Cultural Competence
in Rural Child Welfare
State-licensed and accredited with regard to all 3
aspects of the program: the
1) educational,
2) mental/b ehavioral he alth and
3) residential components?
1) Educational-Communicate the fully accredited nature
of the on-site school by the state and emphasize the
employment of certified teachers; provide consultation
and training services to outlining rural school districts
on how to dea l with “alternative education” youth.
2) Mental/Behavioral Health-Communicate the rigorous
accreditation adherence (e.g., Joint Commission for
Accreditation of Health Organizations) for behavioral
health care; offer expertise to outlying rural school dis-
tricts and MH clinicians re: accreditation,
certification; explore options of covering such facilities
with current agency accreditation.
3) Residential Components-emphasize the close
adherence to the Child Welfare League of America’s
(CWLA) Standards of Excellence for Reside n tial
Services (see CWLA’s web-site), including but not
limited to elements of rural service and treatment (e.g.,
cultural competence, child-centered, family-focused
services), organization a nd administration of residential
services (e.g., administrative structure that includes
continuous quality improvement processes), and service
environm ent (e.g., sound building design and
recreational space and equipment). Prom ot e spo nsoring
regional training seminars accenting the delivery of such
principles in aftercare, prevention, et al. (e.g.,
5b. Collaboration is esse n t ial in rural
5c. Rural administrative oversight and
support for creating services is
1. Child welfare professionals should
work with rural populations in accor-
dance with t he unique need of rural
Respect t he wisdom and expertise of
parents and youth?
Accent the d eep comm i tment to involving parents and to
a family- centered philosophy per JCAHO and CWLA
recommendations; provide training to rural regional
providers, deliver regional direct services to parents and
3b. Allow rural children to remain
connected to their home and social
Provide quali t y therapeutic interventions?
RTC can provide training and direc t services based on
high standard therapeutic interventions including
individualized treatment plans for each youth a nd
family, with d etailed explanations for best practice
therapies and interventio n s t o help that particular youth
and family adapted to rural s ettings. For example, an
RTC can train other r ur al agencies to provide monthly
reviews to u p d ate treatment interventions, and testing is
re-administe r ed every 6 months to assess progress.
7b. Maximize community resources
Admit youth with psychiatric diagnoses but then do
not provide appropriate medical treatment ?
In keeping w it h best practice, an RTC c an make thei r
consulting psychiatrist as well as other medical
personnel (nurse) ava il able and on call to monitor,
update, a nd adjust medica tio ns to the best results for
the rural you t h s erved.
2b. Understand the important juncture
of time and di st ance in rural pr actice
ing abreast of current child welfare issues and trends and this is
limited in the rural setting. Again, collaboration with other
professionals can bring this needed information. Professionals
such as attorneys, medical professionals, domestic violence
educators, and invited child welfare professionals from other
locations can provide continuing education and advancement
(Smith, 2003).
3) Applying for grants, conducting fundraisers, and promo-
tion can help rural agencies provide low cost services and will
be much less affected by state and federal funding cuts (Smith,
2003). For example, several universities are looking to collabo-
rate with rural mental health agencies for special federal grants
set aside for rural communities. A phone call or email to the
social work and/or counseling training programs at the state
universities could be a fruitful start.
4) The training of new child welfare professionals should in-
clude a rural emphasis; and those bachelor level social work
students, masters level social work and counseling students,
and doctoral level psychology stude6ns planning on working in
the rural setting should do at least part of their practicum and
internship hours in a rural setting (Smith, 2003).
5) Conducting community outreach programs provides an
opportunity to introduce yourself to members of the community,
explain your services, and decrease the stigma of child welfare
work, plus enhanced training in computer information systems
can relieve record keeping and administrative time. Promoting
online training courses and continuing education classes can
reduce isolation and increase professional development (Smith,
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