Pubdate: Sun, 29 Jan 2006
Source: Washington Post (DC)
Page: B01
Copyright: 2006 The Washington Post Company
Author: Maia Szalavitz
Note: Maia Szalavitz is the author of "Help at Any Cost: How the 
Troubled-Teen Industry Cons Parents and Hurts Kids" (Riverhead Books).
Bookmark: (Cocaine)
Bookmark: (Heroin)
Bookmark: (Treatment)


It is the ultimate parental nightmare: Your affectionate child is 
transformed, seemingly overnight, into an out-of-control, 
drug-addicted, hostile teenager. Many parents blame themselves. 
"Where did we go wrong?" they ask. The kids, meanwhile, hurtle 
through their own bewildering adolescent nightmare.

I know. My descent into drug addiction started in high school and 
now, as an adult, I have a much better understanding of my parents' 
anguish and of what I was going through. And, after devoting several 
years to researching treatment programs, I'm also aware of the traps 
that many parents fall into when they finally seek help for their kids.

Many anguished parents put their faith in strict residential rehab 
programs. At first glance, these programs, which are commonly based 
on a philosophy of "tough love," seem to offer a safe respite from 
the streets -- promising reform through confrontational therapy in an 
isolated environment where kids cannot escape the need to change 
their behavior. At the same time, during the '90s, it became 
increasingly common for courts to sentence young delinquents to 
military-style boot camps as an alternative to incarceration.

But lack of government oversight and regulation makes it impossible 
for parents to thoroughly investigate services provided by such 
"behavior modification centers," "wilderness programs" and "emotional 
growth boarding schools." Moreover, the very notion of making kids 
who are already suffering go through more suffering is 
psychologically backwards. And there is little data to support these 
institutions' claims of success.

Nonetheless, a billion-dollar industry now promotes such tough-love 
treatment. There are several hundred public and private facilities -- 
both in the United States and outside the country -- but serving 
almost exclusively American citizens. Although no one officially 
keeps track, my research suggests that some 10,000 to 20,000 
teenagers are enrolled each year. A patchwork of lax and ineffective 
state regulations -- no federal rules apply -- is all that protects 
these young people from institutions that are regulated like ordinary 
boarding schools but that sometimes use more severe methods of 
restraint and isolation than psychiatric centers. There are no 
special qualifications required of the people who oversee such 
facilities. Nor is any diagnosis required before enrollment. If a 
parent thinks a child needs help and can pay the $3,000- to 
$5,000-a-month fees, any teenager can be held in a private program, 
with infrequent contact with the outside world, until he or she turns 18.

Over the past three years, I have interviewed more than 100 
adolescents and parents with personal experience in both public and 
private programs and have read hundreds of media accounts, thousands 
of Internet postings and stacks of legal documents. I have also 
spoken with numerous psychiatrists, psychologists, sociologists and 
juvenile justice experts. Of course there is a range of approaches at 
different institutions, but most of the people I spoke with agree 
that the industry is dominated by the idea that harsh rules and even 
brutal confrontation are necessary to help troubled teenagers. 
University of California at Berkeley sociologist Elliott Currie, who 
did an ethnographic study of teen residential addiction treatment for 
the National Institute on Drug Abuse, told me that he could not think 
of a program that wasn't influenced by this philosophy.

Unfortunately, tough treatments usually draw public scrutiny only 
when practitioners go too far, prompting speculation about when 
"tough is too tough." Dozens of deaths -- such as this month's case 
of 14-year-old Martin Lee Anderson, who died hours after entering a 
juvenile boot camp that was under contract with Florida's juvenile 
justice system -- and cases of abuse have been documented since 
tough-love treatment was popularized in the '70s and '80s by programs 
such as Synanon and Straight, Inc. Parents and teenagers involved 
with both state-run and private institutions have told me of 
beatings, sleep deprivation, use of stress positions, emotional abuse 
and public humiliation, such as making them dress as prostitutes or 
in drag and addressing them in coarse language. I've heard about the 
most extreme examples, of course, but the lack of regulation and 
oversight means that such abuses are always a risk.

The more important question -- whether tough love is the right 
approach itself -- is almost never broached. Advocates of these 
programs call the excesses tragic but isolated cases; they offer 
anecdotes of miraculous transformations to balance the horror 
stories; and they argue that tough love only seems brutal -- saying 
that surgery seems violent, too, without an understanding of its vital purpose.

What advocates don't take from their medical analogy, however, is the 
principle of "first, do no harm" and the associated requirement of 
scientific proof of safety and efficacy. Research conducted by the 
National Institutes of Health and the Department of Justice tells a 
very different story from the testimonials -- one that has been 
obscured by myths about why addicts take drugs and why troubled 
teenagers act out.

As a former addict, who began using cocaine and heroin in late 
adolescence, I have never understood the logic of tough love. I took 
drugs compulsively because I hated myself, because I felt as if no 
one -- not even my family -- would love me if they really knew me. 
Drugs allowed me to blot out that depressive self-focus and socialize 
as though I thought I was okay.

How could being "confronted" about my bad behavior help me with that? 
Why would being humiliated, once I'd given up the only thing that 
allowed me to feel safe emotionally, make me better? My problem 
wasn't that I needed to be cut down to size; it was that I felt I 
didn't measure up.

In fact, fear of cruel treatment kept me from seeking help long after 
I began to suspect I needed it. My addiction probably could have been 
shortened if I'd thought I could have found care that didn't conform 
to what I knew was (and sadly, still is) the dominant confrontational approach.

Fortunately, the short-term residential treatment I underwent was 
relatively light on confrontation, but I still had to deal with a 
counselor who tried to humiliate me by disparaging my looks when I 
expressed insecurity about myself.

The trouble with tough love is twofold. First, the underlying 
philosophy -- that pain produces growth -- lends itself to abuse of 
power. Second, and more important, toughness doesn't begin to address 
the real problem. Troubled teenagers aren't usually "spoiled brats" 
who "just need to be taught respect." Like me, they most often go 
wrong because they hurt, not because they don't want to do the right 
thing. That became all the more evident to me when I took a look at 
who goes to these schools.

A surprisingly large number are sent away in the midst of a parental 
divorce; others are enrolled for depression or other serious mental 
illnesses. Many have lengthy histories of trauma and abuse. The last 
thing such kids need is another experience of powerlessness, 
humiliation and pain.

Sadly, tough love often looks as if it works: For one thing, 
longitudinal studies find that most kids, even amongst the most 
troubled, eventually grow out of bad behavior, so the magic of time 
can be mistaken for the magic of treatment. Second, the experience of 
being emotionally terrorized can produce compliance that looks like 
real change, at least initially.

The bigger picture suggests that tough love tends to backfire. My 
recent interviews confirm the findings of more formal studies. The 
Justice Department has released reports comparing boot camps with 
traditional correctional facilities for juvenile offenders, 
concluding in 2001 that neither facility "is more effective in 
reducing recidivism." In late 2004, the National Institutes of Health 
released a "state of the science" consensus statement, concluding 
that "get tough" treatments "do not work and there is some evidence 
that they may make the problem worse." Indeed, some young people 
leave these programs with post-traumatic stress disorder and 
exacerbations of their original problems.

These strict institutional settings work at cross-purposes with the 
developmental stages adolescents go through. According to 
psychiatrists, teenagers need to gain responsibility, begin to test 
romantic relationships and learn to think critically. But in tough 
programs, teenagers' choices of activities are overwhelmingly made 
for them: They are not allowed to date (in many, even eye contact 
with the opposite sex is punished), and they are punished if they 
dissent from a program's therapeutic prescriptions. All this despite 
evidence that a totally controlled environment delays maturation.

Why is tough love still so prevalent? The acceptance of anecdote as 
evidence is one reason, as are the hurried decisions of desperate 
parents who can no longer find a way of communicating with their 
wayward kids. But most significant is the lack of the equivalent of a 
Food and Drug Administration for behavioral health care -- with the 
result that most people are unaware that these programs have never 
been proved safe or effective. It's part of what a recent Institute 
of Medicine report labeled a "quality chasm" between the behavioral 
treatments known to work and those that are actually available. So 
parents rely on hearsay -- and the word of so-called experts.

Unfortunately, in the world of teen behavioral programs, there are no 
specific educational or professional requirements. Anyone can claim 
to be an expert.
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MAP posted-by: Richard Lake