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Maia Szalavitz Headshot

Tough Love 3: Questions

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In my last posts on this topic, I explored what I'd learned when researching my new book, Help at Any Cost: How the Troubled-Teen Industry Cons Parents and Hurts Kids, about when parents should seek residential care for their troubled teenagers. The short answer, to recapitulate, is rarely: the vast majority of teenagers currently sent for residential care for behavioral problems either do not need any such care or are held in programs for far longer than is necessary.

But what if your teen is injecting drugs or smoking methamphetamine daily, is violent towards himself or others or is seriously mentally ill with a psychotic disorder like schizophrenia? Excerpted from the book, here are the key questions to ask of any residential care provider you are considering, after you have gotten an initial psychiatric evaluation from an independent provider who concurs with the need for residential treatment:

1. How often may I contact my child, and how often may I visit?

The program should encourage contact and visits. Excessive restrictions are a red flag -- especially if they are rigid (for example, you should always be able to contact him or her in an emergency). A week or two without contact may be OK, but more than that is questionable. You should be able to talk privately with your child. You should never be told not to believe your child. You should be able to visit with little notice, within reason.

2. What are the qualifications of the line staff who work directly with the teens?

There should be someone of at least a master's level working with the kids most of the time; staff should have been subjected to criminal background checks, and the more educated the line staff, the better. Any kind of group should be led by a therapist of at least master's level -- less than that (especially no degree required, trained only by the program itself) is a red flag.

3. What is your policy on isolation and restraint?

They should never be used in addiction treatment or in non-licensed facilities and staff should be trained in specific restraint techniques. Every restraint should be written up and analyzed by staff as to whether it was appropriate and how it could possibly have been avoided, and restraint should be used only by staff. Isolation should be extremely time-limited, and the person should be checked on frequently. Ask also about how often restraint is used -- it should be very rare; only every six months, not daily, for example.

4. What is your procedure for patient complaints?

Ideally, there should be an ombudsman, whose sole job is to investigate patient complaints and solve such problems. At the very least, there should be a written procedure that allows a child to complain to someone at a higher level of authority than the person who makes the usual treatment decisions about him, without fear of retaliation. If you hear something like "the children are always lying and manipulating" in response to a question like this, you want a different provider. Also, ask if there are state hotlines to which the child has access for complaints.

5. What are the rules of the program, and what are the consequences for breaking them?

Again, ideally, you want to hear about clear, minimal rules and little emphasis on punishment. Trivial rules like not being permitted to look at a member of the opposite sex or not being able to look out a window are a red flag. If punishment is used, it should be short, reasonable, and not humiliating. It should almost never interfere with education. If there is any kind of "level" system, it should not punish kids for having "one bad day" with "setback" that involves months of restrictions and/or withdrawal of privileges. There should be a complaint procedure if a teen believes she's being punished unfairly, and levels should not be determined solely (or even primarily) by peers. This can simply become a popularity contest and unfairly penalize kids with poor social skills. Ideally, there should be no level system at all.

6. How do you deal with medical complaints?

You want a program that seeks medical attention immediately, regardless of cost and regardless of the possibility that the child may be "faking." It should err on the side of believing the kid, basically.

7. What is your philosophy on confrontation?

You want to hear that empathetic, supportive approaches are more productive and that necessary confrontations are done with kindness and respect (i.e., "When you do X, I feel Y", and not "You're a selfish monster.")

8. How long will my child need to be in treatment?

Here, you want to get a sense that the philosophy is to minimize time away from home and that there are clear rules about length of stay.

9. What is a typical day in treatment like?

You want to hear about a very structured day, but one that includes at least some "down" time for reflection. You want to be sure that education is given enough time, if this is a long-term program.

10. What are your policies about medication?

Blanket policies against medication are a red flag -- so are policies that don't have staff supervision of medication use (i.e., they have the teens keep and take their own meds, rather than have a nurse, counselor, or physician's assistant distribute them). Except in cases of uncomplicated addiction, teens disturbed enough to require long-term residential treatment typically need at least some medication. Skepticism about over-medication is good -- but seeing medication as a "quick fix" which allows teens to avoid needed emotional pain may miss the complexity of their problems and often represents the kind of black-and-white thinking that is not indicative of the best care.

Keep in mind, however, that even if you ask all the right questions and get all the right answers, this cannot guarantee that you have found a good program. As families who have lost their teens to these programs found out to their great regret, program providers can mislead parents about the services, complaint procedures, and treatment philosophies. So, again, you need to be absolutely sure, first, that your child needs residential care -- and if so, that the program is safe and appropriate.

Search it thoroughly online -- look at activist sites such as the International Survivors Action Coalition, Fornits, Teen Advocates USA, Teen Liberty, Project No-Spank, The Coalition Against Institutionalized Child Abuse, Cafety, Fight Institutionalized Child Abuse, and the Emancipation Project for accounts of problems. My website includes additional links and resources.

Also, check with the Better Business Bureau and state licensing agencies as well. Search local media if possible, too. Google the name of the program and "abuse" or "investigation." Be suspicious and ready to change track if the program you choose doesn't turn out to offer what it has claimed to offer. Trust your intuition: if something doesn't feel or seem right, it probably isn't. You know your child better than any expert does. Sure, kids, like all humans, often try to find the easy way out, but most will not come up with extreme and specific tales of abuse unless it is occurring or something else is making them incredibly unhappy. Even if a child makes a false report, it's a sign that treatment isn't going well, and the incident needs to be properly investigated, not dismissed.

Recovering from addictions and mental illness is often far from pleasant -- but good providers work to make it as easy and painless as possible, not the opposite. Kids may rebel against fair rules and appropriate structure, but most recognize the need for them and, though often grudgingly, agree to comply. Unfairness and unkind and arbitrary displays of power, however, are not good treatment -- and you've raised an ethical child if she disagrees with such policies. If it doesn't seem appropriate, it probably isn't. If it seems too good to be true, it's bound to be a scam: avoid anyone promising "cures" or offering "guarantees."