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Maia Szalavitz Headshot

Tough Talk On 'Tough Love'

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This Sunday, the Washington Post ran my op-ed, The Trouble With Tough Love, and ever since, I've been trying to handle the onslaught of email from terrified parents seeking alternative help for troubled teens.

My story laid out how 'tough love' residential programs -- like boot camps, harsh wilderness programs, emotional growth boarding schools and behavior modification centers -- have never been proven safe or effective by research. In fact, a 'state of the science' consensus statement by the NIH said that 'get tough' programs for juvenile delinquents "do not work and there is some evidence that they may make the problem worse."

Nonetheless, there are still hundreds of such programs, both publicly funded and private, holding some 10-20,000 American teens and making up a billion dollar growth industry.

Space considerations limited my ability to discuss possible solutions to the problem in that piece. Consequently, I wanted to post some of my thoughts about them here and will be returning to this issue and its complicated politics -- much of which has been impossible to get the mainstream media to cover -- in my next posts.

First, and most critically, what most parents do not realize is that the vast majority of residential placements for teen behavioral problems are unnecessary. An official from the World Wide Association of Specialty Programs (the largest troubled-teen treatment group in the business) told the New York Times, regarding the problems of the teens in his program that "about 70 percent are not hard core -- they [just] cannot communicate at home."

Parents believe that cost-cutting insurers deny them coverage for residential care simply to save money; and there is no doubt that insurers are overly tight-fisted when it comes to mental health and substance misuse.

But what most people don't know is that in this particular instance, the insurers are right. It has now been unquestionably documented that for decades, numerous, major private psychiatric and substance abuse facilities for both adolescents and adults ripped off insurers by over-treating minor problems. Some of this occurred because the ideology of the programs coincided neatly with their owners' greed.

Here's how it worked, in the case of alcohol and other drug problems in the late 80's and early 90's. According to the rehab programs (which were based on the 12 steps of Alcoholics Anonymous), even minor problems require lengthy treatment because the "disease of addiction is characterized by denial."

In other words, if you said you only smoke pot on weekends, program officials took this to mean that you probably inject heroin but aren't yet ready to admit it. Thus, all patients got 28 days of inpatient treatment -- unsurprisingly, the number of days of treatment coincided with the maximum number of days most insurers would cover.

One large study found an almost exact correlation between a family's insurance maximum and a teen's residential stay -- regardless of the severity of the diagnosis!!!
[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10114328&query_hl=1&itool=pubmed_docsum]

People would literally show up for "free evaluations" at some treatment centers and find themselves coerced into staying 28 days because they admitted marijuana use (so long as they had insurance, of course).

Actual heroin injectors usually do require longer term care -- but, at least in part because programs admitted so many people with minor problems, when the research was done looking at whether inpatient or outpatient care was more effective, no differences were found. So insurers refused to cover inpatient addiction treatment or limited it to 7 or 8 days: almost useless for severe problems and unnecessary for mild-moderate ones.

Some psychiatric centers, at that same time, went so far as to literally kidnap children who had been identified by school guidance counselors as being troubled: they were kept in treatment until their insurance ran out, their parents threatened with termination of parental rights if they didn't consent to the treatment. [For more on this incredibly under-reported scandal, I highly recommend Joe Sharkey's book, Bedlam: Greed, Profiteering and Fraud in A Mental Health System Gone Crazy, St. Martin's Press, 1994].

The legacy of all this is that insurers are extremely skeptical of inpatient treatment for mental health problems; and providers have yet to prove that their residential services help teenagers. Instead of doing outcomes research -- which would still leave them at the mercy of insurers, even if they could demonstrate positive results -- the people who run many private residential programs decided to simply target parents rich enough to pay for services themselves.

The field is now so tangled that hundreds of people make their livings as "educational consultants", claiming to help parents find the best program for their difficult kids. Unfortunately, these consultants can add another level of problems: some take kickbacks from the industry and they are not licensed or regulated. They use nothing but their own knowledge (no qualifications are required) to steer parents to programs -- usually, for a steep fee, of course. It's one unregulated industry trying to guide people through another.

So how do parents determine, first of all, whether their children actually need residential care and secondly, if they do, how to find a program that is, at minimum, unlikely to be harmful?

The first step is to refuse to allow the treatment industry -- including the consultants -- to induce panic or force hurried decision-making. The industry is built on largely unrealistic fears, often telling parents that their children will be dead within weeks if they don't get help immediately. Given that fewer than 20,000 teens die every year from *all* causes (not just behavioral ones) and that there are some 40 million teens, such fear is unwarranted.

Even if all the deaths from all causes occurred only amongst the 4 million teens with severe mental and behavioral problems (which is highly implausible since many, of course, are passenger deaths in non-avoidable car accidents and deaths from disease), that would still be an annual risk of death of just 4 in 1000 per year.

So, the first thing parents need to do is recognize that while their teens may seem dangerously 'out of control', there are entire government agencies, anti-drug ad campaigns and a billion dollar residential treatment industry -- not to mention the always up-for-a-scare-media in general -- devoted to exaggerating the risks of adolescence.

Life expectancy is growing: the risk of death during adolescence and young adulthood fell by 40% since 1950. Teen deaths due to suicide and drunk-driving have also dropped dramatically; and the vast majority of drug overdoses have always occurred in adults, often in middle age. Teen pregnancy and drug use are also down dramatically. Teens today are far more likely to make it safely to adulthood than their parents were, but parents are continuously told that teen risks escalate in each succeeding generation.

To make the best decisions then, parents need to start calmly, far from the influence of those who would use their fear to sell their product.

Next Post: Genuinely Serious Teen Problems v. Those Most Likely to Be Outgrown