By Maia Szalavitz
Sunday, January 29, 2006
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.
Maia Szalavitz is the author of "Help at Any Cost: How the Troubled-Teen Industry Cons Parents and Hurts Kids" (Riverhead Books).