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Outlook: "Tough Love" Programs for Teens Often Counterproductive
Tactics of Harsh Rules, Confrontation Questioned

Maia Szalavitz
Author, "Help at Any Cost: How the Troubled-Teen Industry Cons Parents and Hurts Kids"
Monday, January 30, 2006 1:00 PM

What do you do when your affectionate child is transformed, seemingly overnight, into an out-of-control, drug-addicted, hostile teenager? Many parents blame themselves before turning in desperation to wilderness schools and therapeutic boarding schools, where their wayward adolescents are confronted with a philosophy of tough love and forced to face the need to change their behavior. But a patchwork of lax state regulations, writes former addict Maia Szalavitz, is all that protects the kids in these institutions, which are regulated like ordinary boarding schools but sometimes utilize more severe methods of restraint and isolation than psychiatric centers.

Maia Szalavitz, author of "Help at Any Cost: How the Troubled-Teen Industry Cons Parents and Hurts Kids" (Riverhead Books), was online Monday, Jan. 30, at 1 p.m. ET to discuss her Sunday Outlook article, The Trouble With Tough Love.

The transcript follows.

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Washington, D.C.: If tough love doesn't work (and I agree with you it does not), what are some alternatives to help troubled teens and their families?

Maia Szalavitz: There are a number of alternate therapies that help. Research finds that the best predictor of therapy success is whether or not the counselor is empathetic and supportive. All effective approaches use this.

Also, inpatient treatment is almost never needed. The exceptions are severe psychiatric conditions in which the person is a danger to self or others (not simply smoking pot and running away): this requires psychiatric care, not tough love. The second is injection drug use: this requires evidence-based addiction treatment, not generic "troubled teen" programs. Unfortunately, evidence-based addiction care is rare, but effective techniques include cognitive-behavioral treatment and motivational interviewing.

For general teen problems the best researched treatments are multisystemic family therapy and functional family therapy. These have been tested on mentally ill, violent, drug addicted and otherwise disturbed teens in the criminal justice system and they work without removing the child from the community.

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Frederick, Md.: As a parent who has dealt with adolescent substance abuse, including a residential treatment approach that included 'confrontational therapy', I find your article misleading and borderline unhelpful to parents looking to help their children. I agree that 'non-compliant' behavior is not THE problem to be addressed but most experts would agree that dealing with the substance abuse is primary before the underlying causes of substance abuse can be addressed. Most kids who are in need of help are not the least bit interested in receiving any. We worked our way through church guidance counselors, adolescent therapy, and out patient approaches before choosing a residential treatment program. While confrontational therapy is a significant component of the treatment, the aim of this program, Substance Abuse Family Education (SAFE), was not simple behavior modification but reaching through to the underlying issues that preceded the substance abuse, learning tools for coping without drugs (including alcohol), and restoring families. You may be right in there being other approaches that do not include confrontational therapy but I saw none offered in the article. I can assure you that the passage of time, which you imply, is NOT a viable alternative for many young people whose lives have dealt them a bad hand and who have turned to self medicating to cope.

Maia Szalavitz: The SAFE program is a direct descendent of Straight Inc. (it opened the day Straight closed with the same staff and the same location) and has been linked to numerous cases of abuse.

Regarding the passage of time, the data from longitudinal studies of adolescent trouble is clear that most, even without help, even amongst the most severely troubled, do outgrow these problems.

Programs like SAFE tell parents that kids who smoke pot and drink alcohol will be dead within weeks if they aren't enrolled-- they say this about heroin, cocaine, methamphetamine, as well, of course.

But the truth is, very very few kids ever die from drugs and alcohol. The total number of teen deaths from all causes, per year is roughly 20,000. There are about 40 million teens. Even if these deaths were only from drugs and alcohol and occurred only in the 4 million teens who have severe behavioral and mental disorders, that's still only a risk of death of roughly 4 in 1000.

This is not to say that you just leave them alone-- but it is to show how oversold these programs are.

What most of these kids need is parental discipline, outpatient treatment and time.

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Tampa, Fla.: How can we better protect our kids against the abuse of some of these programs?

Maia Szalavitz: What we need, I think, are federal regulations which would do the following:

require an independent evaluation of the child (i.e., done by someone who won't make money by putting the child in treatment and who doesn't have any need to please the parents who may actually be the ones with the problem, not the kid). Require that this be ongoing and require that the kid get the least restrictive treatment possible (as in mental and physical health care generally)

require 24/7 access to an abuse hotline-- if the kid is faking, the investigators can find out but they need to have

access to independent help.

best of all, require that a treatment be proven safe and effective via research *before* it can be sold, just as is done with drugs.

Don't let insurance or public money go to any programs that haven't been proven: do the research first, don't experiment on our kids without admitting that that's what you're doing.

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Washington, D.C.: Great article! I have always been dismayed by such programs, and I am glad you're exposing the abuse, inefficiency, and lax oversight of this industry. What I have seen, from my own observations and the experiences of loved ones, is that it isn't "tough love," but often gratuitous cruelty to people who need everything but. These programs say a lot more about our need for quick-fix, low-investment "solutions" than a heartfelt and reasonable answer to a population in pain.

Maia Szalavitz: Thank you!

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Washington, D.C.: Thank you for a great article. I have a question, however.

While I understand the difficulty that parents endure when their teen-ager becomes uncontrollable, but I don't understand the motivation for turning them over to people and programs that guarantee to "fix" them.

I can only surmise that possibly insurance payments may be a factor. Are insurance companies more willing to pay for these programs versus one-on-one therapy or some other more appropriate care?

Maia Szalavitz: Curiously, most insurers won't pay for these or for any inpatient care.

That's because the research is pretty clear that most kids don't need inpatient care (and because they want to save money, of course).

Where this becomes tragic is for the kids who *do* need inpatient care. Sadly, many families have to turn kids over to the state to get treatment for mental illness.

What's worse, that treatment hasn't been proven to help, often. We need research-based treatment and only that should be funded.

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Lovettsville, Va.: Thank you for the illuminating article. I liked your analysis of what teens need, and what they don't need. I was particularly dismayed by the the sexual humiliation tactics. There is ample documentation of links between a right-wing authoritarian world view and anti-gay animus. Can you elaborate on the following:

1. Are many gay youth involved in the programs.

2. Are gay youth (or perceived gay youth) singled out for this humiliation, or is it dished out equally.

3. Are these techniques confined to facilities that espouse a particular ideology or religious affiliation?

Maia Szalavitz: Yes, sadly, many gay kids are sent to these programs-- many specifically for the purpose of being "cured" of their homosexuality.

Public humiliation and use of "drag" dress and homophobic slurs is often part of the "treatment"-- it is used on both straight and gay kids, but gay kids often get the worst of it.

This occurs in both religious and supposedly non-religious programs. It is appalling.

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Frederick, Md.: Um, I'm an adult recovering alcoholic and I would say NO ONE gets to where I am unless they want to. Treatments of any kind do nothing unless self motivation is there. That said, I also know the behavior first hand - lying, promises not kept, manipulation etc. How do parents sort out helping from being suckered?

Maia Szalavitz: What you need to do is see the problem from the kid's perspective: he thinks getting high helps. he wants to feel good. if you offer him a way to feel good without getting high, without appearing like you want to control or humiliate him, he's way more open to it than he will be if you use force.

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Madison, Wis.: So are you saying that ALL wilderness programs, detentions centers and emotional boarding school have the same philosophy of using tough love as their fundamental baseline? My guess is that would be impossible to believe there has been no evolution of this idea since the '80s when tough love was the treatment of choice.

Maia Szalavitz: I'm not saying that all programs use this, but I am saying that the philosophy is so pervasive that even programs that claim not to use it often have employees who *do* use it.

I'm also saying that because tough love has gotten somewhat of a bad name, programs that use it often lie in their publicity material and because there is no regulation, parents can't tell what they'll get.

I had a horrible case where a woman was told she was getting a kind, boy scout camp -- and then her kid was left to die of an untreated ulcer in agony over two weeks. This was in 1996, I believe.

Even the "kind" wilderness programs make kids eat lizards and do not provide enough calories to get by on-- and even the best have had deaths related to kid's health complaints not being believed because they were thought to be "faking."

Without more regs, parents can't tell if they'll get a genuinely kind program, basically.

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Md.: "What most of these kids need is parental discipline, outpatient treatment and time."

No, what most of them need is a trip to a dual diagnosis treatment facility, maybe inpatient hospital care, and THEN an outpatient therapist. Who, if they're good, will combine empathy with confrontation to get to the bottom of the illness.

Out of all the mentally ill or substance abusers I've known, time has never worked, and quite often made the problem worse. I could have avoided 10+ years of untreated illness if I hadn't been left to "she'll grow out of it." To say that to a hurting teen and their family is dishonest and if you were a doctor would be borderline malpractice.

Maia Szalavitz: I agree with you regarding mentally ill addicts. But most of the kids sent to these programs are neither genuinely mentally ill or even actually addicts. most just don't get on with their parents -- some 70 percent by the admission of one program official.

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Fredericksburg, Va.: What do you propose to do with a teen who is not motivated for treatment, highly manipulative, without parental involvement or support for which substance abuse is not the primary issue? You article assumes that most teenagers are just like you were when you were a teen (which a small few may be) but how do you deal with full blown conduct disorder without confrontation? Despite your self-education into the subject, I find you still have a lot to learn.

Maia Szalavitz: Conduct disorder and other serious mental illnesses, anything that starts preadolescence and worsens in adolescence (and these are a tiny minority of kids, and even a minority amongst those sent to programs) have no easy answers.

What we need, and I'm sorry if this sounds like a cop out, but we desperately need more research.

Rather than throwing these kids into unproven treatments, we need to do clinical trials of treatments, see what works, *then* sell the programs.

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Ridgefield, Conn.: By bunching all of these programs together would be to say that there is no difference between a gas power car and a tricycle. By putting them all together you are diluting the truth scaring and people in to thinking that all transportation is the same. There are programs out there that are under funded and unsafe for any child. I hope what people hear from all of this is to do their research. Educational consultants are a good start and will help guide any family in the right direction for their child.

Maia Szalavitz: Many educational consultants take kickbacks from programs, there is no research that guides their selection of programs, they have an incentive to put kids in unneeded inpatient treatment and they are not required to have any qualifications.

There may be some good ones out there, but I have no clue how you'd find one.

I have a list of questions to ask to select treatment in my book, which will appear on my website http://www.helpatanycost.com/ in the next few days and I would recommend parents use that and be sure they've tried numerous outpatient options first before even thinking about such a person.

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Falls Church, Va.: I have a teenage son who is "addicted" not to drugs, but to computer games -- sufficiently addicted that it has consumed all his waking hours and caused him to be suspended from college despite the fact that he is intellectually ahead of most of his peers. It seems clear that he is hiding from the world and probably from himself. My question is, what approach, other than "tough love," do you recommend for pulling him out of the cell he has built for himself?

Maia Szalavitz: I think with such problems, a really good psychiatric evaluation with someone who can build rapport with kids is critical.

The kid needs to see that you are on his side, that you are not trying to take away his fun, but that you want him to have *more* fun... then, he's far more likely to accept treatment.

I think such withdrawal from the world is often depression, but you really need a good evaluation before you do anything, I think.

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Purcellville, Va.: What about "wilderness" programs? What is their record for success? There is one at Alldredge Academy in West Virginia. Have you heard anything about that one?

Maia Szalavitz: The data on wilderness programs is sparse and conflicting: the better the quality of the study, the less likely it is to find that the program works. This is not a good sign.

I think, for kids who like the woods, the best thing is a wilderness program *not* for troubled kids. That way, he gets benefit of woods (which I do think is possible, particularly for ADD) ... but if he has a health problem, he will be believed.

My main problem with most wilderness programs is that they see the kids as liars and manipulators and don't believe health complaints and this has resulted in deaths.

There may be some good ones, but lack of regulation and lack of qualifications for workers means that the quality may be highly variable and what was a good program last week may now be terrible because a tough-love supporting employee has been hired.

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Anonymous: What short term residential therapy did you go to?

Maia Szalavitz: The place I went no longer exists (shut down because like most of the programs in the '80s, it gave everyone the same treatment -- smoke pot once a week and you got a month inpt, inject heroin, same treatment). It was a traditional 28-day rehab which used a 12-step approach.

I found that helpful, but I also know many people who don't find it useful and I think treatment needs to not push one method, but "meet the person where she's at."

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Frederick, Md.: While I am familiar with the Straight program having preceded what has eventually become SAFE, and am aware of issues of reported abuse in that time frame, I respectfully submit that there have been many changes in the SAFE treatment model from that prior program and that there have been no such abuses in the almost four years that I have known about the program. I don't wish to turn your time into a debate about this program, but in its in its current form, has no current staff from that prior program and does not operate from that facility. The larger problem in all this is lack of information and guidance to assist parents and their children in dealing with this difficult issue. While I can agree that confrontational therapy may not be effective for all cases, it continues to be an effective tool for change and recovery for some.

Maia Szalavitz: There is no evidence that confrontation works.

When confrontational counseling is compared with empathetic counseling, the clients of the confrontational counselor take more drugs and drink more and are more likely to drop out of treatment.

The original confrontational Synanon groups were shown to cause lasting psychological damage in 9 percent of participants-- and those were normal college kids who could leave, not kids trapped in treatment.

There is *no* reason to use confrontation-- there are ways to handle drug use and manipulation politely and respectfully without humiliating and attacking people.

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Washington, D.C.: Did you see the TV show "Brat Camp" last summer? I thought it really exaggerated the "success" of this particular wilderness program.

Maia Szalavitz: I believe two of the participants were arrested before the show even aired!!!!

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Tampa, Fla.: I was stuck in Straight because my was sister was there and my parents were told they had no choice but to place me into Straight, or their daughter would be terminated from the program and die in the street and it would be their fault!

I had no drug problem.

One day while on first phase of Straight I stood up and confessed to being molested when I was younger. Guess what I was called? A "fag" along with a number of other things that are not printable.

I want to thank Maia for the wonderful article keep up the good work!

Maia Szalavitz: And thank you as well ... without former participants coming forward and discussing these horrors, these programs would be hurting far more people!

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Maryland: Wonderful article and I agree that alternative solutions are necessary. I also agree that they should be regulated by the Government. I'm a parent of a child who is now in a boys camp in Garrett County, Md. My son has been there for two months. I must say I see a great improvement, but I attribute this to God and my son's belief and desire to want to do better. One of the things I notice throughout the past year of dealing with my son and his defiant behavior, was there really isn't anything to support parents or kids "right at the beginning". In most cases, the kids have to do something major, like get in trouble with the law, etc., before anything is even suggested within the school system. I'm a supporter of tough love; however, I do agree that that is not the best answer in all cases. What would you suggest parents who are concern and really want to bring awareness to this problem do? Start support groups, lobby our local or state lawmakers, what?

Again, thanks for bring awareness to this issue.

Maia Szalavitz: I think people absolutely need support before things get "out of control."

I believe our current school system does not place enough emphasis on the development of compassion, empathy and kindness and by removing recess and focusing almost entirely on testing, it hurts kids (esp. boys) and does not serve us well.

I think we need more support for families -- in terms of time with their kids and information on child development. How to get that to happen, I don't know!

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Takoma Park, Md.: What would you advise a parent who has been told that the only way for their child to get help is to report their drug behavior to the police and get a judge to commit them to treatment?

Maia Szalavitz: Does the kid know this? I would first try to find the best treatment program you can, then tell the kid he can either go to the one you select or be mandated into one that you have no control over. In terms of finding the best program, it depends on the drug, but unless he's injecting or physically dependent on opioids, I would start with intensive outpatient and search for one that appears kind, empathetic and understanding.

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Md. Again: You miss my point. I'd wager at least half of troubled teens, or those using drugs, have an underlying mental illness. The term "dual diagnosis" refers specifically to this - it's a diagnosis of mental illness and substance abuse.

The ONLY way to treat this type of behavior is to get a medical evaluation and then determine whether inpatient care is needed. Or outpatient therapy. Unlike you, I am of the opinion that mental illness in adolescents is underdiagnosed, although I do agree that more research needs to be done on how to treat it. FTR, Johns Hopkins Hospital is one of the leading sites to be doing this research - did you contact them for your book?

Maia Szalavitz: This depends on what you mean by "using" -- there are numerous pot-smoking, drinking teens who are by no means addicts or mentally ill.

My research on these programs shows that many of their "patients" are kids who don't get on with their parents and smoke pot on weekends. These kids do not need anything more than time!

The heavy users, yes, probably half are dual diagnosis. They need care that treats both the drug problem and the mental illness -- but you don't have to be drug free to start treating the mental illness, that's a myth.

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Frederick, Md.: I'm Kathy and I e-mailed earlier today about my 20-year-old son. So many troubled young people. We've tried everything and now he's back home after being thrown out and homeless. We're trying to be positive and expect nothing more than stay at your job (since we drive you and pick you up). What do you think about the "accept and approve" approach?

Maia Szalavitz: that sounds about right, based on what you told me. most kids don't do what he was doing unless they are deeply unhappy. try to find the source of that, help with alternatives and in most cases, with time, he'll improve.

When he's stabilized, you can then increase your expectations.

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Silver Spring, Md.: I am curious how you were able to identify what your difficulties were and how you raised yourself out of them. I have a 21-year-old son with different problems than yours but he is stuck and I am so worried about him. He has always been different and we have tried so many things to help him. He has made small progress but I'd like to know how you were able to self realized and identify what you needed to do to help yourself.

Maia Szalavitz: I had an unfortunate incident where I realized I was willing to sleep with someone to get drugs. I'd never done that -- and the idea that I would even consider it shocked me into awareness that I needed to stop using. I weighed 80 pounds and was injecting up to 40 times a day at that time. I called my parents and they got me into detox the next day.

If I had known there was treatment that wouldn't be humiliating and degrading, I would probably not have waited until I was that desperate to consider help.

I know I've said this a lot, but the more you can see it from his perspective, the more likely you'll be to be able to reach and help him, I think

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Williamsburg, Va.: The article was great, my daughter could have written it from her experiences also. Most folks miss the parent's desperation in these situations. By the time the real problem is defined the behavior is so out of control that there is little option other than a rehab program (of any stripe) or jail (juvenile justice system). When we stopped protecting my daughter from jail she started to realize that we could get "tough" when we showed up for every visiting session (no matter how stressful) she realized she was 'loved'.

What I know is a loving parent will do anything to help their child, even if it's the wrong thing.

Maia Szalavitz: That's absolutely true -- which is why I think we need regulation, so parents aren't taken advantage of when they are so desperate as to consider anything.

It should be like cancer: you can search the evidence online and go to the best center based on what you learn about treatment. It shouldn't be that you get the equivalent of quack cures promoted in the mainstream press without any info that there's no data to support them other than anecdote.

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Atlanta, Ga.: I am a success story that has come from drug addiction through a wilderness program and on to live a very fruitful, clean, happy life. I have sense made a career at working with troubled youth. The part that you are leaving out is that the wilderness program teach responsibility, leadership, and self esteem. It also brought power, control and choice back in to my life. In my experience a PhD therapist found the core issues that led to my self destructive behavior. If you are writing for such a large audience I expect you to know that drug abuse is not just a fear of acceptance, the core issue starts much earlier and runs much deeper. There is a VERY large distinction between private and public programs, wilderness camps and boot camps and emotional boarding schools. You cannot group those together since they do not share the same philosophical foundation. This information in this article is so vague and diluted. The only weight it does carry is that there are some programs out they that should not be open due to bad management or funds that cannot support their safety. If you educate yourself with the help of the Internet and professionals such as educational consultants you can find a placement that will assist you and educate you in making the right decision.

Maia Szalavitz: There are unfortunately numerous wilderness programs that are staffed entirely without professionals.

And because there is no regulation, they can claim to be as good as those which have professional staff -- and even lie about the credentials of their staff.

I'm glad to hear that you did well -- but the industry is filled with horror stories and the good people in it need to stop opposing regulation for fear of increased costs and get behind it to help the kids!

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Trenton, N.J.: In your article, you note that a counselor disparaged your looks. Could you please elaborate on this? I do not understand why someone would do that in the course of drug counseling, even as a part of tough love. I am having a hard time believing that there was no one you could complain to about such behavior...?

Maia Szalavitz: This woman was completely absurd -- she told me I looked like Jiminy Cricket! [I did weigh 80 pounds and my hair was a mess].

Unfortunately, in many of these programs, if you complain, you are seen as being "in denial" or "resistant" and I couldn't risk that because I had a court case against me (I wasn't mandated, but I'd told the authorities I was in treatment).

In some, if you "go over someone's head" you are "breaking chain of command" and that itself is a rule violation! It is a recipe for abuse of power.

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Midland, Va.: A kid was given a camping knife and cut himself, then the next day hung himself to death. It seems that at the time of that incident at Alldredge Academy in West Virginia, that company's owner was initially charged with negligent homicide.

Maia Szalavitz: I believe I have been in touch with the father of that child and it is a truly horrific story. I couldn't recall whether Alldredge was the name of the program, but that sounds like the story.

They sent the boy there for depression -- and then the program claimed he was "manipulating" when he expressed suicidal thoughts!!!!

It is sick.

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Fredericksburg, Va.: The information you are presenting is biased, slanted, skewed, misrepresentative, manipulated and a gross distortion of the facts so that you can make money selling a book exploiting desperate parents trying any way possible to help their children when they have already been failed time and time again by "the system" which has already been researched to death. You think residential programs should be investigated and researched, fine. That is a given. Nobody is arguing about that. But, don't sensationalize a few grievous incidents like kids being forced to dress in drag like its an acceptable treatment technique. You are needlessly scaring people who are already scared. Shame on you!

Maia Szalavitz: No, it is those who promote the industry who are needlessly scaring parents by claiming that weekend pot smokers need inpatient treatment and that they will be dead in days if they don't get it!!!

I have literally thousands of accounts by children and parents of these abuses. They are not isolated incidents: they are what happens when you give untrained people absolute power over vulnerable children who have no way to complain about what's going on.

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Philadelphia, Pa.: I wonder if you would agree with my thinking or if you have some comments or a different slant on my belief in having a positive attitude. I believe people, especially the young, as very susceptible to verbal suggestions. If you tell a child that the child can do something, they are more apt to be successful. If you tell a child it can't be done, failure is more likely. Having a positive attitude seems to have worked in so many situations and is the basis of the philosophy of Norman Vincent Peale to several religions who believe in the positive impact of prayer. Thus, isn't tough parenting sort of the opposite: tell a child they are bad and beyond your help, aren't they more likely to then agree they are beyond help and will possibly fall further into the depression or drugs that they are already into? Wouldn't giving a child the ability to see a more positive road out of their problems a better approach?

Maia Szalavitz: I think that's pretty well right: people live up to or down to your expectations of them.

If you treat people with dignity and respect, they tend to do likewise.

Not always, of course, but you can't teach politeness and kindness by being rude and brutal!

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San Francisco, Calif.: Our daughter is in a psychiatric center, not a therapeutic boarding school. Do you talk about these youth centers in your book? The kids go to school, but also participate in individual, group and family therapy, as well as attend 12-step meetings and engage in clean and sober leisure activities such as horseback riding and snow boarding. Our daughter was so out of control, she left us no choice but to place her out-of-home. We continue to hope that she will mature to a point where she can once again live in an unstructured setting, but the only time she seems sane is when she is confined and the only communication with us is by telephone.

Maia Szalavitz: Most of the psychiatric centers are better -- though some have horror stories, too. But at least, these are regulated and at least, they are staffed by professionals and often have some research base. and at least, the kids have a way to reach outside from them, usually and they are required to allow complaints.

I think it's not so great that they are using a 12-step only approach however-- this has some problems for teens, like making them admit to having the disease of addiction, which is lifelong and carries a 90 percent chance of relapse. that can be a self-fulfilling prophecy and I think the research is pretty clear that kids need alternatives as well. but if it's working for her and she likes the steps, probably not a problem.

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