Members of Congress heard jarring testimony from the Government Accountability Office (GAO) last week about people who were denied medical care, starved, beaten, and "forced to eat vomit, lie in urine and feces, forced to use toothbrushes to clean toilets and then on their teeth."
A latecomer to the proceedings might "think we were talking about human-rights abuses in Third World countries," said Rep. George Miller of California, who convened the hearing. In fact, Congress was for the first time discussing abuses in "tough love" residential programs for teenagers.
These programs -- variously known as "boot camps," "emotional growth schools," "wilderness programs," and "therapeutic boarding schools" -- sell themselves to parents as a way of fighting teen drug use, behavioral problems, and various mental illnesses like depression, attention deficit disorder (ADD), even bipolar disorder (formerly known as manic depression). Some programs are public and are part of the juvenile justice system, others are run by private, for-profit organizations. Some are part of large networks of affiliates; others are independent. All lock up teens without contact from the outside world.
At Miller's request, the GAO recently investigated 10 deaths in such facilities, and found thousands of other allegations of abuse. Miller had called for the investigation after reading media accounts of abuses and discovering that not only are the private prisons for teenagers unregulated, but no one even knows how many there are or how many teenagers are held incommunicado in them without any civil-rights protections. It is time, Miller says, for federal regulation of these programs.
The ranking Republican on the committee, Howard P. McKeon of California, said the testimony of three parents whose children had been killed "boggled the mind." He noted that while he usually doesn't support broadening federal oversight, "there are some times when it has to happen."
But successfully regulating this billion-dollar industry will be an enormous challenge. The GAO investigation showed that when many abusive programs are exposed, they simply change names and/or move to different states, with staff avoiding accountability. And the programs often have powerful political allies, allowing them to skillfully dodge regulatory frameworks such as those that cover psychiatric hospitals or prisons.
To understand just how daunting it will be to implement federal oversight, one need only to hear the story of Straight Inc. and its offspring. The Florida-based anti-drug program is the granddaddy of the teen "tough love" industry. It was shuttered in 1993 following reports of serious abuses, but several programs derived from it remain open, state-licensed in addiction treatment, and, in many cases, accredited by respected organizations like the Council on Accreditation.
Straight was founded in 1976 by Republican heavyweight Mel Sembler-- who chaired the finance committee for the party during the 2000 elections and heads the Scooter Libby defense fund. Straight was based on a federally funded experiment in the 1970s called The Seed that had been denounced by a congressional investigation as "similar to the highly refined brainwashing techniques employed by the North Koreans."
Nonetheless, Straight spent the 1980s as Nancy Reagan's favorite drug treatment program and won wide praise from Democrats as well. By the early 1990s, it had nine facilities in seven states, and it claims to have "treated" 50,000 teens. It only went from media darling to media devil when reports of its regime of psychological and physical abuse became too ubiquitous (and civil lawsuits too expensive) to ignore. Terminal attrition followed the bad press, lawsuits, and state investigations, ultimately causing Straight to shut itself down.
After Straight finally closed its doors in 1993, The St. Petersburg Times wrote an editorial headlined, "A Persistent, Foul Odor." It covered a state investigation that suggested influence from Sembler and other politicians had contributed to Straight's ability to stay open despite documented abuse.
However, just as The Seed produced Straight, Straight spawned as well. At least six programs using identical "therapeutic" language and the same model still operate today in the U.S. and Canada. They are all run by former Straight participants or former employees of programs copied directly from Straight.
The largest remaining Straight-descendant program, the Pathway Family Center, has sites in three states and support from major companies like Emmis Communications and the professional basketball team, the Indiana Pacers.
Founded by Terri Nissley, whose expertise lies in the fact that she had an addicted daughter and her family participated in Straight, Pathway opened in Detroit in 1993. In fact, according to The Tampa Tribune, the facility was simply Straight's Detroit affiliate, reincorporated under a new name.
Pathway has continued to expand, swallowing up another former Straight facility and opening several new ones. In 2006, Pathway took over Kids Helping Kids, an Ohio program which evolved out of Straight-Cincinnati. The program also has centers in Southfield, Michigan, and in Indianapolis and Chesterton, Indiana. The Chesterton location opened just this year, despite efforts from survivors of the Straight model to warn the community that the program was outdated and harmful.
What makes these "tough love" programs uniquely dangerous is that they are led by amateurs who believe they are experts. No qualifications are needed to own, operate, or work with kids at such programs -- although they often employ some professionals, their influence is subsumed by the organizations' strict rules and regimes. And while they claim to treat serious mental illnesses and addictions, many of their tactics conflict with proven therapies for these conditions and they often don't even have the expertise to diagnose them properly.
The programs also tend to endorse an outdated view of teen problems in which confronting, humiliating, and degrading adolescents is seen as beneficial -- while kindness is stigmatized as "codependence" or "enabling." As leading addictions-outcomes researcher William Miller, Ph.D. put it in a recent paper, "Four decades of research have failed to yield a single clinical trial showing efficacy of confrontational counseling, whereas a number have documented harmful effects, particularly for more vulnerable populations."
The programs descended from Straight are especially problematic because they house kids from one often-dysfunctional family in the home of another. To regulators, this appears to be "outpatient" treatment, but kids are not free to leave. In these programs, new teens are held in the houses of families of teens who have been at the program longer ("oldcomers"). Newcomers spend their first nights in bedrooms with specially set alarms and where, teens say, the "oldcomers" frequently keep their beds against the door -- a fire hazard that's meant to prevent escape attempts.
At night, these "oldcomer" teens -- many of whom were admitted to the program due to anti-social behavior -- have absolute power over "newcomers." According to former program participants I interviewed, they can restrain them if they try to run, deny them the right to go to the bathroom, and impose other punishments. Every program that has used this Lord of the Flies system has, not surprisingly, run into serious problems.
Some of the more egregious physical practices at Pathway centers and other Straight descendants appear to have been dropped. They no longer make kids flap their arms wildly instead of raising their hands to get attention, or deny newcomers freedom of movement by having oldcomers push them around by their belt loops, whenever they aren't seated.
But according to teens, parents, and a former employee, the amateurish and confrontational core of the program remains.
Holly Guernsey's 15-year-old daughter -- I'll call her "Blair" -- had been caught stealing a pint of Schnapps from a store. She had previously been diagnosed with depression and ADD and had also been cutting herself. After the shoplifting incident, Blair's grandmother found Pathway in a Michigan phone book, and in January 2007, Blair was brought in for an evaluation. "We were concerned, but we didn't think she was an alcoholic," says Guernsey. "We thought the pot and alcohol were just symptoms. We were told [Pathway] would deal with the underlying problems," Guernsey told me.
But Blair soon found herself in a program where drugs were the focus. She says she was repeatedly told that she was lying about the amount of drugs she'd taken, and she quickly became severely depressed.
She spent her nights in a host home, with an alarm on the locked bedroom windows and a doorbell and alarm on the door. To go to the bathroom, she'd have to wake her "oldcomer" to ring the bell, wake the parents to silence the alarm, and then be escorted to the bathroom. At this "phase" of the program, kids are not allowed to read, watch TV, hear music, go to school, or even talk without permission. For most of the 10 to 12 hour days they spent at the center, teens say they have to sit still and straight with their feet flat on the ground.
One night, Blair broke a glass candleholder and slit her wrists. "There was blood everywhere," she says, explaining that she was made to stay up all night in the bathroom, apparently so that she could be monitored and so that she would not leave bloodstains where they couldn't easily be rinsed away. She says she was not seen by an internist or psychiatrist -- nor did Pathway inform her mother of the suicide attempt, which left scars.
Months later, Blair "earned" the right to go home. "As soon as we got alone with her, she would just sob," Guernsey says. But Blair didn't tell her mother what had happened.
Parents and teens who have been through Pathway told me that if an adolescent says anything at all negative about the program to her parents or anyone else, Pathway considers it "manipulation," and if it's reported, the teen will become a "newcomer" again, forced to return to a host home. Other teens get in similar trouble if they overhear such "manipulation" but do not inform program staff.
Guernsey only learned of her daughter's suicide attempt because two girls who were living with Blair decided to break this rule. One had been living with her in the host home where she'd slit her wrists. The girls told Guernsey that Blair needed professional help and begged her not to report them.
Soon, Guernsey discovered that another family had had a similar experience. I spoke to them as well. A woman -- I'll call her "Ada" here because she wishes to remain anonymous -- told me that her daughter had been admitted to Pathway for being suicidal. Yet Ada says she wasn't told when, while at a Pathway host home, the girl swallowed dish detergent and jumped off a 7-foot-high balcony. Again, both mother and daughter say the teen wasn't seen by a doctor.
A woman who attended the now-Pathway-affiliated Kids Helping Kids in 2003 reported similar abuses, including teens being made to restrain and even beat other teens who did not comply with the program.
Pathway's Executive Director Terri Nissley says every one of these negative allegations is "not true." In an e-mail, she wrote, "Pathway Family Center provides a professional and effective therapeutic community evidenced by our quarterly Parent and Client Satisfaction surveys, Exit Interviews with all families upon discharge, and countless testimonials from parents and clients. Our accreditation with CARF [the Commission on the Accreditation of Rehabilitation Facilities] is a testament to our commitment to person-centered, quality services. The agency was given an exemplary rating for our host home component... The adolescents are always treated with respect and dignity."
She also wrote, "A recent allegation was investigated by Pathway, CARF and the State of Michigan and was determined to be unfounded."
However, a knowledgeable state official who did not want to be named said that recent complaints regarding the host homes have not been resolved.
For reasons unrelated to the allegations, Pathway says it recently switched accreditation agencies from the Council on Accreditation (COA) to CARF, but a COA staffer said that Pathway had been put on probation due to complaints and had not resolved the situation before it switched agencies.
The Florida Straight descendant, Growing Together, finally folded last year after a 2004 exposé detailed bizarre sexual molestation of teens in host homes going back to 1997. And the reports out of Canada's Alberta Adolescent Recovery Center, which also uses the Straight host-home model, are just as horrifying.
These problems are clearly not just the result of a few "bad apples" taking charge. Allegations of abuse have rapidly arisen against any program using this treatment model. Consequently, careful regulation is desperately needed to ensure that adolescents with mental illnesses and behavior disorders are not subjected to it or to similar forms of quackery and to see to it that they actually get appropriate treatment. Straight and its descendants prove conclusively that troubled teens are too vulnerable to be left under the care of amateurs -- especially amateurs who are under less oversight than mental health professionals.
Rep. Miller is writing legislation intended to remedy the situation, which he plans to introduce early next year. The support from his committee's ranking Republican is enormously promising. However, the details here are truly devilish: bad regulation might further legitimize the industry, rather than successfully rein it in.
For example, if lax regulation is imposed, parents might be led to believe that these programs are being closely overseen by authorities. Straight was state-regulated as an addiction treatment center, as is Pathway, despite official complaints from families. Federal regulation without strict enforcement could allow programs to claim that there is oversight, even if it is toothless.
Effective regulation would at minimum ban the use of "host homes," ban corporal punishment in residential facilities (including punitive use of isolation and restraint), and require that mental illnesses and addictions be evaluated and treated only by professionals. By requiring independent evaluation before placement and on an ongoing basis, such legislation could restrict lockdown institutional care for teens to short periods of professionalized, empathetic inpatient care necessary for safety. It should also outlaw coerced placement in "wilderness programs" and the marketing of any unlicensed, locked facility for teens as treatment for psychological disorders or drug problems. (In fact, just this week, Rep. Miller asked the FTC to look into the industry's deceptive marketing practices.)
To have the strongest impact, regulation should also ban employees found to have engaged in corroborated abuse from further work in the industry and should prevent organizations found to be abusive from simply renaming themselves or moving to another state. It would have to be funded to provide for strict enforcement and ideally, would also have to fund evidence-based, outpatient alternatives to help desperate families.
Tough love cannot be made safe when carried out by lock-down institutions; since it doesn't offer any therapeutic advantage and carries serious risks, there is no need for an "alternative" system of unregulated private jails to impose it on teenagers. Regulation should provide for care that actually works. Four decades of Straight and its offspring is more than enough.