Reconsidering Rehab
The last thing teens need?
By Tana Ganeva

“She was lying on the ground, incoherent,” Rita Mauro, a project manager from New Jersey, recalls of her daughter, Lisa. “She was absolutely out of it—couldn’t get up, walk—so I called an ambulance. Turns out she was on alcohol, pills and I don’t know what else.”

Lisa, who was 15 at the time, had gotten messed up hanging out with friends. She had been drinking, smoking pot and taking various pills for months. Another time, her basketball coach had smelled vodka on her breath during practice and called home.

Desperate and afraid, Rita did what many parents would do. She committed her daughter to a teen treatment facility, hoping it would help her straighten out. “I thought, ‘a few weeks in rehab, everything’s cool’. It wasn’t. It was just the beginning of years of rehab, relapse, rehab, relapse.”

Lisa Tarr is now 24, and has struggled with heroin addiction for almost a decade. “My mom was scared and didn’t know what else to do,” she says. “Every time I got out … I’d end up using shortly, because I wasn’t there by my choice, so I had no desire to stop.”

It might seem logical, or kind, to institutionalize your child before their situation deteriorates. But doing so is normally unnecessary and often ineffective. It carries multiple additional risks—from misdiagnosis and life-disruption, to negative peer-influences and negative self-identification, to browbeating and outright abuse. In most situations, there are far better alternatives.

“I would never send my kid into group inpatient treatment.”

The idea that people with addiction need treatment, not jail has become commonplace among US public officials since opioid-related deaths began surging in the early 2000s. Policy has yet to catch up. Still, it’s a welcome shift from the carceral approaches of the ‘80s and ‘90s crack era (a shift that sadly owes much to the perceived racial profile of those involved).

But “treatment” can mean many different things—and very little treatment currently offered in the US is based on sound evidence.

Danielle Ramo, assistant professor of Psychiatry at UCSF, points out that private facilities aren’t required to collect or share data, leading to a shortage of information on outcomes and best practices: “It’s hard to know what they’re tracking, how well they’re doing, what positive outcomes they’re achieving.”

And figuring out how to address risky substance use is even trickier with teenagers. Adolescent brains, habits and self-identity are fluid and vulnerable. Even the best-intentioned efforts to help “troubled” kids can backfire.

“I would never send my kid into any kind of group inpatient treatment,” says Thomas Dishion, a psychologist and researcher who studies adolescent behavior and child development and runs the Arizona State University chapter of Reach Institute, a think tank addressing mental health issues in young people. 

Overreacting to Teen Drug Use Is Itself Dangerous

One factor that makes inpatient treatment a poor fit for this age-group is that severe addictions just don’t often occur in young teens.

“The most common situation is teens using drugs, smoking a lot of pot and drinking. Usually it’s not daily use but binges,” says Maia Szalavitz, an author, journalist and researcher specializing in addiction, whose books include Help at Any Cost: How the Troubled-Teen Industry Cons Parents and Hurts Kids (2006). “Most teens in treatment are not using often enough to have a physical dependence.”

The National Institutes of Health’s 2016 “Monitoring the Future” survey found that drug or alcohol problems among younger teens are surprisingly rare. Occasional binge drinking among eighth-graders (defined as five or more drinks in a row,  within the past two weeks) is down to 3.4 percent, and falling. Only 20.5 percent of high school sophomores say they’ve ever been drunk—down from over 40 percent in 2000.

There are two key reasons severe substance use problems are relatively rare among under-18s. First, with parents breathing down your neck, it’s not that easy to sustain regular enough use to become dependent. Second, forming addictive behaviors can often take time—and teens, self-evidently, tend to be newcomers.

None of this should minimize the seriousness of addiction for the small minority of kids who do experience it. It should, however, caution against knee-jerk reactions to isolated incidents, or the misdiagnosis of experimentation-gone-wrong.

“If a child is acting out because of trauma, they need caring people around them—not to be shipped off to a wilderness camp.”

“Let’s say a kid has a rough two weeks, or a month,” asks Dishion; “does that mean they have a lifelong addiction problem?”

Amid the current outcry around opioids, it’s more understandable than ever that a parent suspecting drug use might panic. And the stigma still surrounding addiction might well cause them to secretively type “addiction” and “teen” into a search engine, rather than reach out openly to professionals to learn more and seek advice. A Google search for teens and addiction yields 46,700,000 results. Residential programs dominate.

But experts think inpatient treatment should be an absolute last resort—only suitable in very specific circumstances or acute emergencies.

“Parents: Before you do anything, take a deep breath,” Szalavitz says. “Get a psychiatric evaluation from someone who’s not affiliated with the rehab treatment industry. Address any mental illness that might be there. If you don’t address those issues first, you can really make things worse.”

If a child is acting out because of trauma, she adds, especially the trauma of loss, they need caring people around them—not to be shipped off to, say, a wilderness camp. “You don’t send someone away to get ‘fixed.’”

There are some justifying scenarios, of course, such as “if a kid is actively suicidal or needs to be stabilized or have their meds adjusted,” Szalavitz says. “But residential is very rarely the answer.”

Danielle Ramo says that worried parents often approach her when she gives talks about teens and addiction. “I often get parents asking me, what’s the best solution? Should I be calling treatment programs? I definitely tell them that’s not the first thing they should be thinking about. Not an extensive inpatient program that wouldn’t involve the family.”

“Their concern is extremely valid and the desire to do something to help the situation immediately is acute,” she continues, but there’s just not enough evidence that inpatient (or even outpatient) interventions work. From a harm-reduction angle, one promising strategy Ramo has seen—at least as a short-term measure—is paying teens, “literally giving money or other awards,” for drug-free urine samples.

But overall, “what helps immensely is the involvement of parents in the treatment process and continuing care—a model that supports teens and families.”

Teens in Rehab Are Heavily Influenced by Their Rehab Peers

It isn’t just that rehab can be an uncalled-for interruption, removing a teen from important adults, friends, routines and comforts in their regular life. It’s that rehab peer-groups—comprised of other, equally or perhaps much more “troubled” teens—are likely to exert powerful, unforeseen influences on a new arrival’s behaviors and outlook.

“There’s good data to suggest kids learn from other kids, they develop friendships, and you end up encouraging the very behavior you’re trying to discourage,” Thomas Dishion says. “It can inadvertently make things worse.”

In a paper for Society for Research in Child Development, with Kenneth Dodge and Jennifer Lansford, he examined how inpatient treatment for young people can backfire. Their 2006 meta-analysis of 19 randomized controlled trial studies found that trying to correct any kind of teen “deviant” behavior in a group setting—ranging from segregating unruly kids in a classroom to “Scared Straight” programs—more often than not yielded adverse or mixed results.

“Placing a deviant adolescent with deviant peers can reduce the intended benefits of interventions and lead to less positive, sometimes even negative, outcomes, especially under conditions of poor supervision and lack of structure,” they concluded.

“Rebellious experimenters mixing with peers who do have severe problems greatly exacerbates this.”

Lisa Tarr jokingly compares one of the facilities she attended in New Jersey to some messed-up version of the TV show DeGrassi High, a cult classic about Canadian high schoolers. The rehab had all the show’s drama, only with drugs, trauma and addiction thrown in.

“No one wanted to be there,” she says. “Everyone’s trying to rebel because they’re a teenager. People smoke cigarettes, get high on everything they have, have sex in bathrooms. If one person goes in actually wanting to stop using, you’ve got 90 people telling them why they shouldn’t.”

This may have had profound consequences for Tarr. She first went into treatment in the early 2000s, as problems with opioids began to soar nationally. The very first heroin users she got to know well were her rehab roommates.

“They opened up that gate of curiosity for me,” she says. She would end up using heroin for a decade.

All teens in such an environment have the capacity to influence each other negatively. But the fact that many residents are misdiagnosed and should not be there—rebellious experimenters mixing with peers who do have severe problems—greatly exacerbates this issue.

“Let’s say you’ve got some teen shooting up two times a day, selling their body on the street for drugs,” Szalavitz says. “That story is ‘cooler’ than, ‘I smoked pot a few times and got caught by my parents.’”

“Then, you tell this kid who smoked some pot they’ve got a chronic disease for the rest of their lives and that there’s a 90 percent chance of relapse and then they’re around this ‘cool kid,’ they might think, ‘Damn! I didn’t even get to see the interesting stuff,’” she continues. “At the same time, if you have kids that are actually addicted, which is rare, they’re going to have a high rate of relapse.”

Teaching Teens That They’re “Addicts” Can Become Self-Fulfilling

The idea that addiction is always forever is yet another reason inpatient rehab can be problematic—for teens, particularly. It’s pervasive in treatment because the vast majority of the US rehab industry is based around the 12 Steps of Alcoholics Anonymous, the fellowship which encourages lifelong sobriety.

Raging controversies over the nature of addiction and the role of AA in this field won’t end anytime soon. But there should be a consensus that it’s not the best idea to convince an adolescent, in a volatile period of their life, that they have a disease that will never leave them.

For one thing, there’s plenty of evidence that it isn’t true. Many young people—most, ultimately—will grow out of problematic drug and alcohol use, even without intervention or treatment.

Second, the idea that addiction is a chronic, relapsing disease that requires constant vigilance as the sufferer forever teeters on the brink can be inherently harmful. One study found that a major risk factor for alcohol relapse was a person’s belief that alcoholism is a chronic disease.

“I thought, I have a disease that will kill me; it’s only a matter of time. That’s the message you get in the recovery movement.”

Tina Dupuy, a 41-year-old journalist and political commentator living in New York City, once experienced an extreme version of early institutionalization and indoctrination.

She was a rebellious child, often clashing with her mother, during the 1980s, when the media—as they often are—were consumed with “problem” teens, as portrayed in many an after-school special. By age 11, having been caught drinking, Dupuy was sent to a residential mental health facility. She was subsequently introduced to AA and by age 13, she self-identified as an “alcoholic.”

“I thought, I have a disease that will kill me; it’s only a matter of time,” she says. “That’s the message you get in the recovery movement.”

The psychological toll can last years. According to Dupuy, being told she was an alcoholic at such a young age warped her identity and sense of the future. “I was pathologized,” she says. “I thought I had a self-destruct button. I thought I was going to live the rest of my life in one institution or another. I lost all hope, thinking I’d never live a normal life.”

Szalavitz agrees that it’s problematic to convince people they’re “addicts” at an early age. “You have these kids take on the identity of, ‘I am an addict’ and then they’re told that recovery is really, really hard.” This, combined with exposure to rehab peers, she says, can negatively impact a young person’s problems.

Many Rehabs Confuse “Treatment” With Punishment —Or Even Abuse

The irrational tactics employed by many rehab facilities reach far beyond what is suggested by any recovery program. Large numbers of treatment centers have bizarre, oppressive rules—aimed at using confrontation and punishment to “set teens straight.”

At one New Jersey facility where Lisa Tarr spent 19 months in her late teens, the kids weren’t allowed to skip any steps—literally. They had to walk up the stairs one at a time, or they’d get punished.

“It was a rule written on the wall,” she says. Violations were not treated lightly. If you got caught breaking this or any other of the facility’s commandments, you faced the “haircut.”

“That’s when they sat you in a chair against the wall and people lined up in front of you, pointing fingers at you and telling you you’re a horrible person,” Tarr says. The imposition of some unpleasant chore, like washing the dishes of the facility’s hundreds of residents, would follow. “It was supposed to make you a better person.”

Starting in the mid-20th century, a confrontational approach to addiction gained ground in America. It still prevails in the public eye: Think Dr. Drew’s Celebrity Rehab, where D-listers’ struggles with drug use are fishbowled and broadcast. But scientific research has shown that such approaches tend to be ineffective,  and even do more harm than good. In their 2007 survey of the history of the recovery movement, William L. White, MA, and William R. Miller, Phd summed up why.

“Defensiveness is a normal human response when one is accused, demeaned, labeled, disrespected or threatened,” they wrote. “In other words, suspicion and confrontation are self-fulfilling prophecies.”

“There are predators employed by residential programs with unlimited access to children.”

Kevin Mackus, a 24-year-old bearded New Jersey native with a tattoo of a ram on the side of his head, had—unlike most of his peers—developed a very severe addiction very quickly.

“I started shooting up heroin as a freshman in high school,” he says. He first got the drugs from an upperclassman, and before long he was injecting daily. “There was no progression for me. A lot of people get into pills first, but I went from one side of the spectrum to the other very quickly.”

First came jail—30 days—after he got caught breaking into a house. “It was juvenile detention but it still sucked.” Then came repeated, court-mandated inpatient treatment. That was better than jail, he says, but he doesn’t think the programs helped him all that much—in part because of their harsh rules and questionable tactics.

“It was very strict, you had to wear a shirt and tie, do intensive group therapy,” he says. “You’d have people calling you out on your behavior.”

It didn’t work. “The day I got out, I got high.”

At one facility in New Jersey, “They used to cut our food … like, not feed us. They would sleep-deprive us. They constantly forced us to yell at each other. We always had to confront others about their behavior. Even if I had my shirt untucked … they’d always tell us we were doing something wrong and they’d call us out on it. If you were bad, you’d get dragged in front of all the residents to be humiliated. They’d all take turns telling me how much of a piece of shit I am. They’d beat you down, build you up—but then what?”

Mackus adds that there were staff members who genuinely tried to help, but that they were in the minority. “Ninety percent of staffers were sadistic fucks that just wanted to make kids do fucked up shit.”

Part of the reason such a wide, often-bizarre range of programs and tactics exists is that treatment facilities are almost entirely unregulated. No federal agency oversees rehab programs, and the degree of government oversight varies state by state.

Maia Szalavitz likens the status quo to the US Food and Drug Administration’s lack of power to create best practices and punish abuses—only much worse.

“Imagine a thing where there’s no FDA,” she says. “That’s what you have with teen rehabs. There are some well-intentioned people doing good work, but you’ve also got people screaming at kids in therapy. That’s a massive regulatory problem.”

In the worst cases, “treatment” adds up to outright abuse, which might compound existing trauma.

“There are predators employed by residential programs because it gives them unlimited access to children. There are programs that tell the parents not to believe their kids, that expose them to horrible sexual, physical or emotional abuse, and call it treatment,” says Szalavitz, who detailed such incidences in her book. “There have been programs that make the kids dress up as prostitutes, that use isolation rooms, starve them…”

In Most Cases, the Risks Outweigh the Benefits

Obviously, some of the appalling abuses recorded in certain facilities are not widespread, and individual experiences vary greatly. Lisa Tarr, for example, doesn’t think she was abused, just that most of her stints were pointless.

But even well-meaning facilities with caring staffers may be ineffective or counterproductive for a range of reasons, as we’ve seen—and when a young person’s well-being is on the line, that’s quite enough cause to worry.

“When you send a kid off to rehab, you send them away from everything they’ve known,” says Tina Dupuy, whose experience and research have led her to vehemently oppose residential rehab for young people. “It’s supposed to shock the system—or whatever philosophy you’ve got for why you should be spending $50,000 on rehab—but what you’re doing is [potentially] traumatizing a child, and then wanting them to act better because of the trauma.”

Maia Szalavitz also points out a problem inherent in treating a teen away from home: “Whatever you learn doesn’t [in general] transfer back into the real world.”

Kevin Mackus agrees. He says knowing how to make his bed the right way is useful and everything, but won’t help him grapple addiction.

But there are myriad personal experiences, and mixed feelings are common. For example, Mackus also says that AA—an option that never needs to be paid for—has so far been working for him, and wishes he’d been introduced to it earlier. And he adds, “For all intents and purposes [rehab] probably kept me alive because I was separated from the street.”

It’s important to acknowledge, too, that people’s motives for sending their kids to rehab are normally honorable. “Parents are trying to do the right thing,” Thomas Dishion says. It’s just that “they think they’re listening to professionals and then it can have bad outcomes.”

He recalls of one former client: “I had this mother, her daughter was running around out of the house, getting drunk. Someone told her the child was an alcoholic. She got sent to a treatment facility, and came out using many more substances that she’d ever have dreamed of before.”

What Might Have Been

No one is arguing that rehab for teens never works—only that the odds are bad, and that better options usually exist.

Over time, during Tarr’s many rehab stints, she developed a weird dynamic with her mother, Rita Mauro. Seeing her mom panic felt so awful that she’d say anything to make her feel better—like promise to stop using drugs, even though she didn’t plan to.

Having relied on a series of rehabs to help her family, it took Mauro a few years to realize that her daughter had “graduated” from drinking and pills to snorting heroin, to shooting up. “I didn’t see the signs. I should have,” she says.

Last year, at 23, Lisa Tarr was working as a maid in Florida when she got caught stealing and pawning hundreds of thousands of dollars’-worth of jewelry and other items. Her picture was splattered across the evening news. Local papers grimly advised Florida homeowners on how to protect themselves against devious maids.

She’ll never know for sure how things might have been if her mom had received different advice, if she hadn’t spent her teenage years going in and out of rehabs.

Many people hated high school. Lisa’s just sad that she didn’t get to go.

Tana is a New York-based journalist covering criminal justice, politics and drug policy. She has written for publications including the Washington Post, Vice, Glamour, Rolling Stone, the Huffington Post, Salon, Gothamist, the Stanford Social Innovation Review and many more... read more >>

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