THE TROUBLE WITH TOUGH LOVE

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.