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Professional News
Popular Therapy Alternative Plagued by Abuse Charges
Psychiatric News
Volume 42 Number 23 page 6-9

A report released by t he Government Accountability Office (GAO) in October identified thousands of allegations of patient mistreatment at" residential treatment programs" across the country.

The GAO report cited allegations of abuse, some of which involved patient deaths, at what the report refers to as residential treatment programs— such as "boot camps" and "wilderness therapy programs" that treat substance abuse and behavioral problems—between 1990 and 2007. The report did not define residential treatment programs other than describing them as "intended to provide a less-restrictive alternative to incarceration or hospitalization for youth who may require intervention to address emotional or behavioral challenges."

The allegations included reports of abuse and death recorded by state agencies and the Department of Health and Human Services (HHS) between 1990 and 2004. The allegations in the GAO report were detailed in pending civil and criminal trials involving hundreds of plaintiffs, along with claims of abuse and death posted online.

During 2005 alone, 33 states reported 1,619 staff members involved in incidents of abuse in residential programs, according to the National Child Abuse and Neglect Data System (NCANDS). Critics of the programs estimate 10,000 to 20,000 children are enrolled in them each year.

The GAO report came at the request of the House Education and Labor Committee to verify whether allegations of abuse and death at residential treatment programs were widespread and to examine the circumstances of closed cases in which teenagers died while enrolled in private residential programs.

The investigation follows the establishment of hundreds of residential treatment programs and facilities for troubled youth since the early 1990s by state agencies and private companies.

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Although many programs have received the praise of parents for providing professional and competent staff who helped to improve children's lives, others have raised concerns that have resulted in media attention and lawsuits.

"Sporadic news accounts of specific incidents have built a record that should never have been ignored, but shamefully was," said Rep. George Miller (D-Calif.), chair of the Education and Labor Committee, at a hearing on the report in October. "The federal government has completely failed to grasp the urgency of this situation."

The overarching problem identified by the GAO report was the lack of a single Web site, federal agency, or other entity that collects comprehensive nationwide data on public and private residential treatment programs, which treat boys and girls for a variety of "addiction, behavioral, and emotional problems."

The NCANDS database, operated by HHS, collects some data from states, but data submission is voluntary, and not all states with residential treatment programs contribute information.

Due to the lack of centralized information on such programs, the GAO investigators said it was not possible to generalize the results of their investigation to all residential treatment programs, whether privately or publicly funded. The information shortfall complicates the effort to obtain an overall picture of even the extent of the "residential treatment program industry."

For example, while states often regulate publicly funded programs, a number of states do not license or otherwise regulate private programs. This lack of oversight extends into the design and approaches of these programs, whose leaders decide how to describe them without even standard definitions for such treatment approaches as "wilderness therapy programs" or" boot camps."

The GAO plans to conclude an industrywide review in 2008, providing a more comprehensive look at such programs.

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Petros Levounis, M.D., chair of APA's Council on Children, Adolescents, and Their Families, told Psychiatric News that addiction specialists have long thought that programs like those identified in the GAO report are much less effective in the treatment of addiction than therapeutic approaches based on positive motivation. The confrontational treatment approaches they use were abandoned by mainstream addiction programs 30 years ago after they were found ineffective.

"We tried this type of confrontation route and very strict discipline and found it simply doesn't work," said Levounis, director of the Addiction Institute of New York and chief of the Division of Addiction Psychiatry at St. Luke's and Roosevelt Hospitals. "It is particularly detrimental for people who suffer from other mental illnesses, as well, such as schizophrenia or depression or bipolar disorder."

The report's findings that many programs have dangerous conditions and" tremendous side effects" are additional reasons for keeping children with co-occurring mental disorders away from such treatment approaches, he said.

The report echoes concerns raised by a 2006 study funded by the Substance Abuse and Mental Health Services Administration of residential treatment facilities serving adolescent populations, which indicated that they often lacked comprehensive services for the participants, especially when other co-occurring illnesses were involved. For instance, almost all adolescent-focused, residential substance abuse treatment facilities conduct comprehensive substance abuse assessments. However, only half of those facilities also conduct comprehensive mental health assessments, which are recommended as part of an integrated treatment approach.

Children with co-occurring mental illnesses in such residential treatment programs, Levounis said, are at best deprived of safe and effective treatments for their dual diagnosis—in terms of medication or psychotherapy—and at worst, they are at risk for death or severe physical harm.

Levounis suggested a multipronged response to the findings, including regulatory changes to establish minimum quality assurance, that program participants have access to physicians and mental health professionals, and that there be an adequate patient-to-staff ratio.

"Also, all of us need to keep working to debunk the myth of harsh confrontation being the ultimate weapon against severe addiction," he said.

Miller previously introduced legislation that would provide resources to states to help them create licensing standards for private residential treatment programs.

The GAO report is posted at<www.gao.gov/cgi-bin/getrpt?GAO-08-146T>.

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