On 2004-03-25 22:47:00, Anonymous wrote:
"WOW! She got that the "stupid" rules had a deeper meaning! She's a keeper! "
I'm one of the first ones to rail against the stupid rules. Here's why:
They are appropriate in a "boot camp" setting---military boot camp works well with them.
They are *not* appropriate in a setting where the patient is "section 8."
This young woman's experience was in large measure luck. Luck that she didn't develop worse psychiatric problems from the harsh regime--that she tempered instead of breaking.
You can't treat real children like omelettes where it's okay to break a few eggs. Okay, correction: You obviously *can*, but you shouldn't.
This young woman was an appropriate candidate for residential treatment, no question, because of the cutting.
But there was also great risk that the regime provided would provoke a suicide or add PTSD on top of her other problems.
There is a good, sound *reason* why the military doesn't accept people with certain psychological problems, and why if they find the problems in boot camp they discharge that recruit "for the good of the service."
My problem with boot camp regimes (take away everything and you earn it back through learning the proper behaviors--"nothing is free") is not that they don't work when applied to the right sort of problems. My problem with boot camp regimes is that to avoid the omelette "have to break a few eggs" result, you have to screen potential participants very carefully.
Unfortunately, the programs only seem to screen for whether the patient will be too dangerous to *them* to handle, and whether the parents have enough cash.
This patient also probably would have had a positive result from supportive therapy in a residential setting with the same close supervision to prevent cutting but without the stupid rules just for the sake of stupid rules.
Believe it or not, I do (and always have) understand the point of the stupid rules---it's that rules are rules and you'll always have to cope with stupid rules and to give you practice coping with them in a controlled environment. It trains in, firmly, unconditional obedience to authority.
I just don't happen to agree that unconditional obedience to authority is a *good* thing.
Still, for *some* problems it's appropriate.
My biggest problem with the programs is that they seem to tend to be rather one-size-fits-all with the cashectomy from the parents being the priority.
One of the fundamentals in mental health rules and ethics for adults is that a patient with a mental illness, even one that occasionally makes him or her dangerous, to receive treatment in the least restrictive form that is effective for the treatment of that problem.
Minors don't have the same *legal* rights, but the underlying ethical principle still holds.
Putting a major depressive in a mental hospital where you can watch him/her night and day, either on medication or in a padded room, and just keeping him or her there for life *also* "works"---but mental hospitals aren't allowed to do that anymore, and for damned good reasons.
It doesn't say here that anybody ever considered getting this girl stable on medication in a supportive, well-supervised care environment and then releasing her to continue medication and supportive therapy on an outpatient basis.
Supportive models of therapy have just as good a track record as confrontational models, without the downside--psychiatric casualties of PTSD in some program patients.
One dirty little secret the programs are keeping is that there would be a certain statistical amount of improvement just from warehousing these kids for a year with no therapy at all---because a lot of the problems the parents are upset about are a function of the physiological brain development stage of humans that age. In a year, the kid's frontal lobes will be more developed, his/her logic abilities and ability to reason cause and effect will be more developed, his/her hormones will be more settled, he/she will have more impulse control----all because of physiological development that would have happened no matter where the kid was.
Parents compare their kid who comes home a year later to who he/she was before he/she went. Program kids compare *themselves* a year later to who they were before they went. What they *don't* do is compare their coming home behavior to a statistical sample of controls with the same problems who *didn't* go and just grew up some in that year of development from their normal daily lives.
Some of the not directly abusive programs that are restrained in their use of restraints, provide sound nutrition and the full nights' sleep teens require (more than an adult), that just have strict rules are appropriate treatments for *some* problems.
But there needs to be oversight to make sure that kids are not placed in programs when they either don't have problems requiring residential treatment or when for their particular set of problems that particular kind of program is contraindicated.
Programs also need government oversight to ensure the kids get: enough sleep; nutrition that is appropriate calorically, is a balanced diet, and is supplemented with vitamins where necessary to reach US RDA; adequate and clean shelter and clothing; proper medical care; and educational support appropriate to the child (an IEP).
Any residential program that ever uses restraints needs oversight---whether for children or adults. There need to be training programs and certification, you need to have to be certified to apply restraints as an employee, and all patients who may be subject to restraint need a physical especially checking heart health at or prior to admission and a check of health including heart health post-restraint. All use of restraints needs to be logged and reviewed by a state oversight agency.
Unnecessary program admissions are like unnecessary full-term C-sections. They "work" in that at the end of the procedure the woman is no longer pregnant, and many women have a good result in that they have the baby and are no longer pregnant, but you also have many women with complications from the unnecessary procedure that they wouldn't have had if you'd only done the medically necessary C-sections and let labor run its course with proper supportive care for the rest.
I'm glad this former patient is okay.
But she's "anecdotal evidence." And both sides can produce anecdotes all day--the plural of anecdote is not "data."
The limited sound research done on these programs does not support that their model is clinically more effective than less restrictive competing models for certain sets of patients.
The research done on "Outward Bound" doesn't transfer well to these programs with major differences in their treatment model and patient/participant pool.
I'm not against all residential treatment. I'm against involuntary residential treatment for conditions that don't require it. I'm against models of residential treatment that are inappropriate and contraindicated for the particular problems of that particular patient. I'm against residential treatment that is neglectful or that uses restraints too readily or applied by inadequately trained personnel.
I want reform, regulation, and oversight.
Red tape is a pain in the ass, but some of it is sometimes necessary.
Many things need less red tape and regulation. The troubled teen residential treatment industry needs more.
A lot of these places could be reformed if you put together a traditional prep school, not lockdown, under traditional prep school faculty, facilities, and rules, with a therapy and acute care facility on the same grounds.
If a kid meets the criteria that in an adult would justify involuntary commitment, put him in the ward until stabilized. Once stabilized, stick him in the dorms on the prep school side with classes, etc., and let him walk over for therapy/psychiatric appointments. Medication for outpatients could be done on the DOTS system in the cafeteria.
When admitting a new kid to the facility, *don't* start them all off on the ward---not unless the kid meets the same criteria as an adult for involuntary commitment. Put him/her in the dorms and combine prep school with any necessary outpatient therapy/treatment.
*Don't* make "group" therapy mandatory for all patients---it invites psychotherapy-cult type abuses. Use the same standards for what therapy is appropriate for what patient used to individually assess patients in normal mental health clinics. Some patients at some point may just need medication maintenance and not therapy. Some may need neither after a limited course of therapy. Some may need short courses of therapy as and if problems arise.
I don't think these places would get nearly as much flak if they were real prep schools with treatment services attached, where if the parents were nuts and the kid was basically sane it would end up with the kid essentially just being in a decent boarding/prep school instead of reliving "One Flew Over the Cuckoo's Nest."
The more these places resist oversight and reform, the more convinced I get that they need it.
