Coercive "therapy"

[Anne Bonney]

Jump on Cafety and ask Dr Huffine

Coercive Treatment of Adolescents - Dr. Huffine        
By Charles Huffine, M.D.

As a psychiatrist I must confess and disavow some bad history for my profession in the area of coercive treatment. At least we are not in the leadership of the residential therapeutic school movement, but in hospitals and older treatment facilities we presided over some horrible examples of treatment where our patients were without rights. In recent years (since the 1970's) involuntary treatment for adults, mainly commitment to psychiatric hospitals, has been governed by a tight set of criteria. These involuntary stays are usually very brief and designed to intervene to save lives in an extreme situation. This has not been so with adolescents. Forced hospitalizations and residential treatment stays lasting for months or years were common from the 1980?s on where psychiatrists were part of the leadership of the facilities. But such facilities were licensed by states; often they were accredited by an independent agency and held to some sort of standards of humane care. But the rights of youth to consent or refuse care were not in place. My profession, like most mental health disciplines has not taken the issue of youth rights seriously.

My style of practice in providing mental health services to youth.

I work primarily with adolescents in an outpatient setting. I have grown very comfortable with the realities of adolescent life; its pitfalls and its glories. I have learned to respect confidentiality, even when I hear of things that youth I work with do that are clearly risky. Almost all youth referred to me have had terrible experiences with other therapists. Mostly prior therapists didn't respect confidentiality, freaked out and disclosed very sensitive things to parents, who subsequently freaked out causing a bigger mess. So most youth don't come to me with automatic trust or positive expectations. As I hear about a new patient?s outrageous activities from parents I do my best to not freak out. I try my hardest to come to understand that kid, know their strengths and potential. If I have done my part in forging a good working relationship with a kid they come to know and trust me while I come to know them as individuals. We then can work together. A working relationship depends on getting beyond the adult ? kid power imbalance where we come to respect and like each other as human beings. In such a relationship youth tell me things about their lives that most adults never hear and I use my influence to help youth who are taking huge risks and are on the edge of self-destructing. I try to cool their jets a bit and offer up some good alternatives and common sense to them. I practice a harm reduction approach to treatment. It is my observation that troubled youth are almost always hungry for such a non-judgmental relationship with an adult who can serve as a mentor. I rarely suggest a kid go to the hospital and I never recommend to a kid or their family that they seek long-term placement in a facility such as many of you have suffered. When I have such a relationship with a youth, I almost always witness their toning down their behavior to a level that is not dangerous. They don?t need to be protected from themselves. They come back for their appointments without being forced. I stay involved in their lives actively for a period of time in their adolescents and many come back for counseling as young adults if they have issues, trusting that they will be respected by me and that I will handle personal information sensitively. I am aware that my perspective and my style of working with youth is somewhat unusual given very mixed standards of care in the mental health treatment of adolescents. But I am confident in my approach. I see my patients respond well to me.

Some of my patients are referred to me with a history of having been in a therapeutic boarding school. Once they have come to trust me they will share with me the kind of tales we find on this web site; horrific details of abusive and grossly inappropriate treatment. I have heard these stories too many times. The stories vary however. Occasionally I have heard some positive stories where a youth has been treated with respect and caring in an appropriately run facility, but even then it is against their will. I see very little evidence that even these kids have been helped. The bad stories prevail. I care deeply for youth I work with. I have a strong bias of positive regard for all youth I meet because I genuinely like adolescents. When I hear of mistreatment in facilities that are supposed to care for youth I feel the betrayal and see the harm it has done to my patient. My reaction has been one of extreme anger. This has mobilized me to be an activist in trying to address the system failings that allow these travesties to continue. How could any adult do differently if they are a decent human being and have normal instincts of care and concern for kids? It horrifies me that in our society we can enter into a mass denial that lets these facilities exist.

Youth rights, a major societal failure.

In treatment facilities that treat kids (including hospitals) in almost all areas of the country except my state, the state of Washington, youth rights are violated when they are forced into care, especially forced to stay in a facility. Why are youth rights not violated in the State of Washington? Let me explain. We have an unusual law, a law that is constantly threatened by regressive elements of our legislature. That law states that youth must consent to their mental health and substance abuse treatment from the day they turn 13! Why 13? The thinking of the legislators who drafted these laws is lost in history, but there are hints. They also gave reproductive health rights to all post pubertal woman in this same time period. All these laws came about in an era of consciousness over reproductive rights in the 1970?s. The drafters of the legislation did not have the advantage of good data, but these laws do make some sense based on more recent research. Puberty happens for almost all youth before 13 and is near completion by that time. Social expectations change when youth are post pubertal. Youth are forced to make many complicated judgments at this time in their lives, as they become more independent players in society. Social choices are foisted on youth whether they are prepared or not. They have to make choices that require judgment, even if their brains are not fully developed to the point that they can exercise adult like judgment. We know that emotional arousal will cause a youth?s social judgment to deteriorate. Adolescents depend on their parents, and sometimes other adults in their lives, to moderate their having more independence in their communities and more complicated social choice making. Mostly this parental guidance works for youth if it is respectful and lovingly delivered. Mostly, once in a calmer state after a conflict with parents over a reprimand or limit setting, youth will come around and see the wisdom in their parents concerns. But what happens when youth are not blessed with parents who are competent to offer such good advice, or don?t have their adolescent child?s interests uppermost in their heart and mind? It is these exceptions where there is need for clarity about youth rights is.

When can youth competently exercise judgment regarding major decisions in their lives?

Some research has found that sometime between 12 and 14 (12 and 15 in another study) individuals make as good a judgment about their health care, including mental health and substance abuse services, as did youth at 18, or even those 25 years old. Suffice it to say, some individuals at all ages make terrible judgments, especially when emotionally charged up, but the research supports youth having a capacity for competent, confidential and self determining decision making on all health care matters at age 13 or 14. The right to consent equals the right to NOT consent. One without the other is meaningless. The right to refuse protects youth in my state from being forced into any coercive care in the same way as adults are protected. So let me explain that when youth are forced into care in my state why their rights are not violated.

When is it all right and necessary to force individuals into protective treatment?

It is important to understand the conditions under which individuals can and should be coerced into care. The commitment laws of most states are designed to address those situations when an individual is in eminent risk of lethally harming themselves or someone else due to a mental disorder, or are so incapable of functioning due to such a disorder that they present an immediate risk of incurring harm. My state is very strict in observing these criteria before they detain such an individual. A trained County Designated Mental Health Professional (CDMHP) must screen each person detained before they can be held for 3 days. At the end of an initial 3-day period a court hearing must occur where an independent attorney represents the individual. If the evidence continues to indicate a high degree of eminent risk of harm the individual must stay for an additional 14 days. At the end of 14 days a rigorous legal process sorts out those few individuals who don't respond to crisis level care in 14 days of hospitalization and must be detained for 90 to 180 days. In the state of Washington all youth 13 and older are subject to this process if they are to be detained for a mental disorder. In Washington State there is an alternative method for detaining youth designed to address outrageous behavior that may not be recognized as due to a mental disorder. This process is called either an ?At Risk Youth? (ARY) or ?Children In Need of Services? (CHINS) petition, both of which can inform the judge that a child is at risk due to emotional problems indicated by their behavior. A judge can detain a youth, ages 13 through 17, for 5 days maximum. A longer stay can be theoretically initiated if a parent physically takes a youth to a hospital and the hospital evaluates and accepts them based on the same criteria. An appeal process involving an attorney is possible if the youth is hospitalized. That process, if completed successfully for the youth would take no more then 30 days. No hospital has ever detained a youth under this provision in our current law for fear of a lawsuit.

So what makes an involuntary commitment for an adult or a youth over 13 not against their rights?

It is that a legal review process with access to an attorney is assured. Such a process is the rule in involuntary treatment, and the ARY and CHINS petitions. Of course, if a youth breaks the law a judge may order them to treatment in lieu of jail, but that is not involuntary treatment, it is just giving a youth an option to not go to jail, even if it feels like a "deal they can't refuse."

Involuntary residential care outside of such a legal process cannot be therapeutic, no mater how humane and well intended the staff, as it undercuts and essential aspect of adolescent development, the achievement of autonomy. It is NOT therapeutic because the loss of rights does damage to a sense of self. It undercuts the formation of a personal identity. As with restraint and seclusion, it may be necessary to save a life, but it has a very large cost. It represents a failure, or an absence, of community-based treatment. In such circumstances, such active coercion needs to be ended in the shortest possible time, preferably only a few days. Individuals detained, even in a state of psychotic thinking, should be offered trauma support and counseling, similar to what is commonly recommended after an episode of restraint, to undo the damage caused by such coercion.

I personally believe that if our laws that protect youth rights in mental health and substance abuse treatment were changed from 13 to 16 or 18, the State of Washington would have a flood of locked residential programs emerge around Seattle just as in Idaho, Utah and Montana. I strongly believe that we will not solve the problem of unsafe, non-therapeutic, inappropriate residential treatment until youth are given rights to consent to care in all 50 states. If Idaho, Montana and Utah and all other states had such laws, and had strong Protection and Advocacy agencies in their states to assure adherence to such laws, we would not have the problems we do today and youth such as most of you would no longer endure the abuse and humiliation you have suffered.

Giving youth legal rights doesn?t take away parental rights.

Assuring that youth under 18 have rights would not cause them to run amok. It is an insult to youth to assume that the much-maligned stereotype of an unruly teenager is the rule. It is a very clear minority of youth who are out of control of their parents and in these cases the breakdown of parental authority and respect most often represents a serious emotional problem for the youth, or within their family. Almost always families have the resources to instill decent values in their kids and kids don't violate such values with their behavior without guilt and shattered self-esteem. We know that caring parents who set limits and intervene on the basis of their love for their kids are successful at influencing their kids and can be assured that their youth's behavior will be reasonably safe and decent. It is also true that if trust between parents and youth has been broken by parents who are abusive themselves, or have neglected their kids, a youth's behavior may very well reflect their upset with such parents. Allowing parents to place such kids in horrible facilities is simply a continuation of that abuse. We also know that youth from decent, ?good enough? families do things, and will continue to do things, with peers that would give parents heartburn if they knew. Incurring some risks; i.e. learning to not be stupid with drugs or alcohol, handling sexuality responsibly, learning to drive a car safely are all not without risks, but are normative challenges for youth in our communities. Youth who are upset due to depression or anxiety or some other mental health problems may act out their pain with gross and inappropriate behavior, (1.e. cutting themselves, abusive drinking, gorging and forced vomiting, shoplifting or getting into fights) but good evaluation and treatment can help youth to no longer need to do these kind of things to express their pain. In these types of situations parents need the support and skill of someone who can work with their son or daughter and have the tools to define and treat the problem. Parents with troubled youth need support and it is the obligation of a mental health therapist to either provide such support or arrange support for such parents. A community based treatment within the context of a mentor like relationship with a therapist is more respectful of a young person who has to find their own way through the complexities of growing up, but it is also more respectful of parents who need a sense of community support if they are to handle the rough edges of parenting a youth with significant emotional problems.

My views on the need to limit coercive care stems from my success in treating youth in their communities, amongst all the so-called bad influences. It is born of my learning the power of strength based care and believing that every young person has talents and capacities that are untapped in their adolescent years and that supporting the growth of maturity and uncovering such capacities is the best form of treatment. My views are also shaped by an appreciation of social and family context. I am very aware that families and communities can fail youth. Families of emotionally troubled youth need ?clued in? therapists to work to correct such difficulties while helping youth cope with often non-optimal growing up conditions. I have seen the power of helping families and building community as an alternative to ripping a kid out of their family and community.

Clearly community based care for troubled youth is preferable. We need to do much more to think through if and when there are medically necessary reasons for forcing youth into hospitals or residential treatment programs. Their may occasionally be such circumstances, but current research is insufficient to forge an informed opinion on this issue. Certainly we know that such interventions, when the result of an involuntary treatment process, should be rare and brief and subject to legal scrutiny. I hope that these thoughts will inspire some discussion, and possibly some debate. I plan to participate on this website in discussions about ?good therapy? and provide some thoughts from the land of sympathetic professionals.
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