Last week I spoke to Casie FAIRY Fariello of Other Parents Like Me, a support platform for parents with teens struggling with their mental health. We talked about her son’s journey with residential treatment and therapeutic boarding school. I followed up that interview with a Substack post about how to manage insurance issues regarding residential treatment.

But after having published both Casie’s episode and the Substack post, I realize there’s still so much I want to say about the decision to obtain a higher level of care for your teen. I’ve thought about this a lot over the past 6 years after having our then 17-year-old son jerked up in the wee hours of the morning and transported by strangers all the way to the other side of the country to a residential treatment facility we hoped would fix all of his problems – all of our problems.

Are you trying to figure out what to do about your teen who seems hell bent on ruining the future you envisioned for them? Do you wonder if there’s a place out there somewhere that will completely reverse course for them—make them think differently about themselves and their life, and completely change their behavior?

Maybe a wilderness program would help? Maybe a residential treatment facility  (an “RTC”) or a therapeutic boarding school (a “TBS”)? Stay right there and let me help clarify this question for you.

PODCAST INTRO

How do you even begin to decide whether your teen needs to leave home for treatment for their mental health or substance use?

For most of us this decision is driven by fear—fear that our kid is headed down the wrong path. Their behavior is what frightens us.

The level of behavior issues (and the associated fear) you’re willing to tolerate may be much different than the next parent, depending on your emotional intelligence, your understanding of adolescent behavior and your expectations of them, your mindset, your lived experiences, and your parenting skills.

Based on all of these things, one parent’s level of desperation to change their child’s behavior could be set off by circumstances that for another parent, might not even feel like anything other than typical teen behavior.

Without an understanding of adolescence, the self-awareness to regulate your emotions, and the parenting skills necessary to navigate these issues, many parents have a very low threshold for typical teen behavior and make the decision to send their kid away for treatment when it really isn’t necessary.

The same issues can cause other parents to exacerbate typical teen behavior into something that may actually need a lot of work to turn around—which turns into a decision to send their kid away for treatment.

The overriding sense of fear and panic parents feel when they decide to send their kids to a wilderness program or to an RTC (residential treatment) is very real in any case. We feel we’ve lost control; we’ve messed up, they’re going to ruin their life. We just want someone to step in and fix them—fix the situation.

But the truth is, there are far too many teens who end up a long way from home, feeling abandoned, frightened, and even more hurt and angry than before—and most of the time it could be prevented.

……………….

The American Academy of Child & Adolescent Psychiatry published guidelines on this issue back in 2010. The first words in that document are, “the best place for children and adolescents is at home with their families. A child or adolescent with mental illness should be treated in the safest and least restrictive environment and needed services should be ‘wrapped-around’ to provide more intensive home or community-based services.” This basically means providing a combination of different therapies, parenting support, medical management, etc. at home.

The guidance goes on to say that “When the treating clinician has considered less restrictive resources and determined that they are either unavailable or not appropriate for the patient’s needs, it might be necessary for a child or adolescent to receive treatment in a psychiatric residential treatment center (RTC).” And, “The assessment of an individual’s appropriateness for treatment within a RTC must include a number of factors, foremost being the child or adolescent’s safety and the safety of others.”

This is the general consensus in the mental health field—a child should never be removed from the home and sent away for overnight treatment (sometimes for weeks or months) unless all other treatment options have been exhausted, with the biggest decision factor being their safety and the safety of others.

But there are a couple of really big problems when it comes to these guidance.

First, depending on the mental health professional you’re working with—a therapist, a psychologist, a psychiatrist or all three (let’s just call them “the provider”)—there’s no telling what sort of advice you’ll get. They may not even be aware of this guidance, understand it, or may choose to ignore it.

Not all providers in the mental health space give this advice or are capable of guiding you to other treatment options prior to resorting to sending your teen away for treatment.

As much as we’d like to be able to trust them, I’ve learned through my own experience (and other’s) that it’s a bit of a crapshoot when it comes to getting the best advice about next steps. All too often, parents are told or left to feel that inpatient treatment is their only other option when that’s simply not the case.

The second problem with the guidance that all other treatment options should be exhausted before sending a teen away to inpatient, completely ignores your role in their mental health and behavior.

This is such an obvious problem that I can’t believe it’s not emphasized more often. Parental mental health and behavior are the most influential factors impacting adolescent mental health and behavior.

If you don’t believe anything else I say here today, believe this: your mental health, your substance use, your mindset, your attitude, the way you think and feel about your kid, the way you talk to your kid, the way you discipline your kid—these things impact their mental health and behavior more than anything else—period.

They may have a genetic predisposition, they may have a certain temperament, personality, developmental issues, learning issues…but your behavior, will influence them more than any other single issue. More than friends, more than school, more than social media. YOU.

You may have heard me say this before, but I don’t believe we would have ever had to consider putting our son in an RTC if I had known then what I know now.

If I had known how the adolescent brain worked, If I’d had help understanding my own thoughts and regulate my emotions about his behavior, If I’d learned how to communicate with him properly, to help him with his emotions, to become more emotionally connected to him so I could work with him to help improve his mental health and behavior issues…everything could have been completely different. That’s what I did after he came home, and it changed everything.

It’s why I do what I do.

So, I’m really perplexed as to why many if not most therapists who work with teens (especially those with behavioral issues) don’t suggest parent coaching, a parenting course, therapy for the parents, family therapy…at least a book or two. I don’t get it.

Some therapists might involve you minimally in a way that helps you support your teen and the therapeutic process, while ignoring the fact that if your teen is struggling with their mental health or substance use, you probably need to be working on yourself as hard as you want your kid to be working on themselves.

Please understand that your teen didn’t get here alone, their mental health doesn’t exist in a vacuum, it exists within the family unit, with you as a parent.

Yes, they could have trauma issues or mental health issues like anxiety or depression, which may lead to substance use…and no, you had nothing to do with creating the issue—but it’s your response to their behavior that can make their mental health and behavior better or worse.

So, again, it really blows my mind how too many providers focus very little on the parents when a kid or teen shows up in in their office.

Why is that not one of the first issues addressed? A parenting assessment maybe? Even a mental health assessment for the parent. The parent is part of the equation, and this must be addressed as a central part of the therapeutic process.

Working with the child alone is never going to yield the same results for that child. Never.

You can have your kid evaluated by a psychologist, you can send your kid to therapy, you can get their meds adjusted by the psychiatrist, you can do this for years—but until you address your role, learn to parent them in a way that will improve their mental health and their behavior, you’ll never get the best results.

The same is true if you choose to send them to wilderness, an RTC, a boot camp, a military school or a therapeutic boarding school. This is not the quick fix you may think it is. If they go away for a year but come back home to you and you’ve not changed anything about your parenting, any success they’ve seen while they were away, will quickly dissipate.

This is not just my opinion. Numerous studies have shown the importance of including parents in programs to help prevent teens from initiating substance use and to curb existing substance use. The literature shows that parent’s attitudes and behaviors have a crucial impact on their teen’s substance use.[1]

Scientific studies have also consistently shown that when parents receive instruction or training about parenting strategies and also receive therapy themselves, their kid’s mental health improved more than children of parents who did not receive the same support.

These “approaches” are called parent-directed interventions, and include things like proper communication techniques, coaching, how to better understand and respond to teens with mental health disorders, how to manage their own emotions.[2]  Things like I discuss on this podcast and teach in Parent Camp.

Even in cases where a provider may not be able to directly work with the parents, they could still strongly urge the parent to take certain steps to improve their parenting skills, their mental health, and the relationship with their child, if appropriate. And now that you know these things, you can make those suggestions and seek out the support you need.

If you still need convincing that your behavior impacts your teen’s behavior, for starters you can listen to episodes 151, 153, 155, and 157. I’ll of course, have all the links in the show notes.

Alright, so now you know that before considering any inpatient type of treatment for your teen, you need to consider whether you’ve tried all other therapeutic options that will keep them at home, and whether you’ve gotten help for your own mental health and gotten support in helping you parenting your teen in a way that improve their mental health and behavior.

Your therapeutic options would of course include a therapist or counselor at the very least. But even with that, having a full neuropsychological evaluation by a qualified psychologist will help them know for sure what issues they’re dealing with.

Maybe you need to also be working with a psychiatrist if they have a developmental of mental health disorder that can be treated with medication.

If they’re using substances maybe there’s a substance use counselor or perhaps a community program that can evaluate them for a substance use disorder and help them with that.

Are there other community services you could utilize, and have you already tried a partial hospitalization program or an intensive outpatient program, or both? These levels of care keep your kid at home with you.

You may want to check out episode 7 of the podcast where I explain the various levels of care to consider and episode 29 about getting the proper mental health diagnoses.

But remember the other factor here is working on yourself and your stress level, your mental health, your substance use (if that’s an issue), learn about their neurobiology, how to improve your relationship with them by improving your parenting skills, learn how to communicate with them better, discipline them more effectively, and reduce the conflict between you.

I know it’s hard to be in the middle of the storm and try to think through all of these issues. I know it can seem like the thing to do is just get them somewhere to let the professionals work their magic and make everything all better.

But I’m telling you, that’s simply not how it works.

Your goal should always be to avoid sending your child away if at all possible.

So, let’s say you get to the point where you’ve exhausted all other options and you and those providers advising you feel you must try something radical like sending them away for treatment.

You may be terrified. There are people who will tell you that absolutely no facility or boarding school or wilderness program is safe to send your child.

You may have heard horror stories about some of these places. There’ve been documentaries, news stories and law suits about abusive treatment in RTCs, boarding schools, wilderness therapy programs, and on and on.

And there’s no question that some of these facilities have turned out to be hell holes, some of them have been run by unqualified, uninformed, or misguided people who employed others who were the same or even worse – abusive.

Kids have been mistreated, suffered traumas, and yes, even died. It’s true. The “troubled teen industry” is enormous, not heavily regulated, and a real money-making venture. You do have to be careful—but there are some very good, reputable, highly regarding facilities that do a lot of good in the world. It’s simply up to you to do your homework.

One of the major problems with any of facilities or programs is there are no federal regulations or laws that apply to them—that’s the state’s responsibility. How they operate, who they employ, the rules for how they treat your kids—that’s all governed by state law, which varies greatly depending on the state.

There have been plenty of “treatment facilities” started by people who have absolutely no mental health credentials, employing people with absolutely no credentials. Religious-based facilities have been shown to be some of the worst.

And even in states where there may be stringent guidelines, you may find very lax inspections and enforcement of those guidelines.

So, what are all those “seals of approval”, “affiliations”, “sponsors” or “partners” you see on an RTC or a Wilderness Program’s website? What do those mean?

It depends.

Some of these are associations that the facility simply pays to join (but that seal looks official). It doesn’t mean they passed any sort of rigorous test or adhere to anything at all. It simply means they paid their dues this year.

For example, NATSAP (The National Association of Therapeutic Schools and Programs) is simply a trade association any program can join.

I’ve also seen a website using two different seals from the same organization.

Now, there are national quality programs like the Joint Commission, that will accredit an RTC if it meets their standards. It will also accredit a wilderness program under its Behavioral Health Care or BHC accreditation program. So those are important seals to look for.

But again, there’s no requirement that these facilities or programs have these accreditations unless the state says so—they just need a state license.

The American Academy of Child & Adolescent Psychiatry has suggested standards for residential treatment centers, but it doesn’t appear any state has adopted those standards.

Some progress has recently been made at the federal level to try and protect young people in these places. Just this year a bipartisan bill was signed into law—the Stop Institutional Child Abuse Act. This came on the heels of Paris Hilton’s appearance during a Capitol Hill press conference where she talked about her 2-year experience in the troubled teen industry…including strip searches, isolation, beatings, and being restrained.

This Act implements recommendations from the Government Accountability Office (GAO) (which has been investigating such facilities for over 2 decades) and the Substance Abuse and Mental Health Services Administration (SAMHSA).

The recommendations include things like information-sharing between states, implementing educational training, gathering data, conducting studies and determining the effectiveness of tactics like using restraints and seclusion.

But there’s nothing in this new law that institutes guidelines or standards for the operation of such facilities. So you may want to research your states requirements to see how strict they are.

Now you would think that perhaps your providers would be able to tell you which facility or program would work for your teen, but they’re not likely going to be able to help you with a referral.

In most cases, they’re simply not going to have a clue—they just don’t venture into that territory. That’s not their area of expertise so they’re probably not going to know much about which facilities or programs are good and which aren’t.

You may want to start your research on the website for the Alliance for the Safe, Therapeutic & Appropriate Use of Residential Treatment (ASTART). You can gather lots of information about RTCs, wilderness programs, and therapeutic boarding schools in general. Their website is a treasure trove of information to help you make an informed decision, including a searchable database of reports filed against facilities. Again, don’t worry, I’ll have the links in the show notes.

There are also educational consultants that will charge you a lot of money to help you find the best facility for your kid.

But unless you get a referral for someone from another parent it can be a little dicey trying to figure out which ed consultant to use. The problem is this is a totally unregulated field, and people can call themselves an ed consultant and actually be receiving kickbacks from the facilities they recommend (or they could even be the spouse of the person who owns the facility). In those cases, you obviously can’t trust their input.

My best advice is to talk to other parents, join support groups like Other Parents Like Me. Other parents are your best resources. Ask around and find out who’s used an ed consultant that truly helped them or just ask other parents where their kids went and if it worked out well for them. I find people are very forthcoming and honest about their experiences.

For example, I think as far as treatment centers go, the one my son attended was pretty good and it comes up right at the top of the Google search for sure. But I would have never sent him there if I’d not known someone else who’d sent their child there.

But I will also say this—it doesn’t matter where you send the, they are going to say it’s the pit of hell and be angry about it. AND, no matter the glowing recommendation you may have gotten from other parents, there will be things that you don’t like about it.

For example, I had no idea that all the adults – the mental healthcare providers at these places generally leave at night…and kids not too much older than our teenagers are left in charge. Yeah – I was surprised. I thought surely they at least had a psychiatric nurse or someone on staff that stayed at a desk or something all night. Nope. Generally these overnight babysitters are in their 20s, without any formal training in mental healthcare or substance use. There may be some that are different, but I think this is a common practice.

I will say that there are some places in the US that are private pay (they don’t take insurance) that are top of the line and you probably wouldn’t have any complaints. But there are few of us who can afford it (that’s a different episode altogether). McLean Hospital in Massachusetts being one of them. It’s a fabulous place but it’s thousands of dollars a day.

To wrap this up let me just say again that sending your teen to an RTC, a TBS, a wilderness program or anything like it, should be your absolute last resort.

It’s simply not the magic cure-all that you may think. How they do when they get back home depends on a multitude of factors that you cannot predict in advance. The work does not end when they leave home—it’s still just beginning. You still have to do your work.

Understand that teens do risky things, they’re emotional, they have tantrums, they rebel, they can be really angry and behave horribly. And often these issues are caused by mental health or developmental issues and perhaps exacerbated by your behavior. It can be a real struggle.

But sending your kid to wilderness, a boarding school or residential treatment should never be your first choice. It’s traumatic just being sent away from home (especially if it’s against their will)—for both your child and you.

If you must, you must—I certainly don’t want to make you feel guilty because I did it! I regret it knowing what I know now, but I don’t blame myself because of where I was back then. And I believe being there did plant some seeds in his mind that may have allowed my new parenting skills to work a little faster.

But that’s the key my friend—far too often kids come back home and everything goes right back to the way they were before, because we haven’t changed.

That’s it for speaking of teens today. Be sure to check the show notes for those resources and please do share this episode with people you think may need it. I think this is important for parents to understand.

Until next time, try to connect with your teen in some small way, each and every day.

[1] https://www.sciencedirect.com/science/article/abs/pii/S0272735815300465#:~:text=Since%20they%20are%20likely%20to,on%20their%20offspring's%20substance%20use.

[2] https://systematicreviewsjournal.biomedcentral.com/articles/10.1186/s13643-021-01615-7; https://link.springer.com/article/10.1007/s10567-024-00481-8#:~:text=Involving%20parents%20from%20these%20families,involvement%20to%20improve%20treatment%20efficacy; https://www.sciencedirect.com/science/article/abs/pii/S0272735815300465#:~:text=Since%20they%20are%20likely%20to,on%20their%20offspring's%20substance%20use.