Opinion | The Teen Mental Health Industry Is Failing Them

It’s known as the troubled teen industry. Spread across the country, this array of boot camps, wilderness therapy programs, therapeutic boarding schools and residential treatment centers is supposed to help children with mental health and behavioral issues, through a mix of therapy and tough love.

In reality, it is harming many of the children it purports to be treating, because of a reliance on archaic tactics, a lack of oversight and regulation and a focus on maximizing profit.

Desperate parents who don’t know what to do with their difficult kids turn to this industry for help. Many kids have already been through foster care, therapy, rehab, hospitalization or the criminal justice system. Lumped in with them are children who need long-term professional care for autism or complex problems, including severe depression, eating disorders, addiction and emotional trauma.

Our society is failing some of our most vulnerable by warehousing them in an industry that is woefully equipped to deal with their mental health needs.

New York Times Opinion interviewed more than 50 former patients, experts, advocates, regulators, legislators and employees about this industry. These voices bear witness to one of the most inadequate dimensions of our mental health system: treatment facilities that don’t sufficiently address the core problems but instead attempt to punish them away.

According to lawsuits, government reports and the testimonies of former patients and employees, children are often abused, assaulted, sedated and placed in solitary confinement. Sometimes they are treated in ways that are illegal to treat prisoners, let alone kids seeking mental health treatment. Dozens of children have died.

This industry, generating at least a billion dollars annually, enjoys little federal oversight or regulation. For decades, kids who have gone through these facilities have been talking to anyone who will listen. But even after years of scrutiny, not enough has changed.

Former patients have compared these centers with the insane asylums of centuries past. Future generations will look back on many of the tactics used in the troubled teen industry in the same way we look back on forced lobotomies and ask: How did we allow these practices to pass off as mental health treatment for so long?

Now there may finally be an opportunity to reform this industry, thanks to the work of activists and one unlikely figure.

Punishment as Treatment

From the outside, residential treatment centers can look like schools or hospitals. But they are actually often more akin to low-security prisons, where patients might spend months without ever leaving.

In the United States, there are almost no rules about the type of mental health care that these facilities are supposed to provide. Some claim that their treatment is innovative and evidence-based and utilizes a personalized trauma-informed approach. They advertise all sorts of special programs — equine therapy, recreation therapy and art therapy.

But former patients from residential treatment facilities whom Times Opinion interviewed said they received one-on-one therapy only once a week, if that. They said the treatment they received wasn’t intensive or specialized. It often felt more like emotional abuse.

The Texas Department of Family and Protective Services investigated many of Jordan’s claims and concluded, “No concerns that reach the preponderance of abuse or neglect were noted at this time.”

A key problem is that the employees who spend the most time with the children — supervising their activities, taking them to school or recess or to see nurses to get medications — typically receive only minimal training beyond first aid, several former employees told us. They said these positions are often paid near minimum wage, with high turnover. This leaves them ill equipped to handle, let alone help, patients with such complex issues.

Some children inside become physically aggressive toward themselves and others. Instead of de-escalating these situations, staff members sometimes use extreme tactics, according to former patients, employees and disability rights groups.

These include use of physical restraints, an intervention in which employees take hold of patients and physically restrict their movement so that they can’t injure themselves or others. Additional interventions include chemical restraints (which can involve nurses injecting patients with sedatives to calm them down, commonly known among patients as booty juice) and seclusion (the practice of placing patients in small, often windowless and padded isolation rooms until they cool off).

These techniques are often legal, but only under certain circumstances. It is typically permissible to use restraint and seclusion on children who are an immediate threat to themselves or others. But it is not allowed to use restraint and seclusion as punishment for misbehavior.

Yet these tactics have been incredibly common. A former chief executive and another high-level employee from one facility said their facility often used 20 or more physical restraints per day. The Salt Lake Tribune reported on another facility where a 14-year-old girl was injected with booty juice 17 times over just a few months in 2019. And former patients we interviewed described spending weeks in isolation in total.

Many former patients and employees told us that the rules governing restraint and seclusion are often not followed. Instead, they said these tactics are sometimes used as tools of punishment.

Universal Health Services, one of the largest health care companies in the country, owns the Utah facility where Jaxtyn was held. The facility told New York Times Opinion that it cannot comment on individuals’ treatment due to privacy laws, but that it does not use solitary confinement or medication as a form of discipline. Other programs do across the country.

The American Medical Association and the American Psychological Association have demanded the end of punitive solitary confinement for youths. It can harm children’s cognitive development.

A former employee of this facility who reviewed the footage told us that the employee’s response was inappropriate. The patient should have been restrained, not assaulted.

In a statement, a spokesperson for the program said that the episode was reported to law enforcement officials, who investigated in 2013 and again in 2020, with no charges filed.

Taken on its own, the episode would be easy to write off as one rogue employee physically assaulting a kid. But it does not appear to be an isolated incident. Six former UHS employees told us they knew of or had witnessed episodes in which staff members misused force. UHS told Times Opinion in a statement that their staff are trained in effective de-escalation techniques and if a staff member acts inappropriately corrective action is taken, which can include termination.

This problem is endemic to the industry. In 2020 the Alabama Disabilities Advocacy Program sent a letter to state commissioners about the conditions at four facilities run by Sequel Youth and Family Services. The letter, co-signed by the Southern Poverty Law Center and Children’s Rights, characterized the facilities as “violent and chaotic places where youth are physically and emotionally abused by staff and peers.”

Out of Sight

The industry depends on desperate, often compassionate parents, some of whom fall for slick marketing.

Brenda Ballard is the grandparent and legal guardian of Mi’Cayla, a teen in North Carolina who has struggled with suicidal thoughts for years. Ms. Ballard told us about frequently having to stay up through the night to keep watch on Mi’Cayla. On her last legs and worried she might lose her granddaughter, Ms. Ballard turned to the industry for help and sent her to a series of residential treatment facilities.

But last year, after Mi’Cayla told her about being attacked by another patient, according to Ms. Ballard, the program retaliated and restricted communication between Mi’Cayla and her grandmother — even though that’s illegal in the state. Ms. Ballard said she felt trapped, unable to find out what was happening to her granddaughter.

UHS and others have denied that they illegally restrict communication. But some institutions have said they deploy the practice to keep children focused on the program. That also keeps what happens inside inside.

Profit From People

This industry has been voracious in finding struggling teens to pull into its web. The foster care system, the criminal justice system, the mental health system and the public school system provide the industry with children — and revenue. Many states use taxpayer dollars from some of these systems to send their kids across the country for treatment. States paid one program as much as $800 per day to treat a single child.

The industry also cuts corners in the pursuit of profit. According to lawsuits, investigations and the testimony of former employees, some of these facilities are run with only minimal staff levels, keeping returns high but creating a more dangerous environment for kids and workers.

Brian Blohm was an executive at a Universal Health Services facility in Utah from 2015 to 2019. He told us that he eventually persuaded UHS to adjust his bonus plan to allow him to staff appropriately. In a statement, UHS said that it does not provide financial incentives that “would minimize the quality of care provided at the facility nor encourage unsafe staffing levels or ratios below legal requirements” and that it has complied with all staffing requirements. The company also disputed Mr. Blohm’s claim that it manages for profit, saying that it “never places financial gain over the quality of care.”

The company owns dozens of hospitals and hundreds of behavioral health facilities and makes about $11 billion a year. Fortune called it one of the world’s most admired companies. But its practices in this industry have come under fire.

A slew of news investigations published in recent years document abuse at UHS facilities. UHS and many of its centers face ongoing lawsuits, including one in which more than half of the 49 plaintiffs allege sexual abuse by a former medical director. An international labor union led an effort to collect stories of patient abuse and corporate negligence.

In 2000, UHS purchased the facility where Paris Hilton said she was abused. After she shared her story, that facility released a statement saying it couldn’t comment on what happened under previous ownership. She said that other people have had similar experiences even after the takeover.

Eventually, UHS caught the attention of federal investigators. In 2020 the Justice Department announced that UHS reached a settlement, agreeing to pay $117 million to resolve allegations — which it continued to deny — that include holding patients longer than medically necessary and failing to provide adequate services.

But this settlement did not bring widespread justice or restitution for the kids who have suffered.

UHS and the rest of the industry largely remain free of strict federal oversight and rigorous monitoring and standards. Companies continue to profit while kids continue to suffer.

The Toll

Few know the toll that these facilities and their business model can take better than Branden Petro, who has severe medical and neurological disorders, including autism and epilepsy.

In 2017, when he was 15 years old, his mother, Renee Hanania, sent him to a UHS facility in Virginia. She said it was advertised to her as one of the only places in the country that could care for a child with his intense medical supervision needs.

Even though these programs are generally for behavioral and mental health issues, residential treatment centers commonly market themselves to people with developmental disabilities and their guardians as well. But Branden’s story illustrates a problem with this approach.

Branden is suing the facility and UHS for negligence and abuse, as part of a series of consolidated lawsuits by former patients against UHS, the hospital and the facility’s former medical director.

UHS denies Branden’s allegations, saying that the facility at which he was treated is in good standing with licensing and regulatory authorities and that any deficiencies or complaints are thoroughly investigated and addressed.

Stories of abuse and neglect surface time and again. Many have even more tragic endings.

We don’t know exactly how many children have died at the hands of this industry. One estimate counted 86 deaths from 2000 to 2015. More have died in the years since.

Austin died at 19.

2016 Austin Skidmore was restrained at a UHS facility in Georgia, according to a lawsuit filed by his family, and choked on his own vomit. The medical examiner ruled it a homicide.

Naomi died at 17.

2020 Naomi Wood became ill at a Florida facility. According to an investigation, the staff members refused to let her see a doctor. A state agency determined the cause: inadequate supervision and medical neglect. No charges were filed.

Cornelius died at 16.

2020 As seen in a video above, Cornelius Frederick was restrained for more than 10 minutes after throwing a sandwich in the cafeteria at a Sequel facility in Michigan. Several of the employees were charged with involuntary manslaughter.

A Path to Reform

Not every program in this industry is bad. And not every child gets abused.

After Jaxtyn’s horrific experience in Utah, he was sent to another program in Texas. He described the night-and-day contrast. “It wasn’t degrading. It wasn’t demeaning. Sometimes the staff would get injured, but they would never hold grudges against any of the patients. They’re there for the patient. They’re there for the child,” he said.

He credits this compassionate approach to treatment with helping him finally address his mental health issues. He said: “I learned, like, ‘All right, so I’m not that horrible scum abomination. I am someone worthwhile.’”

Because there is so little government oversight, it’s hard to know how many facilities are providing quality treatment. There isn’t even a reliable count of how many of these facilities exist.

In 2007, Congress decided to investigate the troubled teen industry because of the many reports of abuse and death in its facilities. In the end, Congress concluded it was impossible to determine the true extent of the industry’s problems because of inconsistent regulations and reporting.

And yet Congress failed to take action to solve the problem. Legislation to reform the industry has repeatedly failed, even though hundreds of millions in public funds have been funneled into it every year.

Things might finally be changing. Ms. Hilton and other patients-turned-activists have lobbied Congress to pass tougher regulations and reporting requirements and to increase funding for government watchdogs.

These efforts have already had success at the state level. In 2021, Utah passed legislation limiting restraint and seclusion and increasing funding for abuse investigators. Oregon and California pulled the children who were sent from their welfare systems to out-of-state facilities — putting financial pressure on the industry to clean up its act.

The momentum has put a target on some of the industry’s largest players. Two senators recently began an investigation into four companies, including UHS and a new venture by one of the founders of Sequel.

“This nation’s residential child care system is broken — and without oversight, congregate care often becomes congregate abuse,” Senator Jeff Merkley of Oregon told Times Opinion in a statement. He added that he’s working on “a bipartisan basis to write legislation that will protect children by reforming our congregate care system with adequate oversight and accountability.” The legislation is expected to be introduced this year.

Activists and survivors hope that this time will be unlike the others and this sprawling network of facilities may truly be on a path to reform. It’s a relief to imagine the most brutal institutions being shut down and stricter regulations being put in place at facilities that previously acted with impunity.

America’s patchwork mental health treatment is still insufficient. Parents will remain desperate; teenagers will still struggle. But when they seek help, they should find compassionate, responsible, safe treatment. Until then, how many more young people will find physical restraints, chemical injections and emotional abuse instead of the treatment they need?