Long Term Residential Mental Health Institutionalization of Teens Does More Harm Than Good

Content notes: mental illness, institutionalization, sexual abuse

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Twenty-five months: It may seem like an insignificant amount of time to most people, but when you live in a lockdown mental health facility, time seems warped, drawn out, almost painful. I was 16 years old when admitted to my first residential treatment center — a small specialized program for girls and boys with eating disorders in the desolate Maricopa County of Arizona. Soon after, I was shipped to Utah for a 15-month stay in “therapeutic boarding school” for girls. Then, I was flown back to the East Coast for yet another program.

Twenty-five months.

At age fourteen, I was diagnosed with depression, anxiety, an eating disorder, and oppositional defiant disorder, and my parents were forking out thousands of dollars for mental health facility care. My mental illnesses were rooted in ongoing sexual, physical, and emotional abuse at the hands of a close family member. As a young, teenage girl—especially as one who was mentally ill—I was well aware of the repercussions of coming forward about sexual and domestic violence. I knew I wouldn’t be believed, even by the mental health professionals who had a duty to protect me. So, I stayed silent about what fueled my outward hurt, pain, and rage. It was much simpler to let psychologists and my parents chalk up my bulimia, self-harm, and hypersexuality as a “behavioral issues” or a “defiant teenage stage,” rather than pull back the veil and look for the trauma that laid behind my self-destruction.

I counted the days on my school planner and dreamed about a distant life where I was an average teenager — going to school, attending prom, fighting with friends, dating, having a job. However, my reality consisted of strict programming. From the time I woke up in the morning, every activity and move I made throughout the day was planned for me. Back-to-back therapies, three hours of school, thirty-minute meals, scheduled hygiene times, and on some days, if lucky, we got a thirty-minute block of free time.

Reintegrating back to “normal” life upon discharging from my last program — shortly after my eighteenth birthday — proved to be intensely challenging. I craved freedom for so long, that, when I finally had it, I didn’t know how to wield it. Only after I was an adult did I receive the appropriate diagnoses of bipolar II disorder, borderline personality disorder, body dysmorphic disorder, and severe PTSD. I felt othered, infantilized, and isolated because of my mental illnesses for the majority of my life. I had no idea how to care for myself, create boundaries, or do everyday tasks without a staff member peering over my shoulder.

After countless hours spent attending group and individual therapy 365 days a year, I still possessed no tools to put into practice these skills I learned. Unsurprisingly, my first relationship following institutionalization was toxic, unhealthy, and co-dependent, not unlike the relationship I had with my father, or those I fostered before I was institutionalized.

There are thousands of long-term mental health facilities and hospitals across like the ones I attended as a youth that are considered safe havens for mentally ill people by mental health professionals and parents alike. But these facilities may be doing more harm than good.

The mass institutionalization of mentally ill people in the U.S. is oft thought of as a practice by and large left in the past—halted during the Reagan era, historically captured in semi-autobiographical novels like The Bell Jar and Girl, Interrupted. However, unbeknownst to many, girls under the age of eighteen who live with mental illness are still routinely institutionalized.

Nowadays, mental health institutions may go by a different name, but the practice is still alive and well: Every year, thousands of adolescent and teenage girls with mental health disorders are placed into the system dubbed the “Troubled Teen Industry.” This private sect of mental health care is comprised of wilderness therapy programs, for-hire legal “kidnapping” services, boot camps, and residential treatment centers (RTCs), which are sometimes referred to as “therapeutic boarding schools” or “emotional growth academies.”

Though organizations such as the Building Bridges Initiative and the American Academy of Child and Adolescent Psychiatry (AACAP) have set forth evidence-based guidelines for how residential treatment centers should operate, there is still limited state and federal oversight of these institutions. In a position statement on residential mental health facilities Mental Health America (MHA) noted: “The private for-profit residential care industry has grown very fast, without yet incorporating the ethos of the public sector alternatives that it is replacing, is impervious to community pressures, and is resistant to transparency and family collaboration.”

In 2007, the Government Accountability Office discovered cases of “serious abuse and neglect” that occurred at numerous private residential facilities for minors, and they presented their report to Congress. What’s more, in recent years, the high-profile lawsuit lodged against the treatment center Midwest Academy in Keokuk, Iowa, has helped bring widespread attention to this industry often rendered invisible. And in April 2019, a student riot erupted at the Red Rock Canyon School, a residential facility for teens in St. George, UT. Following the event, numerous states began investigations into the verbal, physical, and sexual abuse of prior Red Rock students, and multiple staff members were brought up on charges. The Red Rock Canyon School permanently closed in August.

When placed in these highly-structured facilities, mentally ill teenagers tend to be stripped of their sense of sovereignty. Making decisions for yourself (and about your body) is treated as a privilege that must be earned as you progress through the program, rather than a basic human right. Residential treatment centers often have stringent rules that students must follow, and more often than not, punishments doled out involve losing even more of the limited freedom these programs allow.

Though the Federal Trade Commission (FTC) explains that residential treatment centers are considered a “less-restrictive alternative to incarceration or hospitalization,” many of these programs still rely on what the FTC vaguely describes as “military-style discipline.” Students are sometimes placed in isolation, lose off-campus trips, aren’t allowed to call their family members, or are even instructed not to speak to staff or peers for a set amount of time as consequences. Sure, rules are necessary when you’re dealing with teenagers who may self-harm or engage in impulsive behaviors, but taking away autonomy can have egregious consequences.

“[Youth in residential treatment centers] haven’t been allowed to have those healthy childhoods, adolescent experiences, and social interaction,” Amanda Alkema, LCSW, a forensic system administrator at the Utah Division of Substance Abuse and Mental Health, tells me. “They haven’t been given the ability to choose and experience the consequences or positive rewards. I don’t like to say it, but they’re almost caged a bit because of this. These children feel so hopeless, and like they have no power over what’s happening to them.”

This becomes even more troubling when you realize just how many young girls enter residential treatment already traumatized, with a warped perception of autonomy and sense of self. As a 2013 report published in the Journal of Family Violence revealed, upwards of 70 percent of all youth in residential treatment centers are believed to have experienced some sort of trauma. Specifically, a 2004 study estimated 60 percent of girls in residential treatment centers had experienced physical abuse prior to admittance, and 64 percent experienced sexual abuse. Psychologists have long found a core facet of trauma therapy is about regaining a sense of trust, intimacy, connection, and autonomy. However, many believe the practices at residential treatment centers are not just non-conducive to this but can be wholly damaging because young survivors aren’t given a chance to put consent and decision-making into practice.

Though we often think about consent only in terms of sex, the idea of “consent culture” — as opposed to rape culture—has moved to include how we teach kids about recognizing power dynamics in relationships. As the Rape, Abuse and Incest National Network (RAINN) sums it up, “consent is about communication.” Rather than develop a healthy outlook on consent, teenage girls in residential treatment are told at all times what to do, when to do it, and are likely to be punished if they push back against any daily programming. Adolescence is the stage when youth develop and learn self-governance — which includes decision-making skills and self-reliance. So, while precautions and protective measures are sometimes necessary to keep young adults in treatment safe, the inability to make autonomous decisions during long-term residential stays is in direct opposition to overall healthy development.

“Common practices in residential treatment centers can be re-traumatizing,” Alkema explains. “Sometimes, with a youth in congregate care for several years, they really feel like they have no control over their life.”

Olivia, a 20-year-old college student who spent fifteen months in various inpatient facilities says she also struggled with developing a sense of autonomy after leaving treatment. “By the time I left [residential], I was completely phobic about intimacy. […] It was driven into us over and over that physical intimacy is wrong, and above all else, sex is wrong,” she explains. “When I left, it took me forever to rewire my brain from the ‘if you touch somebody you’re dirty and wrong’ perspective. I still sometimes struggle to define appropriate physical boundaries, because my entire concept of touch and physical communication was skewed.”

“Personally, I think there’s no way for a residential treatment center to do more good than harm. I think that we need to focus on fixing the broken system,” Olivia says.

Many believe that inpatient mental health care for minors needs to be radically transformed and addressed through a restorative and community-based lens. As a possible solution, some states have more recently adopted the System of Care approach — a philosophy developed in 1986 that places an emphasis on keeping mentally ill adolescents in their community, and out of residential treatment when appropriate, so they never lose their autonomy in the first place.

“Overall, we have some programs that are doing great work,” says Alkema. “I just think as a system, we have opportunities to achieve better outcomes long term. We really need to make sure, as professionals, youth voice is at the table. We need to ask, ‘Are we treating the whole person?’”

Institutionalization isn’t a distant practice: it’s happening right now, in real-time. I sometimes wonder if I’d feel less ostracized and isolated for my mental illnesses if I’d not been cut off from the world for over two years, if I’d been allowed to have normal childhood experiences, and if I’d been allowed to learn to say “no.” Though philosophies like System of Care have helped combat the practice of long-term institutionalization, I believe we still have a long way to go with enacting policies that protect mentally ill minors, and their basic human rights. We, as a culture and community, have a responsibility to ensure these young women have a voice in treatment and beyond.

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