Use of Stress Positioning and Other Forms of Physical Abuse in Residential Behavior Modification Programs for Adolescents: A Survey of Adults Survivors

Background and Purpose: The “Troubled Teen Industry” (TTI) includes an expansive network of residential programs and facilities which claim to treat, reform, or rehabilitate youth who need specialized care due to mental health problems, family circumstances, disabilities, or learning problems. States, school districts, county social service providers, tribal authorities, struggling parents, and the federal government rely on these private for-profit institutions to provide residential care for children and youth. Separated from the protective oversight of their families, institutionalized youngsters are particularly vulnerable to neglect, maltreatment, and/or violence; this mistreatment and abuse can include treatment methods and interventions purportedly designed to “help” the young person.

Methods: Adults from diverse communities who were placed in TTI programs during their adolescence (n=248) were recruited via snowball sampling and interviewed over the phone about their experiences and the impact of the TTI program experiences on their post-intervention functioning. Information was obtained on the use of restraint, stress positioning (such as requiring the student to stand “at attention” facing a wall), seclusion, and painful stimuli (such as forced exercising, electric shock, and corporal punishment).

Results: The use of stress positioning was a widely reported technique experienced by respondents regardless of type of placement, funder of their services, or ownership of the facility with 89.8% of respondents (n=219) reporting use of this technique on themselves or others. The type of stress positioning, the length and conditions of seclusion, and the use of pain varied by facility type, program ownership, reason for placement in the facility, and treatment funder. Respondents who had been placed in for-profit facilities and were funded through a private pay arrangement were most likely to report use of stress positioning, use of painful stimuli to effect change, physical injury due to the treatment, and long-term medical problems or complications related to the intervention.

Conclusions and Implications: More than 120,000 children are placed in institutional care each year. Nearly all belong to one or more vulnerable groups: people with mental or physical difficulties, children involved in juvenile justice, special education, and/or child welfare systems, lesbian/gay/bisexual/ transgender (LGBTQ) identified, or members of a Native American tribe. An additional vulnerability includes those of marginalized cultural or racial ethnic backgrounds (for example, a third of the children sent to out of state TTI facilitates by the State of California in 2019 were Black or Latino, though this population comprises only 6% of California's special education students). The prevalence of abusive interventions in residential programs demands a strong, human rights-based response from the social work profession; indeed, many of the children and youth in abusive institutions are overseen at some point by a social worker and some reported being under the supervision of a licensed social worker during the time the abusive incidents took place. The findings of this study raise serious ethical questions about the use of stress positioning and other physically abusive methods in TTI programs and they also highlight a need for targeted policy changes to protect vulnerable children and youth.