The Ethics of Referral: Social Work, Children's Rights, and the Troubled Teen Industry

Background and Purpose:
Each year, thousands of children and adolescents are placed in therapeutic boarding schools (TBS), often through the recommendations of social workers or other helping professionals. While marketed as treatment programs, many TBS facilities operate without licensure, oversight, or adherence to clinical standards. Despite the high stakes involved in such placements, little empirical research exists on their long-term outcomes—and even less reflects the voices of those who experienced these programs firsthand. This presentation examines the ethical concerns raised by referrals to unregulated TBS programs, drawing on a literature review and an in-depth case study of Iowa's Midwest Academy to assess whether these placements align with the core values of the social work profession.

Methods:
A systematic literature review was conducted using databases including PubMed, PsycInfo, and SocINDEX, with search terms such as “therapeutic boarding school,” “residential treatment,” “outcomes,” and “long-term impact.” Of the five peer-reviewed articles meeting inclusion criteria, only three presented empirical findings. To supplement the literature, a case study of Midwest Academy—a now-defunct TBS program in Iowa—was conducted. Data included over 180 hours of semi-structured interviews with survivors, staff, investigators, and advocates, as well as 5,000+ pages of documents including journals, court records, program manuals, and media reports.

A grounded theory approach guided analysis. Interviews and documents were coded iteratively and inductively to identify patterns in language, reported experiences, and institutional practices. Survivor narratives were central in constructing a theory of harm that examines how therapeutic justification was used to legitimize coercive, punitive, and often abusive practices. Constant comparison and memoing allowed for emergent themes to be situated within broader ethical and professional frameworks.

Findings:
The literature suggests that though some families of TBS attendees report neutral or positive outcomes following institutionalization, many also face lasting harm, including posttraumatic stress disorder, substance use, and family estrangement. Programs are often described as “totalistic”—highly controlled, isolating, and punitive. In the case of Midwest Academy, youth endured forced silence, isolation cells, monitored communication, unlicensed counseling, and peer-enforced discipline systems. Informants recounted knowing peers who died prematurely from suicide, overdose, or violence. The referral of clients to such programs—often under the guise of therapeutic care—raises profound ethical concerns regarding informed consent, autonomy, and the duty to protect vulnerable youth.

Conclusions and Implications:
This study challenges the assumption that therapeutic boarding schools are a neutral, helpful, or therapeutic intervention. When placements occur without licensure, clinical oversight, or meaningful youth input, social workers risk violating ethical codes and exposing clients to additional trauma. The profession must reexamine referral practices, advocate for regulatory reform, and prioritize community-based, trauma-informed alternatives grounded in evidence and human rights. Ethical referral is not only a clinical task—it is a moral responsibility central to social work’s mission.