When 'rehab' sets people up to die.

The horrific ways "treatment" can backfire.

Lisa’s curly hair flopped over her face as she banged away on the drums at a punk show at a dive in St. Petersburg, Florida, in the winter of 2018. My friend and I were in Florida for a brief vacation during a brutal New York winter, and Lisa was there because the terms of her parole forbade her from leaving the state. Tall and lanky, with glasses she managed to make look cool, she bounded over to us after the set, ecstatic we’d come to see her. We slugged cheap beers and watched the other bands. For a person stuck in Florida on parole, away from friends and family in the Northeast, she was in high spirits.

A little over a year later, Lisa was dead.

Lisa had entered addiction treatment early in her life, at age 15. Her panicked mother sent her to a treatment for teens after she caught her getting drunk. After that, she was in and out of treatment for years, punctuated by stints in jail.

Her mother told me, “I thought, ‘a few weeks in rehab, everything’s cool’. It wasn’t. It was just the beginning of years of rehab, relapse, rehab, relapse.” 

“My mom was scared and didn’t know what else to do,” Lisa told me for a story I was reporting about the teen rehab industry. “Every time I got out ... I’d end up using shortly, because I wasn’t there by my choice, so I had no desire to stop.” 

The idea that people with addiction need treatment, not jail, has become commonplace among US public officials since opioid-related deaths began surging in the early 2000s. Policy has yet to catch up. Still, it’s a welcome shift from the carceral approaches of the ‘80s and ‘90s crack era (a shift that sadly owes much to the perceived racial profile of those involved). 

But “treatment” can mean many different things—and very little treatment currently offered in the US is based on sound evidence. And the lack of success means that, like Lisa, people forced into rehab end up entangled in the criminal justice system anyway, and potentially more vulnerable to a fatal overdose.  

Figuring out how to address risky substance use is even trickier with teenagers. Adolescent brains, habits and self-identity are fluid and vulnerable. Even the best-intentioned efforts to help “troubled” kids can backfire. 

“I would never send my kid into any kind of group inpatient treatment,” Thomas Dishion, a psychologist and researcher who studies adolescent behavior and child development and runs the Arizona State University chapter of Reach Institute, told me.

One factor that makes inpatient treatment a poor fit for this age-group is that severe addictions just don’t often occur in young teens. 

The National Institutes of Health’s 2016 “Monitoring the Future” survey found that drug or alcohol problems among younger teens are surprisingly rare. Occasional binge drinking among eighth-graders (defined as five or more drinks in a row,  within the past two weeks) is down to 3.4 percent, and falling. Only 20.5 percent of high school sophomores say they’ve ever been drunk—down from over 40 percent in 2000. 

“Let’s say a kid has a rough two weeks, or a month,” asks Dishion; “does that mean they have a lifelong addiction problem?” 

With deadly illicit fentanyl contaminating the wider drug market, it’s more understandable than ever that a parent suspecting drug use might panic. And the stigma still surrounding addiction might well cause them to secretively type “addiction” and “teen” into a search engine, rather than reach out openly to professionals to learn more and seek advice. A Google search for teens and addiction yields 46,700,000 results. Residential treatment programs, with savvy SEO marketing, dominate the space.

But experts think inpatient treatment should be an absolute last resort—only suitable in very specific circumstances or acute emergencies. 

It isn’t just that rehab can be an uncalled-for interruption, removing a teen from important adults, friends, routines and comforts in their regular life. It’s that rehab peer-groups—comprised of other, equally or perhaps much more “troubled” teens—are likely to exert powerful, unforeseen influences on a new arrival’s behaviors and outlook.  This is a known phenomenon called “deviancy training.”

“There’s good data to suggest kids learn from other kids, they develop friendships, and you end up encouraging the very behavior you’re trying to discourage,” Dishion says. “It can inadvertently make things worse.” 

In a paper for Society for Research in Child Development, with Kenneth Dodge and Jennifer Lansford, he examined how inpatient treatment for young people can backfire. Their 2006 meta-analysis of 19 randomized controlled trial studies found that trying to correct any kind of teen “deviant” behavior in a group setting—ranging from segregating unruly kids in a classroom to “Scared Straight” programs—more often than not yielded adverse or mixed results. 

“Placing a deviant adolescent with deviant peers can reduce the intended benefits of interventions and lead to less positive, sometimes even negative, outcomes, especially under conditions of poor supervision and lack of structure,” they concluded. 

Lisa jokingly compared one of the facilities she attended in New Jersey to some messed-up version of the TV show DeGrassi High, a cult classic about Canadian high schoolers. The rehab had all the show’s drama, only with drugs, trauma and addiction thrown in. 

“No one wanted to be there,” she said. “Everyone’s trying to rebel because they’re a teenager. People smoke cigarettes, get high on everything they have, have sex in bathrooms. If one person goes in actually wanting to stop using, you’ve got 90 people telling them why they shouldn’t.”     

This may have had profound consequences for Lisa. She first went into treatment in the early 2000s, as problems with opioids began to soar nationally. The very first heroin users she got to know well were her rehab roommates. 

“They opened up that gate of curiosity for me,” she says. She would end up using heroin for a decade. 

At the age of 25, she suffered a fatal overdose in a flophouse in Florida, away from friends and family. It took days to discover her body.