3 - Chapter Two: Global Disarray
An Unchanged Mind: The Problem of Immaturity in Adolescence
Dr. John A. McKinnon
Ten years ago, we left town. Within a year we had encountered a riddle the answer to which would change everything.
At the time we knew only that we wanted to create an affordable, open-air residential treatment program for troubled teenagers. To this end we purchased a 400-acre cattle ranch in a remote Montana valley called Lost Prairie. There we hoped to protect parents from the crushing overhead of a medical center. We wanted to emancipate our adolescent patients from the antiseptic confinement of a hospital lock-box. On an open ranch we wanted to situate a sustainable clinical collaboration among teenagers and their parents.
We were in flight, too—refugees from managed care. We proposed to elude those phony intruders by shifting venue: from hospital to ranch. Clinically, we wanted to change set: from weekly outpatient visits to the intensive 24/7 culture of an enlightened boarding school. We planned to banish insurance companies from the doctor-patient relationship. We were determined to repel managed care at the cattle-guard. At the ranch, only parents would authorize our work with their children.
All this we anticipated, more or less. We could picture a healthy community of adults and adolescents. We were itching to set free our clinical work from insurance-company interference. We could imagine the ranch as a developed campus—lodge, cabins, bunk-houses, classrooms, barn, pastured horses, soccer field, shop—long before we re-mortgaged our homes and hung up our beepers. With an irrational faith we imagined that, if we built it, they would come.
Yet it was what we did not anticipate that changed everything. What we could not foresee would alter the way we understood every teenager entrusted to our care. What we did not see coming would transform our approach to treatment.
Oddly enough, we did not know ahead of time precisely who would come. And so we could not anticipate the makings of a clinical riddle that—along with fishing rods and backpacks—our new students would carry with them to Lost Prairie. We did not anticipate that when parents came to visit they would present us with a rebus that, for a time, we would be unable to decipher.
We encountered this enigma in the context of a unique ranch society. Over the years all our students and professional staff arrived from American cities or suburbs. But for various reasons, the ranch community evolved into a distinctive social order—distant in space, a throw-back in time, and as different from American mass culture as Prospero's island.
And so, to introduce this clinical conundrum I must first pause to describe this remote society, the outcome of a peculiar anthropological experiment: a throwing together of well-meaning adults and troubled teenagers, who were strangers to one another, but would have to live and work together on a remote Montana ranch. It would be here that students would attend classes, study, do homework, play in vigorous sports, accomplish chores, hike and ski, make their own music, create art, act in theatrical productions and pursue outdoor adventures. It would be in the ranch dorm and at the dining-hall table that they would struggle to make and keep friends, to help each other and to learn to get along. It would be on the ranch campus that they would engage affectionate adults and, in time, reengage their parents.
It would be here, also, that we would encounter the clinical riddle the solution to which is the subject of this book.
At the ranch we unplugged from the matrix. On the new campus there would be no satellite dishes, no televisions—no sit-coms, no casual, repetitive violence; none of television's mind-numbing idiocy; no shifting images and sound bytes, which shorten the human attention span. These choices were deliberate, of course. We knew that, instead of their watching Friends, we wanted our students to make friends. Instead of experiencing a community vicariously on Seinfeld, they ought to create a community and belong to it.
To protect this fledgling culture from the barrage of media stimuli—whether ads for vodka or military shock and awe—we disconnected from network feed, so that the tidings of battle filtered into the ranch after a lag of days, much as the ancient Greeks received news from Thermopylae. We admitted political debate, but only after the bombast had been flattened onto the page, the ranting muted by distance. We banished sexy consumer ads, except in the classroom, where they could be analyzed. We turned off MTV's erotic peepshow. We took control of our own hi-fi speakers, and turned down the mind-boggling volume, so as to make it possible to listen to one another, to hear one another's words, to speak in completed paragraphs.
In short, we banished those noisy intrusive sound bytes that distract young people from personal relationships with other human beings. We banned Walkmen and Diskmen. We permitted no iPods or cell phones, got rid of instant messaging and video-games, forbade net surfing and i-porn, and provided no car-keys to automobiles in which teenagers could go elsewhere, vanishing into the night leaving adults behind. Absent these intrusions and distractions, there soon came to be: conversations. Young people and adults talked to one another over meals, in the lodge, in class, in team groups and in private encounters with therapists.
To join this community wholeheartedly, we discovered, each student would also have to unplug, or to be unplugged, from the old school, from old friends, from drug dealers and, at least briefly, from home. Deliberately we barred distractions so that students would attend to their relationships here, and encounter their thoughts and feelings now.
Some, reading this account, may wonder, as we did ourselves, whether we would best help our students by controlling these elements in their lives. They would have to return to that American mass culture and would have to learn to handle those distractions. Yet, our students were not teenagers who had done well despite temptations. Every student who ever came to the ranch already had failed to thrive in that larger social order, already had been victim to intrusive come-ons and too-available distractions from all the tasks of adolescence. Moreover, we learned the hard way that if we permitted students to bring Diskmen and headphones to Lost Prairie, if we turned the television back on, allowed cell phones or permitted free use of e-mail, we would never capture our students' full attention—and they would never listen to one another, either. We had to turn off mass culture so as to hear each other's words, to take note of each other's presence. For social reasons, in part, the ranch community began to feel different from American mass culture—less harried, less intruded upon, less hurried.
This altered atmosphere also had to do with a sustained close encounter with the natural world. On a remote ranch weather intruded. Time slowed. The diurnal cycle and change in seasons, encountered every day as students worked and played outdoors, became prominent rhythms in their lives, just as the motions of the planets once preoccupied the proto-Indians who left their petroglyphs on outcroppings below Meadow Peak. Each new student, having to go cold-turkey from the incessant noise, chatter, flashing lights and commercial come-ons of city life, experienced a squirmy withdrawal. The tranquility of Lost Prairie, set off by the sibilance of wind in the pines, made it hard, at first, for new students to sleep. Students had time and scope for thinking and feeling, for loneliness and regret, for anger and shame—and had no ready access to drugs or other distractions from those immediate feelings. There were no video-games, no city lights to dim the night's starry vastness.
This slower pace was amenable to talk, however. Students had a lot to do, but few scheduled events that required rushing off somewhere else. A typical ranch day provided structured occasions for discussion—hours set aside for group and individual talks that often included adults. Dining-hall noise was but talk and laughter undisrupted by text messages, lyrics in a head-set, video games, rant radio, or the woozy siren song of intoxication. No one was selling anything. And no one with a cell phone sat across the table like a hallucinating lunatic talking to someone who was not there.
Adults were in charge. At the ranch, teenagers were supervised. We only enrolled students who had not been assaultive, and rules limiting aggression were enforced. Therefore, the ranch became a peaceable kingdom, where students and staff were safe, and adults insisted that it remain so. We did not tolerate assault, and there was little thuggish behavior or reason for a student to fear to say what was on her mind. We also enforced rules about sexual behavior. There were no unsupervised beds, no parties without adults. Although romance and erotic fantasy were rampant, the grown-ups in a friendly way refused to provide opportunities for adult sexual encounters for which adolescents are neither emotionally ready nor economically competent to take responsibility. Nor did adults permit the sexual bullying that vulnerable girls regularly described in their home communities. Boys and girls at the ranch have always been as beautiful and sexy as young people anywhere, but they lived at the ranch in an erotic calm, about which, oddly enough, they seemed to be relieved.
In this protected context, conversation among students shifted into a frank and honest key. Therapeutic conversations between teenagers and adults became less stilted, more affectionate, informal, and parental. Students, teachers, team-leaders and therapists dined together, and heard the news and encountered rumors simultaneously. All witnessed the same squabbles and social operettas. Staff knew each student's room-mates, team-mates, friends, lovers, and rivals. Parents visited, so that other students and staff knew a student's family, too. Moreover, a therapist talking with a student in her office was not left in the dark about the quotidian events in the student's life, since teachers and team-leaders talked with therapists regularly. Therapists knew how much a girl was eating, because they shared meals together. Team-leaders knew whether a boy was turning in his homework and whether at night he was crying himself to sleep.
Once that intimate culture emerged, adults and adolescents felt close, talked frankly, knew one another's opinions, and understood how the other thought and felt. Without mass media, instant communications, up-to-the-minute gadgets, without automotive mobility, without drugs or laptops and unsupervised space for hooking up, the ranch felt as different from American mass culture as an extended visit to Lilliput.
Although Lost Prairie was but forty miles from town, located only an hour's drive from a modern airport where big jets land, the ranch seemed to be situated in a time warp, hidden behind a piney ridge, stuck in a time zone located fifty years behind contemporary Los Angeles and New York. For students and staff at the ranch it might as well have been 1956—and Eisenhower just reelected.
At the time Montana Academy opened, there were three ironies that we had little time to notice. All we knew was that, from the start, the ranch filled and we were working harder than we had ever worked in our lives. All we could focus on were the risks and the problems, which were greater than we had anticipated. We had no time to consider what it meant that, even as our capacity doubled and tripled and quadrupled, even as tens of other adolescent programs opened over the ensuing years, our beds stayed full. Starting at twenty, our student body grew to eighty-five. In ten years we enrolled some 500 troubled students from thirty states—and these were but a fraction of the young people that educational consultants wanted to refer to us. As we got busy, in those first years, we were naďve enough to congratulate ourselves on the excellence of our model, the quality of our staff and the virtues of our clinical work. It did not occur to us that another force was shifting the ground under adolescent psychiatry.
We did not make the connection—that insurance company tactics, which we had so resented, were successfully emptying the nation's adolescent hospitals and RTCs. In effect, managed-care companies were successfully pushing troubled teenagers out of psychiatric facilities, which were supposedly covered in their policies, and into alternative residential programs like Montana Academy—not covered in the fine print of those same medical insurance policies. Troubled teenagers still needed this level of care. Parents who could afford to pay out of pocket were searching out alternative programs, such as Montana Academy. But medical insurance companies simply shrugged off the duty, as part of medical insurance, to provide sustained residential care for disturbed teenagers.
In a second irony, we imagined that Montana Academy was an innovation. We thought we were inventing something, that the ranch school was a fresh idea, albeit an innovation that started from extant programs in the remote mundo of alternative schools and programs. Yet in retrospect, this convivial, intense therapeutic community of trained adults and struggling pilgrims—eating, sleeping, studying, working, conversing, recreating, and resolving intrapsychic problems together—was not new. The ranch community was simply another expression of a venerable idea—of utopian retreat to an asylum, removed or walled off from a troubled society. Such communities, in the ideal, were guided by wise and experienced elders, structured with firm discipline, and constituted a haven from a stressful or a corrupted world—and so became places where balance, inner strength, and peace of mind might be recovered. This idea, implicit in the cloistered mediaeval abbey, was also the avatar of a benevolent, more recent era in hospital psychiatry.
Finally, in a third irony, our flight into the outback actually put us, for the first time in our professional lives, at the informational hub of contemporary urban/suburban American psychiatry and psychology. The ranch school, located forty miles from the nearest town, immediately provided a ringside seat on modern clinical practice—a vantage, all but unique in the nation, from which we could to see one of psychiatry's most striking errors.
Why? Because each student arriving at Montana Academy brought to the ranch, along with spare shorts and skis, a detailed account of an unsuccessful contemporary psychiatric treatment. Parents themselves, at our request, reconstructed detailed developmental histories, which we read carefully. But also, along with their applications, parents forwarded records—outpatient work-ups, psych testing reports, educational assessments and hospital discharge summaries—that constituted a national sample of American clinical thinking about unhappy teenagers. These records—hundreds of them—invariably described failed treatments. For if our students had not already been treatment failures, their parents never would have paid the emotional price or would have bourn the out-of-pocket tuition expense to send them to the ranch.
Of course, parents had not started their search for help in Montana. On the contrary, they arrived in Lost Prairie months and years after that first attempt—usually after a second or third try. When they journeyed to Lost Prairie they were making what they usually considered to be a desperate last attempt, in the short time remaining before their sons and daughters turned 18, and it would be too late to find a remedy.
These failures begged the question: why? Why did all that conventional expert out-patient (and occasionally also brief inpatient) treatment fail to remedy the psychiatric problems of all those troubled teenagers? From our vantage, forty miles from town, this was the first articulation of the riddle.
Who & What
To find a solution to that puzzle, one must first ask not why, but who and what? Who were those students? What parents sent their troubled children so far away? Was this act careless or irresponsible? And what troubles? What problems had contemporary psychiatrists and psychologists failed to solve?
Who? The answer begins with our admission criteria. In brief, we welcomed troubled girls and boys between the ages of 14 and 18. Invariably they had many problems, not only one or two. By serendipity, one criterion came to be intelligence. But quickly I must add that, despite good intelligence, our students usually arrived at the ranch school after protracted and intractable academic failures, whether at large public high schools or in intimate private day or boarding schools. They came from more than thirty states, from most of the urban/suburban hubs of the nation. Prior to their arrivals almost all had ceased to try at school, were not doing or turning in homework or classroom assignments, had stopped showing up for school at all or were intoxicated in class. Many of them had been suspended or expelled.
We also selected parents. We welcomed mothers and fathers who agreed to participate in treatment from start to finish. Most of our parents were intelligent and well-educated, energetic and well-meaning—criteria that, of course, only deepened the clinical enigma. For surely it has always been less of a mystery when a failing teenager emerged from a family devastated by drink, drugs, illiteracy, unemployment, poverty, or mental illness. Among our parents these handicaps were rare. These parents could and would pay a steep tuition and they insisted on participating. They were competent in their own challenging careers—as attorneys, teachers, professors, researchers, inventors, district court judges, surgeons, internists, editors, entrepreneurs, psychiatrists, psychologists, psychoanalysts, investment bankers, venture capitalists, CEOs, engineers, and artists. The prevalence of university degrees—BAs, MAs, MBAs, JDs, PhDs and MDs—and advanced training were off the chart.
These criteria also gave new emphasis to the riddle—why did these teenagers have so many troubles? After all, their parents had worked hard and traveled far at great expense to look for solutions. Their parents already had consulted experts, had tried conventional therapies, including bushels of pills. They had looked elsewhere and could afford to take their children anywhere on the planet where they found effective help. Surely no plausible explanation for these teenagers' troubles could be based upon a lack of parental good intentions, intelligence, or education. These parents had all that—and their sons and daughters nevertheless had serious, multiple problems.
What? Oddly enough, we did not foresee, before they arrived, the panoply of problems our students would bring. We probably had a choice in this matter, but we did not take it. For some consultants, who were trying to figure out what kids to refer to us, asked us whether we wanted to specialize in particular symptoms? Did we aspire to treat mood disturbances? low self-esteem? eating disorders? learning differences? Other consultants, who had less use for the Diagnostic and Statistical Manual (DSM-IV), employed their own informal lexicon. Did we want soft kids, or hard? internalizing or acting-out teenagers? cutters? Did we wish to treat trauma? What about young people already taking medications—could we handle that?
At the start, we were reluctant to say. We refused to limit enrollment to specific symptoms. It simply went against the professional grain. In all those years when we practiced on the medical or psychology faculties of universities and hospitals, our colleagues would have thought it presumptuous—either for me, or for them—to mention a preference for particular symptoms. Within the general category of psychiatry, who cared what symptoms I liked? If her patient became suicidal, a surgeon wanted my help ASAP, and the last thing she cared about was whether suicidal thoughts happened to be among my favorite presenting symptoms. So, out of habit, we kept mum. Apart from exclusionary criteria, we would take any referred problem.
Our exclusionary criteria were merely scruples about safety—the defining qualities of young people we thought we ought not to risk treating on an open ranch, given that there would be knives in the kitchen, axes and rope in the barn, gasoline in mower tanks, and winter weather that would quickly freeze an impulsive or careless runaway. We would not accept parents who would not cooperate, who would not commit to go the distance. We did not want to start if we would not be permitted to finish. Otherwise, in those first months, we did not pre-select our students.
This being so, we had no excuse to be surprised when our first students brought to the ranch an array of problematic symptoms and wretched behavior. A casual survey produced this cumulative list:
Deflated mood; self-loathing; anxiety; insomnia; nightmares; mood swings; tantrums (with or without property destruction); threats; fights; brandished weapons; assaults; vandalism; theft; shoplifting; self-injury (covert or overt) including scratched, cut, abraded or burned skin on wrists, thighs, ankles or breasts; pulled hair; suicide gestures, threats, hints or serious attempts; school anomie; truancy; collapsed academic effort; poor concentration; classroom squirminess; disruptive talking in class; failure to do or turn in assignments; falling or failing grades; suspension or expulsion; rudeness with adults and peers; oppositionality or defiance with teachers or parents; eating disturbances (binging, purging, self-starvation, compulsive use of laxatives); drug or alcohol intoxications or addictions; arrests for intoxication or possession; drunk or intoxicated use of motor vehicles; drug dealing; sexual harassment; compulsive looking at pornography; sexual promiscuity; rape (perp or victim); family discord, including alienation from parents; mean mistreatment of siblings; family squabbles and fights; destruction of belongings or property; failure to keep curfews; compulsive playing of computer games; compulsive instant messaging or web surfing; hacking; chore refusal; running away; pilfering to pawn; lying; and other sneakiness.
Traditionally psychotherapists considered symptoms, signs, and misbehaviors to be grist for the mill. Out-patient therapists had to trust that a patient who agreed to say whatever came to mind soon would bring to the therapeutic hour the thoughts, feelings, memories, and associations that were relevant, whatever the underlying theme. That is to say, surface symptoms and signs would recede in importance and abate eventually as therapy revealed an underlying conflict, buried trauma or repetitive leitmotif. This, no doubt, was our traditional expectation, when we began. On this basis we anticipated that we would treat any student, whatever the signs and symptoms, to a common regimen of individual and group psychotherapies supplemented by a pragmatic psychopharmacology to target key symptoms.
Nevertheless, we found daunting this long list of symptoms, signs, and misbehaviors. How could we adapt our scheduled program to touch upon all these troubles? How could our program achieve coherence if each student's symptoms or misbehavior needed a unique remedy? How many staff would it take? And how could we train our team leaders to deal with a chaotic collection of symptoms and not have them simply flailing in all directions? How could we schedule psycho-educational groups if separately and simultaneously we had to address a girl's low self-esteem, a boy's shoplifting, a girl's bald spots from hair-pulling, and also a boy's defiant rudeness in the classroom? Did these symptoms hang together? Was there any rhyme or reason?
But formal diagnosis, we presumed, would reduce this complexity. After all, the DSM-IV is but a large collection of laundry lists of signs and symptoms and misbehaviors. The psychiatric nomenclature bundles signs and symptoms into commonly occurring clusters and calls each cluster "a disorder." Therefore, inasmuch as our students already had been evaluated at home by competent psychiatrists and psychologists, and all had been given syndrome diagnoses, we might have expected this welter of signs and symptoms to reduce to a few key disorders that could provide a logical basis for programming.
This did not happen. On the contrary, along with water bottles and fly rods, each of our new students brought along (usually multiple) diagnoses. By the third year after we opened, we had collected a cumulative list of those formal diagnoses, which included:
Cyclothymic Disorder (301.13); Panic Disorder (300.01); Post-traumatic Stress Disorder (309.81); Adjustment Disorder with Mixed Disturbance of Emotions and Conduct (309.4); Generalized Anxiety Disorder (300.02); Social Phobia (300.23); Obsessive-Compulsive Disorder (300.3); Factitious Disorder (300.19); Anorexia Nervosa (307.1); Sleepwalking Disorder (307.46); Hypochondriasis (300.7); Dissociative Disorder NOS (300.15); Somatization Disorder (300.81); Conversion Disorder (300.11); Body Dysmorphic Disorder (300.7); Gender Identity Disorder in Children (302.6); Frotteurism (302.89); Bulimia Nervosa (307.1); Sleep Disorder (307.42); Narcolepsy (347); Pathological Gambling (312.31); Intermittent Explosive Disorder (312.4); Trichotillomania (312.30); Identity Problem (313.82); Adverse Effects of Medication NOS (995.2); Parent-Child Relational Problem (V61.20); Neglect of Child (V61.21); Sexual Abuse of a Child (995.53); Physical Abuse of a Child (995.54); Bereavement (V62.82); Reading Disorder (315.00); Mathematics Disorder (315.1); Disorder of Written Expression (315.2); Asberger's Disorder (299.80); Attention-Deficit/Hyperactivity Disorder (314.01); Conduct Disorder (312.8); Oppositional Defiant Disorder (313.81); Enuresis (307.6); Encopresis (307.7); Separation Anxiety Disorder (309.21); Reactive Attachment Disorder (313.89); Alcohol Abuse (305.00); Sedative, Hypnotic or Anxiolytic Dependence (304.1); Amphetamine Abuse (305.70); Cannabis Abuse (305.20); Cocaine-Related Disorder (292.9); Hallucinogen Abuse (305.30); Inhalant Abuse (305.90); Polysubstance Dependence (304.80); Hallucinogen Persisting Perception Disorder (292.89); Dementia due to Head Trauma (294.1); Schizoaffective Disorder (295.7); Schizophrenia (295.9); Brief Psychotic Disorder (298.8); Major Depressive Disorder (296.33); Bipolar Disorder (296.65).
To complicate matters, the majority of our new students, on the basis of these diagnoses, already had been prescribed (usually multiple) psychotropic medications. Most students arrived taking some combination of antidepressants, stimulants, mood stabilizers, atypical and typical anti-psychotics, or hypnotics—usually two or three different medications per student, and as many as nine.
In sum, our new students arrived with multiple symptoms, signs, misbehaviors, and functional failures. They were bright. Their parents were intelligent, well-educated, and concerned. Many of our students had been hospitalized, but only briefly, of course. In all cases their parents already had consulted experts who had prescribed medications, out-patient psychotherapy, and family interventions. Yet, they were still floundering and—from their parents' vantage and in the judgment of experienced educational consultants—they no longer safely could be permitted to live at home. Neither parents nor educational consultants, nor therapists themselves, thought it made sense to perseverate in an out-patient treatment that had failed.
In her application a mother wrote about her son, David:
By his second year of high school, David's risk-taking worried us. We were shocked to realize that, at 16, he still had so many problems. We thought he would begin to fend for himself, but instead he seemed at risk to cause an awful debacle. He should have been getting ready to steer down the road of life, but instead he kept driving into the ditch.
Even from this brief sketch it becomes clear that this bright boy, who had concerned, intelligent parents, was symptomatic, misbehaving and failing in various areas of his life. Outpatient consultation and intervention had not improved matters. David was removed from his parents' home in handcuffs.
He was so bright. In childhood he was precocious. But in the three years since middle school his grades dropped from A's and B's to D's, even a few F's. He quit the band, refused to practice his sax at all, and stopped his lessons. He became less communicative with us, angrier. His tantrums were pretty hard to take. We knew he had joined a wrong crowd. We discouraged his new friendships with skaters, who had a rep for using marijuana and maybe other drugs. To us, they looked like trouble. . . .
David stopped showing up at all at dinner time. As his 10th grade began, his relationship with his father became very tense. He just seemed so mad all the time, especially with his father, while he was calm and affectionate when he was just with me. With his dad he was so hostile.
His girlfriend broke up with him. He had been affectionate about her, but he picked a fistfight with a senior boy she had met and just got talking to—as if David just could not stand any competition for her attention. The boy hit David's mouth, knocked out a front tooth, and we were upset that David had been hurt—and complained to the principal. But although David was very polite and reasonable, she concluded that David provoked the fight—and so she had to suspend him from school. She said she thought we should get him some help. He agreed to see a psychiatrist and take medication, if need be.
I took him to see my own psychiatrist, who diagnosed Bipolar Disorder and Oppositional Defiant Disorder and R/O Substance Abuse Disorder NOS—and prescribed various mood stabilizers and anti-depressant medicines. But no medication seemed to make much difference. He agreed to take the medication and for a few months he did so, carefully, but he remained as defiant and unhappy as before.
One evening when he did come home for dinner, his father told him we would not sign a permission slip for him to go sky-diving with his new acquaintances, because we thought it too dangerous. David got so angry he threw his plate of food on the floor and punched a hole in the dining room wall—right through.
I was frightened, so his father called 911. David was very polite when the officers arrived, but he kept shouting that his father was "driving him nuts." When one of the officers suggested he come along, and get out of the house, he tried to shove the officer away, and so the policemen wrestled him down and handcuffed him and put him in their cruiser and took him away. We had to call a lawyer friend and go before the court. Oddly enough, when he had to face a lady judge, he became subdued and courteous, even though she insisted that, if he did not cooperate with residential treatment, she would send him to juvenile hall.
In another application, a father described his daughter, Helen:
When she entered high school, she was not really a problem. But in her sophomore year Helen began cutting classes. In December she got in trouble for truancy, lack of work, late arrivals and fast friends whom the vice-principal suspected of drug use and wild parties. Helen came home indignant after the vice-principal described her friends as "losers." She seemed angry at any and all adult authority.
Here, again, an intelligent girl with concerned parents had become poly-symptomatic. Her sneaky misbehavior and risk-taking prompted her parents to banish her from home and from her community, where she had repeatedly gotten into trouble. Conventional diagnosis and psycho-pharmacology had not rectified these problems.
That spring she was arrested for shoplifting. A month later the police showed up at school with warrants to search Helen's locker and the lockers of her friends. He removed a small bag of marijuana and charged Helen with possession. We got a good lawyer, who got her off because of an error in the warrant. But Helen was rude to the judge.
We thought she had learned her lesson. She went back at school, and we thought the problem had blown over. But only a few weeks later she overdosed on pills and cough syrup.
The psychiatrist at the hospital diagnosed Major Depression, Marijuana Abuse Disorder, Sedative, Hypnotic and Anxiolytic Abuse, R/O Polysubstance Abuse—and Parent/Child problem. (We agreed with this last part, for sure.) He started an anti-depressant, but we have not seen any change.
In these words a worried dad described his 16-year-old son, Phil:
Sending Phil off to a wilderness program will be the hardest thing we ever have to do. . . . But it seems to us that things with Phil are entirely out of control. We have no control over him, and he has no control over himself, certainly none over his acid tongue.
In Phil's case, too, a family was in turmoil. At school, at home, and among his social acquaintances, bad had gone to worse. Other interventions had been tried. All had failed.
Phil did all right in grade school, but he was asked to leave two high schools within six months—because of his threatening behavior. At home he has become more and more angry, defiant and verbally abusive. His relationships with his schoolmates and family has been deteriorating. Phil is argumentative and dismissive of all authority. And he has an enormous sense of entitlement. He is unable to take responsibility for his actions.
A neurologist we consulted thought Phil had a post-traumatic neurological lesion maybe from a head injury he sustained in an accident when he was ten, and he got knocked out. The doctor wondered if he had some ADHD, too, and diagnosed Oppositional Defiant Disorder. He prescribed anti-seizure medicine and put him on Ritalin, but none of the pills fixed his many problems or changed his attitude.
The house has been in turmoil. My wife and I have tried everything we could think of. But things have only become more dysfunctional. Everybody in the family has suffered.
Taken together, the surface features of these three accounts differ. Superficial troubles, in each case, are not the same. Symptoms and misbehaviors were not equivalent. No dominant emotional tone was shared in common. David seems angry, and he was throwing tantrums; Helen seems wary and sneaky, and defied authority beneath the parental radar; and Phil is a resentful, smoldering, acerbic, impulsively threatening young man. Specific misbehaviors differ. Helen smokes dope and overdosed on sedatives. Dave did not use drugs, insofar as we know, but had traded reputable friends for disreputable pals. And Phil was taking medications meant to address a remote neuro-psychological head injury and to damp down his labile moods; he also took stimulants for a presumptive neuro-psychological deficit in attention and focus. None shared the same diagnostic profile, and no two took the same prescribed medications.
Yet these vignettes share a common deep structure. For a start, each teenager's troubles were so diverse that no Axis I diagnosis tidily could tie it all together. None of them struggles in only one adolescent venue, either. They seem to be failing in every typical adolescent setting.
That is, they all struggled in school—not showing up, not working effectively, not turning in work, not getting along with educators. They all also struggled at home—alienating parents and siblings, defying rules, resisting parental authority, lying, sneaking, hiding in their bedrooms, not coming home. They all struggled socially among age peers—unable to make or keep friends, unable to sustain romantic relationships, switching to affinities with disreputable teenagers who also were not doing very well—and so slipping down the adolescent social register. And they all were unhappy even when alone—angry, sad, ashamed, guilty, mercurial in mood, tuned-out, uncommunicative, filled with self-contempt. In the disparate details of their interpersonal pathology, too, they were a lot alike—uncooperative, intoxicated, injuring themselves, suicidal, out of control, abusive, defiant, threatening, and refusing to let anyone help—in the protean variety of their unpleasant attitudes and interpersonal failures. They all suffered a broadly-based disarray.
The students discovered this commonality, themselves. Groping for shared grounds for conversation in group therapy, for example, they discovered common themes in their lives, similar experiences, equivalent attitudes, cognate mistakes, and a lot of the same self-defeating errors. Over and over they said aloud to one another: "I can relate to that, because I did [or thought, or felt] the same thing." They noticed that all of them had failed in much the same ways at all the tasks of adolescent life—at school, at home, and among their classmates. They recognized that all had suffered, during the crises that preceded their exiles to Montana, a global breakdown.
Shared Deep Structure?
We, as a staff, also sensed this latent resemblance. In clinical conferences, as we talked about these stroppy teenagers whose lives we now shared, we shook our heads at the inventiveness of a particular student's misbehavior, the eloquence of another's defiance, how cleverly a third student made points in noisy debate. Yet there also emerged among us a consensus that, for all their diversity, our students shared something that was fundamental. We did not yet have a diction to name this common denominator. But for all the surface differences, we sensed that, having met one, we had encountered them all. These sketches illustrate this similarity. For all the disparate details, the story lines are the same: a progressive, repetitive debacle; ultimately an act of violence or risk-taking or lost self-control that finally prompts reluctant parents to take drastic action.
This emerging consensus got reinforced by our early, somewhat inadvertent clinical successes. On occasion a student would get "better" and abruptly begin to do very well. Such students began to make sustained academic efforts, became leaders in their classes and in the dorm. They handled parents with diplomacy. The generational friction subsided. They began to like their parents, to understand adult feelings, to respect mothers and fathers, to repair relationships. Their parents willingly reciprocated, startled by a son's or daughter's new graciousness. Successful students began to make friends with other successful students, implicitly recognizing something they shared. They felt better, complained less, liked what they were doing, cared about friends in new ways, fell in love, and felt new energy and ambition. They began to plan for college, met application deadlines, and began to look forward to lives they would live beyond the ranch, which they began to imagine.
What struck us was that this improvement was also global. Students did not improve piecemeal, only in one narrow dimension. They did better in school and with adults and among age-mates and they felt better about themselves—all at about the same time. Just as collapse happened in many dimensions, so did these recoveries. Their improvement was global. These radical improvements in adolescent functioning looked very much alike from one student to another, no matter what the formal diagnostic profile had been.
We puzzled about these observations, asking ourselves what sort of problem would cause a global breakdown in adolescence? And what kind of a psychological problem, when remedied, produces a global recovery, too?
We did not find the answer in the conventional wisdom. In fact, we came to be skeptical of DSM-IV diagnosis in struggling teenagers. For example, if David's supposed bipolar disorder, a genetic psycho-physiological diathesis, was supposed to explain his aggressive misbehavior, why were his outbursts tied so closely to his father's attempts to say no? Or again, if Helen's depression was supposed to make sense of her academic ennui, what explained her shoplifting and defiance of authority, which are not routinely or necessarily associated with a fallen mood? And how could Phil's childhood concussion, for years of no consequence in his history, now explain an abrupt adolescent collapse in academic effort? or his bitter threats? We could not make formal diagnoses explain the history or predict our own relationships with David, Helen, or Phil. Parents who would visit also seemed to have become skeptical.
This skepticism has also been reflected in the lay press—for example, in a series of contemporary articles on the front pages of the New York Times, called "Troubled Children." In "What's Wrong with a Child—Psychiatrists Often Disagree" reporter Benedict Cary painted an unflattering portrait of contemporary diagnostic practice and polypharmacy.
Paul Williams, thirteen, has had almost as many psychiatric diagnoses as birthdays.
Unimpressed, Carey summarized:
The first psychiatrist he saw, at age seven, decided after a twenty-minute visit that the boy was suffering from depression. . . .
What followed was a string of office visits with psychologists, social workers and psychiatrists. Each had an idea about what was wrong and a specific diagnosis: "Compulsive tendencies," one said. "Oppositional defiant disorder," another concluded. Others said "pervasive developmental disorder," or some combination. Each diagnosis was accompanied by a different regimen of drug treatments.
A child's problems are now routinely given two or more diagnoses at a time, like attention deficit and bipolar disorders. And parents of disruptive children in particular—those who might once have been called delinquents, or simply "problem children"—say they hear an alphabet soup of labels that seem to change as often as a child's shoe size. In another article in the series, "Proof Is Scant on Psychiatric Drug Mix for the Young," Gardiner Harris describes a contemporary reliance upon symptom-relieving pills.
Stephen and Jacob Meszaros seem like typical teenagers until their mother offers a glimpse into the family's medicine cabinet.
This dubiety about symptom-based diagnosis in teenagers, this skepticism about the wisdom of a reflexive attempt to relieve symptoms with pills, which is an uneasiness we have come to share—has also been expressed publicly by academic psychiatrists. For instance, Jerome Groopman, MD, in a recent article in The New Yorker—whose title begs the question "What's Normal?"—described the essential problem with diagnosis of bipolar disorder in children and teenagers. By extension he is also describing the larger problem with psychiatry's nomenclature (DSM-IV), which relies upon the diagnostic concept of a disorder, which turns out merely to be a cluster of symptoms and signs that lacks (in almost every DSM-IV diagnosis) a demonstrated underlying etiology. A disorder is a trouble without a cause.
Bottles of psychiatric medications fill the shelves. Stephen, fifteen, takes the antidepressants Zoloft and Desyrel for depression, the anticonvulsant Lamictal to moderate his moods, and the stimulant Focalin XR to improve concentration. Jacob, fourteen, takes Focalin XR for concentration, the anticonvulsant Depakote to moderate his moods, the antipsychotic Risperdal to reduce anger, and the antihypertensive Catapres to induce sleep.
Over the last three years, each boy has been prescribed twenty-eight different psychiatric drugs.
This clinical preoccupation is like treating only the symptoms of "fever and cough disorder" in ignorance of any underlying cause of fever and cough. It is like prescribing medications that can lower a fever or soothe a cough without yet having discovered the bacteria that causes pneumonia, the thrombophlebitis that is the basis for a pulmonary embolus, the human immunodeficiency virus that causes AIDs, or the viral basis for the common cold. Psychiatric pharmacology is all too much like treating all of these causes of fever and cough with aspirin and cough syrup.
It is no one's fault that we do not know, as yet, what causes most of the disorders listed in the diagnostic manual. But this lack of knowledge is worrisome when these syndrome diagnoses are the sole justification for prescriptions for children and teenagers of vast quantities of potent psychotropic drugs. For these psychoactive medications are prescribed to relieve symptoms, not to attack specific causes of well-understood diseases. Groopman underlines the unknown risk in this practice, given that those prescriptions are written for children and adolescents whose neural circuitry is still actively under construction. He quotes Steven Hyman, MD, recently the director of the National Institute of Mental Health, who shares his uneasiness:
The problem with describing a kid who is up-and-down and irritable and sullen and wild and then grandiose is that he could indeed be [bipolar], but it could be an awful lot of other things, too. . . . Bipolar disorder in children represents the intersection of two great extremes of ignorance: how to best treat bipolar disorder and how to treat children for anything. This diagnostic ignorance brings me full circle—back to a remote ranch in Montana, where over the past ten years several hundred students have arrived, bringing with them (usually multiple) syndrome diagnoses and (usually multiple) psychotropic medications.
This diagnostic dilemma was our dilemma, too. If all those disparate symptoms and misbehaviors were incidental to an unknown underlying cause, what was that cause? If the long list of our students' enrollment diagnoses did does not really explain the clinical common denominators among them, what was the explanation? And if their symptom clusters did not contain an essential insight to guide effective treatment—any more than fever and cough guided an effective treatment for those mere symptoms—then what ought to guide our treatment? And, given that most of the pills already prescribed on the basis of DSM-IV disorders already had failed to remedy their many problems, what should we do to help?
This was a puzzle for which we had no solution.
Visiting parents already had struggled with these uncertainties. Most already had received for a son or daughter at least one DSM-IV syndrome diagnosis, already had tried prescriptions for pills that already had proved ineffective. As we met at the ranch with parents of prospective students, week after week, month after month, this uncertainty was always in the air.
Our interviews with visiting parents became a ranch ritual, which took a standard form: talk about the (absent) prospective student, discussion about the concept and the details of our program, a campus tour, and then lunch in the dining hall at one of the team tables. The prospective student was fully engaged elsewhere—usually in a wilderness program, or in a hospital. Typically, the parents had flown to Montana the night before—from Boston, Dallas, Chicago, Portland, or L.A.—and had rented an SUV to make the hour's drive west from Kalispell on a windy country highway. Beside a deep blue lake they had turned off the pavement and climbed a few more miles up a piney ridge, and then had descended into Lost Prairie. They asked questions, walked over the campus with us, and then, seated at our conference table, they rehearsed a son's academic collapse, a daughter's unseemly relationships, a boy's dalliance with drugs, or a girl's loneliness. They told of a teenager's troubles, and their own anxiety and grief.
Always parents arrive in Lost Prairie like knights on a quest. They have come a long way from home. What they hope to find may make all the difference in their lives, and so the stakes are very high. For they fear a son or daughter will not make it "like this" in a heartless world. They worry about what surely could happen to a son or daughter who fails to become competent, self-disciplined, motivated, and well-behaved. These parents are not blind—and so they can see the future coming, even if their children cannot. Time is running out. And so they are afraid. They arrive having tried everything else they knew to try to change that prognosis. Montana Academy is not their first try. It is their last hope.
In these encounters it touches me that these mothers and fathers have embarked upon a tireless quest for the solution to a problem they cannot name. They have already done their homework—consulted, read our web-site, reviewed our resumes, mastered the jargon, talked to experts, googled DSM-IV disorder diagnoses. They have read up on medications, devoured self-help books, mastered the latest research about ADHD and nonverbal learning differences. Yet they are baffled. They cannot fathom why their highly-honed academic skills and determined persistence have not yet yielded them the answer to the riddle. They are upset that they cannot even name the heart of the problem. They describe its aspects, recite all the explanations experts already have provided, but they sound unconvinced, their confidence in modern psychiatry shaken.
Out of my own curiosity, it has become my habit to ask what problem they think they are trying to solve. What do they think is the cause of all these symptoms and misbehaviors? Their lack of a theory galls them. After a sigh and a pause one father left me with a memorable reply: "I don't know, Doc, and thinking about it is like trying to bottle smoke." Occasionally a parent will cling to a DSM-IV diagnosis, hoping that it provides the answer. But this has been rare. Most parents already have dispensed with syndrome diagnosis. One exasperated mother was typical. After an expensive interview with an eminent psychiatrist, he told her that her son suffered from Oppositional-Defiant Disorder. "Dammit," she said, "I knew that before my son walked into the man's office!"
Their anguish moved me, but it put us on the spot. Although parents could not demand that I provide a diagnosis, since I had never set eyes upon their daughter or son, the riddle hung suspended over those conversations, nevertheless. For its solution was what they had come to find. Like other pilgrims they had covered great distances, going on despite weariness. They had preserved the hope, despite disappointments, that in some remote, unlikely place they would discover what they longed to find, even if, like all knights errant, they had little idea what that grail would look like.
The riddle, of course, was: treat what?
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