You won’t see Steve Awhill of Canoga Park in any TV spots that advertise psychiatric care for troubled teens, but he plays a specialized role in what has become a booming business nationwide.
Sawhill and his wife, Leslie, operate S&L Teen Hospital Shuttle. For a price, from $300 to $2,000, depending on how far he has to travel, he said that S&L will deliver teens to the hospital of their parents’ choice.
It doesn’t matter if the teenager wants to go. Their parents, Sawhill said, sign a release authorizing a pickup.
“We’ve picked up a lot of kids,” Sawhill said. “Well over 1,000.”
“A good percent say, ‘Yeah, well, lets go,’” according to Sawhill.
The other 20 percent? Sawhill, who said he employs some off-duty police officers, does whatever it takes to get the teens there.
Sometimes, after 12 hours of picking up kids, Sawhill wonders why he stays in the business, “but when you get invited to a sobriety party, and the kid days, ‘I wouldn’t be alive if it wasn’t for you,’ then you know it’s worthwhile.”
Sawhill said that his main goal is to help kids, and, clearly, many parents also feel that their teens need professional help. But the actions of desperate parents, combined with the practices of private adolescent care providers in Los Angeles and across the nation, have fueled a growing debate over whether the rights of teens are being violated in the name of care and concern.
Every year in America, tens of thousands of teens are committed to private facilities, sometimes against their will, sometimes without being informed of their rights, and much of this burgeoning trend seems to be tied to slick advertising and the monies to be made off adolescent care.
Marketing the private hospitals
“Real aggressive marketing is going on,” said Barbara Lurie, director of the Los Angeles County Patients’ Rights Office. “All the ads are geared to parents, not the kids.”
Patricia Gilbert, a patients’ rights advocate at Lurie’s office, also noted the growing number of private facilities advertising on TV “when angry parents are more likely to see them. They advertise with the notion that if you’re a good parent, you’ll put your kids into the hospital.”
Jim Price, executive director of the L.A. Mental Health Advocacy Project, finds this disturbing. “Parents are lured to place their kids in these facilities,” he said. “A very large industry has developed [targeting] kids who have problems dealing with their parents but don’t have any serious psychiatric problems.”
The numbers game
The number of teens in private psychiatric facilities in the United States rose 450 percent between 1980 and 1984—a marked increase from 10,764 to 48,375.
And between 1966 and 1981, the number of for-profit psychiatric facilities for youth increased 125 percent.
These are the most recent statistics available, according to the U.S. House of Representatives Select Committee on Children, Youth, and Families.
Such care does not come cheaply. Fees at several Southern California facilities range from $4,000 to $7,000 per week. The average stay at the facilities surveyed lasts six weeks.
However, research by patients’ rights advocate Gilbert revealed an alarming fact in teen mental health care: the greatest predictor of length of hospital stay is not the diagnosis, but the ability to pay. And in most private facilities, ability to pay translates to insurance coverage.
“Sometimes we have to work fast, faster than we’d like, to prepare them to leave before their insurance runs out,” said R. James Perkins, adolescent program director at the Community Psychiatric Center in West Los Angeles. “Occasionally, the insurance runs out, and the child is clearly not ready for discharge.”
The length of stay at Charter Hospital in Long Beach “depends on the patient’s ability to pay—their insurance,” said Tari Moore, program director of the adolescent unit. “We have to speed up the treatment if the patient’s insurance runs out in 10 days.”
Teen patients’ rights
At Charter, few teens contest their admission, according to director Moore. “They are signed in [by their parents] as ‘voluntary,’ for the most part, so that’s covered,” she said. “There’s no need to go to trail over something that’s voluntary.”
That’s the problem, said patients’ rights advocate Gilbert. “Juveniles can be committed (voluntarily) be their parents. They have no legal recourse.”
A glimmer of hope, in the form of a proposed new state law authored by Assemblyman Richard Polanco (D-Los Angeles), was defeated on August 30th on a 5-5 vote in the State Senate Appropriations Committee. Seven votes were required to move it to the Senate Floor. The State Assembly had already passed the bill. Heavy lobbying by organizations opposed to the new legislation was involved.
The proposed law, Assembly Bill 4163, would have prohibited minors 14 and over from being committed to a private facility without a hearing, unless they waive that right.
Previously, the California Supreme Court’s 1977 “Roger S.” decision guaranteed such hearings only to minors 14 and over in public facilities, not private ones.
Assemblyman Polanco was quoted by his legislative aide, Chris Flammer, as being “very disappointed,” It was an “urgency statue,” said Flammer, quoting the actual language of the legislation. That meant it would have gone into effect immediately “in order to protect the rights of minors who might otherwise by hospitalized against their will.”
The organizations that lobbied to defeat the proposed law included the California Association of Health and Hospital Systems, the United Hospital Association, the California Psychiatric Association and National Medical Enterprises. The latter, based in Atlanta, Georgia, owns Charter Hospitals.
According to Carl Weissburg, Executive Director of the United Hospital Association, “There was no funding provision in the bill. Insurance companies won’t pay for the due process hearings and the hospitals certainly won’t dig deep in their pockets to pay the attorney fees and other costs. There was no reimbursement built into the bill.”
Most of the cost of the bill would have been incurred by local agencies, not the private facilities, according to Flammer. These include the person conducting the hearing (a court-appointed commissioner, referee or certification review officer), the patients’ rights advocate provided to the minor, and the basic administration of the mandated local program imposed under the law.
As Flammer pointed out, even the cost of a booklet outlining the specific rights of minors in mental health facilities—which the facilities were required to provide to every teen patient upon admission—was to be borne by the State Department of Mental Health.
Critics also argued that the Polanco bill would have denied parents’ “due process”—to which legislative aide Flammer countered, “These professional and private hospital associations feel due process belongs to the parents, not teens.” He added that participation by parents was in the legislation.
Patients’ rights advocate Gilbert sees money as the overriding reason for the hospitals’ opposition. “Any kind of hearing means that [teen patients] are going to stay less, and I think that’s what the hospitals are afraid of,” said Gilbert. “That’s a lot of money to lose per kid.”
Assembly Member Polanco plans to re-introduce the bill in January. And proponents, including the California Medical Association, plan to press for enactment.
For now, however, patients’ rights advocates are fighting what they see as a major struggle against the practices of some private hospitals and how they are treating teens who are brought in involuntarily.
In L.A. County, teens in private facilities do have the right to seek and obtain a post-admission court petition and have a judge decide whether their hospital detention is legal.
But mental health authorities say that teens are often not told about it and thus are unaware of that option.
“Many, many of them don’t know that they have the right to request a hearing,” said Ruth Olson, Assistant Division Chief of Mental Health Services for the L.A. County Superior Court.
Scenarios
Other teens seek petitions, but then withdraw them under pressure.
A 17-year-old female “wanted to get out, but the doctors scared her enough so she withdrew her [petition],” said Price.
At one of the facilities that Gilbert services, “The therapist threatened to send the kid to juvenile hall if they went to court [for a petition].”
Olson knew of another scenario, in which teenagers opt to “make a deal, rather than seek a petition. For example, she said, “The doctor will tell a patient, ‘If you’ll stay here one month and not go to court, we’ll let you out in one month, instead of three.’”
Teen patients often accept the “deals,” rather than run the risk of a judge misunderstanding their plight, Olson said.
Not only do some hospitals make “deals” with patients, but they also provide parents with “stories.”
One caller to a Southern California facility was advised by an employee on what to do if her son wouldn’t go voluntarily.
“Tell him that you’re going to go shopping … or [to] pick up a prescription at the pharmacy,” the employee told the caller.
Aparently, the shopping “story” is not isolated to a single facility. R. James Perkins, adolescent program director at the Community Psychiatric Center (CPC) in West Los Angeles, said that at CPC, “some parents get the child to the hospital by telling them that they’re going shopping.”
Patients’ rights advocate Lurie related another story of a teenager whose routine visit to a doctor at an adolescent facility turned into an extended ordeal. “Before she knew it, the [facility] door slammed behind her,” Lurie recounted. “She washed her underwear out for a week” until her parents brought her a change of clothing.
Looking for answers
Most advocates of teen rights believe that proposed laws like the Polanco statue are crucial
Professor Jan C. Costello, Associate Dean of Loyola Law School, recently stated that the same concern that motivated the California Supreme Court to reach its “Roger S.” decision regarding teens in public facilities still exists in the private arena: the “serious consequences attendant upon involuntary commitment of a minor as a mentally ill or disordered person.”
The Court found that confinement in a mental hospital involved a substantial impairment of liberty and privacy rights. “not only is there physical restraint, but there is injury to protected interests of reputation, and of not being improperly or unfairly stigmatized.”
In that decision, the court noted “the uncertainties in psychiatric diagnosis and the divergence of expert views which render the possibility of mistake significantly greater than in diagnosis of physical illness.”
It reduced the risk, according to Costello, “by establishing criteria for hospitalization and procedures whereby a neutral decision-maker review[ed] the appropriateness of the minor’s hospitalization.”
In defending the need for an impartial person to conduct the hearing, Costello pointed out that private facilities, while having an interest in providing appropriate treatment, “may also have a financial interest in providing in-patient care to the minor, even where hospitalization is not necessary and treatment could be provided less restrictively.”
But such laws are not seen as a cure-all. And even if statues like the Polanco bill do pass, teen patients’ rights advocates are still concerned.
Beyond what they indicate would be the need for strict compliance and enforcement, they say, is a larger issue: the ongoing effect of aggressive adolescent hospital advertising on defining how parents look at their teenagers, what they regard as acceptable teenage behavior and whether they might opt too readily to put their child into a facility instead of exploring alternatives.
To get insurance companies to consider paying for out-patient care is cited by at least one expert as a potentially important step. Some suggest that this may come about as insurance companies, plagued by soaring reimbursement costs to adolescent hospitals, re-evaluate what disorders and teenage conditions really require prolonged in-facility treatment.
For now, however, teenagers are getting committed every day. And for some—especially those who don’t really need hospitalization, or need only limited care—they must fight their own lonely, and sometimes desperate, battles.
“I don’t know what the answer is,” said Howard Kelner, Assistant Deputy, psychiatric section of the L.A. District Attorney’s Office. “[But] I don’t think the answer is locking them up in psychiatric hospitals.”