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The Relationship Between Shame, Teen Treatment, Dual Diagnosis and PSB

By Stephen C. Schultz


I recently had a conversation with an allied health professional concerning a student who was already placed in a residential treatment program. The family was from the Boston area and were huge Red Sox fans. They are a close family and never planned on being in this very personal and lonely place concerning their son. This particular student has a history of being in previous treatment programs and sexually acting out at some of those programs. Each time he would be separated from the rest of the group, additional staff were brought in and the parents were asked to find another placement within 24-48 hours. This particular student has a low/average IQ and has been diagnosed with being on the spectrum. I got the call because this student, who is underage and is in another program, sexually acted out with a 20 year old.



We had a good conversation and I’m sure the family is in good hands with their consultant. My purpose in sharing this message isn’t to “armchair quarterback” this clinically complicated situation. It is simply to re-frame how we tend to think about Problematic Sexual Behavior (PSB) and how we can better discuss these issues with families when their teens are burdened with a problem.

On more occasions than I can count, referring professionals will share with me clinically significant behaviors from a client. These behaviors and thoughts meet clinical criteria for admission to Oxbow Academy for the 90 day evaluation. It is often stated during the follow-up conversation;

“However, the sexual issues are not the ‘primary’ concern or diagnosis. The parents would like to try a different program first.”

I think it’s important for us to understand that the terms “Primary and Secondary Diagnosis” were set up and established as a way for insurance and third party payers to prioritize what they would pay for. Again, it is language that has been adopted from the medical model in an effort to meet the needs of third party payers. Subsequently, mental health treatment plans soon followed. This had very little to do with Mental Health science or research. We all know, in the world of mental health, the therapeutic process doesn’t  simply happen in a linear manner.

For example, think about the client diagnosed with Depression and Chronic Substance abuse. Simply treating the depression does not take care of the addiction issues. And, switching it around does not guarantee the depression will subside either. Hence, we describe these situations as the client having a co-occurring or a dual diagnosis. It’s the same situation for a student diagnosed with ASD, NLD, ODD, Anxiety or Depression who is also engaged in compulsive sexual behavior. Comorbidity is what we are dealing with and all of the symptomatology must be dealt with simultaneously.

The issues surrounding comorbidity need a very clinically sophisticated and integrated treatment regimen. Unless a program has a system in place to clinically assess all sexualized behavior and thought processes by the student, it is like having a biopsy on a cancerous lump in your arm and not exploring to see how wide spread the cancer is. That is why these sexual issues re-surface time and time again with these students when they are in a more generalized treatment setting.



I have been asked, “Doesn’t the student experience ‘shame’ when they participate in the disclosure process?” My answer is NO! In fact, it’s quite the opposite. They work closely with their therapist and family through the disclosure process. Its difficult family work, but the students learn that their parents are there for them…no matter what gets disclosed. Often there are some pretty raw emotions and a lot to work through, but this is where true healing begins. When they pass the clinical polygraph aspect of disclosure, it is a liberating, emotionally freeing and cathartic event. It is actually the opposite of a shameful experience.

Dr. Brene Brown, a research professor at the University of Houston has taught that there is a difference between shame and guilt. Guilt is actually a good emotion to feel. It helps us recognize how some of our behavior may not be congruent with our personal values and encourages us to change and improve. 

Shame on the other hand is destructive. Shame is more about how we think and how we attribute our self worth. Shame is destructive and tries to convince us that we have limited worth. Shame encourages us to continue destructive behavior.

Parents also need to make sure they ask about any research the program is doing. Not simply outcome surveys, but actual data gathering and interpretation. The program should have visible and verifiable processes in place to not only gather data, to interpret data, but also to inform the treatment process in real time.

So, the next question is, “How do we help parents understand this?” I have seen family after family say they wish someone would have mentioned Oxbow earlier in the treatment process. These families have been faced with embarrassing situations, perceived treatment failure and the depletion of financial resources.

The link below consists of an experience I had while speaking to students at a more generalized RTC. Please don’t hesitate to pass this along to others that may find it useful.

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