Faculty Mentor: Patricia Kerig (Psychology, University of Utah)

ABSTRACT

The Troubled Teen Industry (TTI) refers to a network of private youth programs, wilderness camps, boarding schools, and residential facilities marketed as treatment centers for adolescents with perceived mental illnesses or behavioral problems. However, given that a range of negative experiences have been reported by survivors during their time in the TTI, it is important to investigate whether the outcomes associated with these treatment programs are indeed positive ones.

The present study aimed to investigate potentially stressful experiences during TTI involvement and their association with adult well-being. This association was examined through the exposure to potentially morally injurious events (PMIEs), defined as experiences in which individuals witness, perpetrate, or fail to prevent acts that violate their personal moral code (e.g., experiencing mistreatment at the hands of therapeutic staff). It is understood that PMIEs, when left untreated, result in symptoms which may significantly impact well-being. Additionally, this study further examined the role of meaning-making as a potential moderating factor influencing the association between PMIE exposure and well-being in adulthood. It was hypothesized that there would be a negative association between PMIEs experienced during TTI programs and adult well- being, and that this association would be moderated by meaning-making, such that individuals who have been able to make better sense of moral transgressions and integrate this understanding into their worldviews would be less impacted by PMIEs and have higher well-being in adulthood.

Participants included 302 survivors of the TTI ages 18 and older who were recruited primarily through outreach to online TTI survivor communities. The majority of participants self-identified as male and/or Non-Hispanic White, and most reported having attended at least one TTI program for one to two years during their lifetime. Eligible participants completed a Qualtrics survey assessing PMIE exposure during TTI involvement, meaning-making, and adult well-being. A moderation analysis was conducted to investigate these relationships. Results from our analyses did not support the original hypothesis given that no significant association was found between PMIE exposure and well-being in adulthood. Additionally, no significant interaction was found between PMIEs and meaning-making, suggesting no moderation effects. However, meaning-making was found to be a significant predictor of well-being, irrespective of PMIE levels. Ultimately, this study not only adds to the current literature on moral injury in youth but may also inform efforts to support youth’s recovery from negative TTI experiences.

INTRODUCTION

Each year, thousands of teenagers in the United States are sent, often against their will, to private residential treatment centers that claim to rehabilitate youth struggling with perceived mental illnesses or behavioral problems (Golightley, 2020). These reformatories, operating as boarding schools, wilderness therapy programs, military-style boot camps, secured group homes, religious academies, and drug rehabilitation centers, collectively fall under what is commonly referred to as the troubled teen industry (TTI; Corsello & Hayes, 2024; Krebs, 2021; Mater, 2022).

Although many TTI enterprises emphasize a commitment to supporting the recovery and treatment of troubled youth, concerns regarding the lack of transparency regarding program operations alongside disturbing accounts of survivor experiences have sparked recent media attention pointing towards potential maltreatment occurring within the industry (Etler, 2024; Kingkade, 2022; Porter, 2024; Schreifels & Gilbert, 2022).

Methods of treatment in these facilities tend to lack substantiated evidence for their effectiveness as rehabilitative tools (Pfaffendorf, 2019), with a considerable number of survivor testimonies describing questionable practices employed by staff including coercion, discrimination, medical neglect, and extreme uses of force and isolation as methods of discipline for misbehavior (Chatfield, 2019; Corsello & Hayes, 2024; Friedman et al., 2006; Mater, 2022). Although thorough documentation of program practices is missing from national databases due to the fact that many facilities operate outside federal regulation and oversight (Friedman et al., 2006; Rubino, 2024), the content of existing survivor narratives (Chatfield, 2019; Corsello & Hayes, 2024; Golightley, 2020; Mater, 2022; Mooney & Leighton, 2019) suggests that youth may be exposed to a host of negative experiences during their time in the TTI that have the potential to significantly compromise their adult functioning following their release from treatment.

Adult Outcomes

Given the frequent reports of stressful event exposures by survivors of the TTI, one essential yet critically understudied area of research is the examination of adult outcomes for youth with TTI histories. Current research investigating well-being among TTI survivors has largely relied on individual testimonies, many of which report significant challenges to social reintegration and disruptions to quality of life (Chatfield, 2019; Golightley, 2020; Mater, 2022). For example, in one qualitative study with adult participants who had prior TTI involvement, Chatfield (2019) found that adjustment to life after residential treatment was characterized by debilitating anxiety, ongoing nightmares, clinical mistrust, impaired relations with parents, social withdrawal, and a “lingering sense of violation” (p. 62). Additionally, TTI survivor testimonies from an undergraduate thesis (Mater, 2022) described persistent states of hypervigilance, identity issues, and impairing mental health symptoms that were either maintained or newly developed as a result of the program.

On the positive side, qualitative reports published in the TTI literature also provide valuable insight into the recovery experiences of survivors. However, there have been no quantitative studies to date that measure sources of resilience and their role in promoting positive outcomes for individuals following stressful TTI exposures.

Moreover, among survivors who report challenges to reintegration after their release from the TTI (Chatfield, 2019; Golightley, 2020; Mater, 2022), it is unclear from the existing literature what specific aspects of the TTI experience contribute to impaired functioning in adulthood. This study aimed to investigate a potential mechanism linking adverse event exposure in the TTI to adult well-being and proposed a probable protective factor that may moderate this association.

Moral Injury

Given the range of stressful experiences described by TTI survivors and reports involving trust violations, threats to safety and security, and impaired sense of self (Corsello & Hayes, 2024; Golightley, 2020; Mater, 2022), one construct that may particularly impact adult well-being in this population is moral injury. Initially construed within the context of war veterans, moral injury refers to a type of psychological trauma that emerges as a result of witnessing or experiencing an event that violates one’s deeply held moral beliefs and expectations (Jinkerson, 2016; Kidwell & Kerig, 2021; Litz et al., 2009; Nash & Litz, 2013). Such violations are particularly salient when perpetrated by authority figures or social institutions which the individual holds in high regard or attributes a profound sense of trustworthiness towards (French et al., 2022; Nash & Litz, 2013; Shay, 2014). In military contexts, a moral injury may entail witnessing a superior violate rules of engagement (Shay, 2014); alternatively, in child welfare settings, moral injury may involve observing a trusted caregiver fail to intervene on behalf of a child who is being physically abused (Haight et al., 2022). Additionally, morally injurious transgressions may result from acts of perpetration, such as a soldier committing acts inconsistent with their own core values (Drescher et al., 2011), when individuals interpret their violations as indications of moral deficiency or failure to act in a just manner (Forkus et al., 2019).

Experiences that can lead to moral injury, termed potentially morally injurious events (PMIEs; Litz et al., 2009), produce a state of cognitive dissonance that, if left unremedied, results in symptoms which may significantly impact well-being (Drescher et al., 2011; Jinkerson, 2016; Litz et al., 2009; Nash & Litz, 2013; Roth et al., 2022; Vargas et al., 2013). For example, Battles and colleagues (2018) found in a sample of U.S. veterans that exposure to PMIEs was linked with an increased risk of mental disorders and suicidal ideation. In another study, Roth et al. (2022) described a profound loss of trust experienced by forensic psychiatric patients who felt like they were betrayed by institutions and individuals who were meant to protect them. This breach of moral expectation was found to be associated with prolonged periods of anxiety, PTSD, and a host of depressive symptoms including “intense feelings of sadness, worthlessness, and rumination” (Roth et al., 2022, p. 63).

It is valuable to note that internal conflict resulting from PMIE exposure is often indicative of a moral violation which has “exceeded the information-processing capacity of the person at their current stage of development” (Nash & Litz, 2013, p. 370). Thus, if the ability to rectify morally transgressive events is contingent upon the availability of social and spiritual resources, youth—who tend to lack the autonomy and prior experience necessary for effective coping—may be at heightened risk for suffering the consequences of moral injury.

Moral Injury Among Adolescents

A growing body of work has begun to identify adolescents as vulnerable targets for PMIE exposures, suggesting that a limited scope of moral expertise can hinder a young person’s ability to grapple with adverse circumstances (Alexander et al., 2024; Haight et al., 2022; Kidwell & Kerig, 2021). Given adolescents’ limited expertise in navigating moral dilemmas and their dependence on adults for basic survival needs (Haight et al., 2022; Kidwell & Kerig, 2021; Wainryb, 2011), early attachment figures tend to serve as youth’s primary role models and play a critical role in co-constructing with them expectations of what is “right” and “wrong” across social conduct (Kidwell & Kerig, 2021). Importantly, this includes assumptions around the responsibility of socialization agents, such as that of the family, caregiver, or mental health provider, to care for and protect children’s well-being (Rawls, 1971; Soffer-Elnekave et al., 2023). If the caregiver’s response fails to alleviate these anxieties, youth’s internal moral framework might substitute a belief that reliance on social relationships is untenable or threatening (Sherman et al., 2015) and withdraw from future opportunities for connection entirely (Charuvastra & Cloitre, 2008; Karrass & Walden, 2005). Such disruptions to moral expectations, specifically when perpetrated by trusted individuals, may also impair a child’s ability to self-regulate and can potentially develop into more serious manifestations of psychopathology (Cook et al., 2005; Spinazzola et al., 2005; van der Kolk, 2005).

Further investigating this child-caregiver relationship, Haight et al. (2022) found that experiences of child maltreatment and the failure of adults to protect were the most common form of moral injury among emerging adults with histories of child welfare involvement. These findings support earlier research conducted by Nash and Litz (2013) which highlighted that moral injuries inflicted by those most trusted are among the most severe. For youth under the care of total institutions—defined as establishments where similarly-situated individuals are isolated from the wider community and are subject to rigid and uniform authority controlling all aspects of daily life (Goffman, 1958), such as in the TTI—staff members become sole providers of daily needs and, in turn, may exert a profound influence on youth’s basic morality construction and PMIE exposure risk.

Moral Injury in the TTI

Recognizing adolescents’ heightened susceptibility to moral injury through their attachment needs, there is reason to suggest that TTI institutions may be prime settings for PMIE exposures given that they assume total control over youth’s care and can elicit significant levels of trust and dependence, ones that are comparable to that of a caregiving relationship (Smith & Freyd, 2013). With limited contact to external support networks made available to youth in residential facilities (Chatfield, 2019; Corsello & Hayes, 2024; Friedman et al., 2006), program staff may become primary attachment figures responsible for fulfilling the educational, physical, and emotional needs of children in their care (Corsello & Hayes, 2024; Gilbert et al., 2009). There is thus an expectation for these institutional settings, and those that run them, to be kind, safe, and equipped with the necessary resources to provide effective support to those who depend on them for survival (Monteith et al., 2021; Smith & Freyd, 2013). In contrast, when expectations of secure and reliable protection are not met, as suggested through robust survivor testimonies depicting staff misconduct, neglect, and coercive control (Chatfield, 2019; Corsello & Hayes, 2024; Friedman et al., 2006; Golightley, 2020; Mater, 2022), breaches of trust in TTI facilities may constitute potential moral violations that can increase the risk of moral-injury related outcomes among youth.

In examining the caretaking role of social service professionals, Haight et al. (2022) found that providers may not only fail to provide youth with support and loving care but can sometimes be the ones to perpetrate the abuse or to ignore its presence entirely when the abuse is inflicted by fellow youth. Notably, participants of the study described sentiments which seem to closely correspond with characteristics associated with PMIE exposure, such as the system failing to protect them, betraying their trust, and not being there for them in times of need. In another study, Jones and colleagues (2021) found that youth who experience involuntary hospitalizations frequently report feelings of fear, autonomy loss, and impaired trust, all of which pose additional risks for PMIEs. Such events may also be characteristic of the TTI experience in which youth are admitted into programs unwillingly (Becker, 2010; Golightley, 2020), “legally kidnapped” in the middle of the night under parental authorization and transported from their homes without prior notice (Chatfield et al., 2020; Dobud, 2022; Golightley, 2020; Mater, 2022), and remain in the custody of their institutions with no knowledge of the length of their stay or the date of their discharge (Mooney, 2024).

Finally, power dynamics between staff and residents once at the TTI facility present additional opportunities for youth to experience severe moral transgressions. In a thematic analysis of open-source testimonies from TTI survivors, Corsello and Hayes (2024) found that psychological abuse, defined as a sequence of intentional or unintentional behavior which conveys to the recipient that they are unloved, unwanted, and unimportant (Haque et al., 2020), was particularly widespread in behavioral modification programs where program attendees were often made to feel small and unworthy by staff. For example, one survivor described how “[Staff] had this way of looking at you and identifying your worst fears and self hate and using it to break you down” (Corsello & Hayes, 2024, p. 2943). Additionally, TTI personnel have been reported to sometimes order and incentivize program attendees to monitor and report on their peers’ misconduct (Golightley, 2020), forcing youth into potentially uncomfortable and morally distressing roles that can undermine their personal sense of morality (Roth et al., 2022).

Such experiences are consistent with the moral injury literature which specifies that self-perpetrated transgressions may challenge a person’s self-concept and contribute to a belief in moral ineptitude and failure to live up to one’s own ethical standards (Forkus et al., 2019; Litz et al., 2009; Nash & Litz, 2013). Furthermore, existing theories regarding children’s experiences with moral injury suggest that youth who believe they have caused irreparable damage to others may experience critical alterations to their moral understanding and agency (Kidwell & Kerig, 2021; Wainryb, 2011). However, even in cases of moral disagreement between youth and staff, Corsello and Hayes (2024) noted that fear of punishment often distorted youth’s sense of autonomy and compelled them toward compliance with staff orders. As a result, program residents may feel forced to behave in ways that are inconsistent with their moral code and begin to construct a view of the world and of themselves as immoral, unlovable, and irredeemable (Kidwell & Kerig, 2021).

In sum, there is evidence to suggest that practices in the TTI may significantly increase the risk of PMIE exposures among youth in the program and that these transgressions, if left unresolved, can result in severe psychological and spiritual struggles that may ultimately compromise adult well-being.

Meaning-Making

Whereas research and theory support a link between PMIE exposures and adverse mental health outcomes (Battles et al., 2018; Currier et al., 2014; Litz et al., 2009; Nash & Litz, 2013), not all individuals who encounter PMIEs go on to experience negative effects or impaired functioning (Litz et al., 2009). To understand the conditions allowing for these discrepancies in moral recovery, researchers have suggested meaning-making— defined as the ability to appraise a specific event as violating core values and beliefs and integrate this understanding into existing world schemas (Holland et al., 2010)—as a potential protective factor that may support healing following PMIE exposure (Ferrajão & Oliveira, 2015; Gray et al., 2012; Nash & Litz, 2013).

Litz et al.’s (2009) model of moral injury proposes that there are two routes to moral repair: (1) exposure to corrective life experience and (2) psychological- and emotional-processing of one’s memory about a moral transgression. This second restorative element has been supported by recent literature which has highlighted that the ability to find redemptive meaning in morally injurious experiences is critical in healing from the spiritual pains of moral injury and helps to situate transgressions within psychosocial and cultural contexts (Ferrajão & Oliveira, 2015; Gray et al., 2012; Haight et al., 2017; Soffer-Elnekave et al., 2023). For example, in one study examining the role of meaning-making on the recovery processes of Portuguese war veterans, Ferrajão and Oliveira (2015) found that self-integration of morally discrepant events was a key component in veterans’ PTSD recovery and moral repair. Similarly, Soffer-Elnekave and colleagues (2023) noted that among adolescents, the meanings that children attribute to their moral transgressions likely affect the degree to which those violations are morally injurious. Thus, meaning-making that successfully integrates morally-injurious experiences with current belief systems has been suggested as a process that reduces the impacts of moral injury following PMIE exposure (Forkus et al., 2019; Nash & Litz, 2013).

Despite these promising theories, research to date has not yet examined meaning- making as a potential source of resilience for those who have been involved with the TTI in adolescence. However, some qualitative studies have suggested the potential of meaning-making to support readjustment following discharge from residential care.

Golightley (2020) found in an interview with 16 former therapeutic boarding school students that time and space away from residential treatment allowed them to “redefine their experiences on their own terms” and that “identifying the hardships they endured was an important part of their healing” (p. 61). Similarly, Mater’s (2022) interviewees highlighted that engaging in activism and finding connection with those who had also been in TTI treatment provided a healthy outlet for them to validate and make sense of their personal experiences. Such qualitative reports, while limited, suggest the promising role of meaning-making as redress for harmful TTI exposures and in promoting a space that is conducive to growth and healing. However, more quantitative research is necessary to understand this mechanism, specifically as it relates to moral injury.

Current Study

To address the current gaps in the literature, this study aimed to investigate the impact of PMIEs experienced during TTI involvement on adult survivors’ well-being. This study further examined whether meaning-making moderated the association between PMIEs and adult well-being. Based on previous research and theory, it was hypothesized that there would be a negative association between PMIEs experienced during TTI programs and adult well-being, and that this association would be moderated by meaning-making, such that individuals who had been able to make better sense of moral transgressions and integrate this knowledge into their worldviews would be less negatively impacted by PMIEs and have higher well-being in adulthood.

METHOD

Participants

Participants in this study included 302 survivors of the TTI who were recruited through social media and online survivor communities (87.4%), via participants’ friends and acquaintances (6.3%), and from smaller outreach channels (e.g. fliers, school, other; 6.3%). Eligibility was limited to those who were 18 years and older, with the participant age range falling between 18 and 59 (M = 31.11, SD = 9.06). Self-reported gender identities included 61.9% male, 19.5% female, and 18.5% non-binary or other. In terms of race and ethnicity, participants primarily self-identified as Non-Hispanic White (80.5%), followed by Hispanic or Latino (7.0%), Indigenous (2.3%), Asian or Pacific Islander (2.0%), Black or African American (1.0%), mixed race and ethnicity (6.0%), and other (1.3%).

The majority of survey respondents reported being sent to one (36.8%) or two (35.1%) different TTI programs during their life, with the total number of programs attended ranging from one to thirteen; two participants (0.7%) endorsed having attended thirteen total different programs. While 4% did not provide program type information, the remaining participants indicated attending residential treatment centers (41.4%), therapeutic boarding schools (28.5%), wilderness therapy programs (13.9%), or other types of TTI programs (12.3%). Length of attendance ranged from less than one week (0.3%) to over two years (15.2%), with the majority of participants remaining in programs for one to two years (31.5%); 3.6% did not report the duration of their stay. Of the 32 U.S. states in which participants reported attending programs, nearly half (49.7%) of programs were located in Utah; 4% of participants reported attending programs located outside of the United States, and 4% of respondents did not specify a location.

Procedures

All procedures were approved by the University of Utah’s Institutional Review Board prior to recruitment and data collection. Data for this project was collected as part of a larger study conducted by the Risk to Resilience Lab. Eligible participants completed an online Qualtrics survey which assessed several measures related to the TTI experience. The link to this survey was provided to participants through the lab’s online advertisements on various social media outlets (e.g., TTI survivor Reddit communities, Utah Reddit page, Facebook groups) as well as via QR codes printed on flier materials posted at local coffee shops around Salt Lake City. Upon opening the survey, participants were provided a description of the present study’s purpose, that is, to examine the impact of the Troubled Teen Industry on teens who are sent to these programs and to understand what their lives look like now. Participants then completed informed consent which highlighted the voluntary nature of their participation and explained that they may choose to skip questions or stop the survey at any point without penalty. The survey was broken up into three tiers containing various measures related to the TTI experience, with participants given the choice to proceed to the next tier of questions if they wished. The survey could be completed on any electronic device with internet service and took approximately 15 to 20 minutes to complete. All participants were given the option to enter a raffle for a $50 gift card as part of their survey completion.

Materials

PMIEs. PMIE exposure was assessed using a modified 22-item version of the Moral Injury Scales for Youth (MISY; Chaplo et al., 2019), with slight changes in phrasing from the original 24-item scale. This scale is a downward extension of the Moral Injury Events Scale (MIES; Nash et al., 2013), originally designed to assess PMIEs within military contexts, by adapting it to measure PMIEs experienced among nonmilitary emerging adults and adolescents. The measure contains items assessing different types of PMIEs: commission with agency (“I have done things to other people that break my own personal rules about what is right and wrong”), commission under duress (“I have been forced to do things to others that I think are wrong”), omission (“I let a bad thing happen to someone when I should have done something to stop it”), witnessing (“I have seen other people do bad things”), and betrayal (“I feel betrayed by people I thought I could trust”). Participants were asked to respond using a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). Total scores were summed with possible results ranging from 22 to 110, where higher scores reflected a higher severity of moral injury. The MISY has been found to be a valid and reliable measure of moral injury among emerging adults and demonstrates strong potential utility as an assessment tool for civilian youth populations (Chaplo et al., 2019). Cronbach’s alpha for the current sample was .94.

Meaning-making. Meaning-making was assessed using the Integration of Stressful Life Experiences Scale (ISLES; Holland et al., 2010). The ISLES was developed to measure the degree to which a stressful life experience has been successfully integrated into broader life narratives in a way that might promote coherence and security (Holland et al., 2010). This scale comprises a total of 16-items assessing (1) the degree to which one feels they have some footing in the world following a stressful TTI event (“Since this experience, the world seems like a confusing and scary place”), and (2) the comprehensibility of the stressor (“This experience is incomprehensible to me”). Participants indicated their ratings using a 5-point Likert scale (1 = strongly agree to 5 = strongly disagree). One item (“I have made sense of this event”) was reverse- scored. Total scores were computed by summing up individual responses to produce a value ranging from 16 to 80. Items were coded such that higher scores reflected greater difficulties with integration—that is, those who scored higher on the ISLES were less successful at integrating stressful events into their broader life narratives. This scale has demonstrated good internal consistency as well as convergent validity with adjacent instruments assessing meaning-making (Holland et al., 2010). Cronbach’s alpha for this scale for the present sample was .89.

Well-being. Well-being was measured using the Flourishing Scale (FS; Diener et al., 2010), designed to evaluate several important aspects of human functioning. This measure contains an 8-item self-report summary capturing well-being across dimensions of relationships (“My social relationships are supportive and rewarding”), self-esteem (“I am a good person and live a good life”), purpose (“I lead a purposeful and meaningful life”), and optimism (“I am optimistic about my future”). Items were rated using a 7-point Likert scale (1 = strongly disagree to 7 = strongly agree). Items were summed to create a total score that ranged from 8 to 56, with higher scores representing greater psychological resources and a more positive self-view across important areas of functioning. The present sample demonstrated good internal consistency for this measure, Cronbach’s alpha (𝛼) = .89.

Data Analysis

Statistical analyses were conducted using SPSS version 29. Prior to analyses, all variables were inspected for normality and potential outliers. Visual inspection of histograms and Q-Q plots for the dependent variable, well-being, revealed an approximately normal distribution with no substantial deviations. A box plot analysis did not suggest the presence of outliers. Following assessment of normality and outliers, dummy-coded variables for gender were generated for later inclusion as covariates in regression models. Non-binary/other served as a reference category, and two variables were created: (1) Female (1 = female, 0 = male or non-binary/other) and (2) Male (1=male, 0 = female or non-binary/other). PMIE and meaning-making scores were mean centered prior to analysis.

Missing data ranged from 17.9% (PMIEs) to 23.8% (well-being). Little MCAR’s test was significant (χ²(5) = 12.34, p = .030), suggesting that missingness patterns were not completely random. Chi-square tests indicated that race and ethnicity were associated with patterns of missingness for meaning-making (χ²(1) = 5.71, p = .017) and well-being (χ²(1) = 4.27, p = .039), but were not significantly related to the PMIE measure (χ²(1) = 2.97, p = .085). Specifically, non-Hispanic White participants had higher proportions of missing data compared to youth of color for the meaning-making (22.2% vs. 8.5%) and well-being (26.3% vs. 13.6%) constructs. Additionally, independent t-tests were conducted to examine whether missing data were associated with participants’ ages.

Results revealed that participants who were younger at the time of program entry were significantly more likely to have missing data for PMIEs (t(285) = 2.40, p = .017), while older participants at the time of the survey were more likely to have missing data for well-being (t(299) = -2.35, p = .019). Neither current age nor age at program entry were significantly related to the missingness of the meaning-making measure. No other demographic characteristics were observed to be significantly related to patterns of missingness. To account for missing values, multiple imputation was performed using ten imputations in SPSS, and pooled results from the imputed data sets were used for analysis.

To test our hypotheses regarding the association between PMIEs and well-being, as well as the potential moderating effect of meaning-making, multiple linear regression was run with well-being regressed onto PMIEs, meaning-making, and their interaction term. Gender, race/ethnicity, and current participant age were included as covariates to control for their potential influence on the relationships between PMIEs, meaning- making, and well-being.

RESULTS

In the original dataset (prior to multiple imputation), participants had a mean score of 80.74 (SD = 19.21, range: 10-110) out of 110 on the MISY scale assessing for PMIE exposure, 55.63 (SD = 11.76, range: 26-79) out of 80 on the ISLES scale measuring meaning-making, and 36.68 (SD = 9.25, range: 12-56) out of 56 on the Flourishing Scale capturing well-being.

Contrary to expectations, pooled results from the multiple linear regression model revealed that PMIEs did not statistically predict well-being outcomes (B = .01, SE = .034, p = .77). However, meaning-making was a significant predictor of participants’ reported levels of well-being (B = -.35, SE = .051, p < .001), such that greater difficulties with integration (higher scores on the ISLES) were significantly associated with a lower degree of flourishing in adulthood. In regard to moderation effects, the two-way interaction between PMIEs and meaning-making was not a statistically significant predictor (B = -.003, SE = .002, p = .24), suggesting that meaning-making did not significantly moderate the association between PMIEs and well-being. Among the demographic variables, participants who identified as males reported significantly higher well-being scores compared to those identifying as non-binary or other (B = 3.29, SE = 1.43, p = .022). Additionally, youth of color were more likely to report higher levels of well-being compared to non-Hispanic White participants (B = 3.04, SE = 1.32, p = .022). Participants’ current age at the time of the survey did not demonstrate a significant association with the outcome variable.

DISCUSSION

The Troubled Teen Industry is a multibillion-dollar enterprise which has generated growing media attention and criticism over its ambiguous curriculum, questionable treatment practices, and punitive disciplinary measures (Corsello & Hayes, 2024; Friedman et al., 2006; Golightley, 2020; Mater, 2022). Despite popular media coverage and qualitative studies providing survivor testimonies that describe a range of stressful and negative experiences endured during the TTI (Chatfield, 2019; Corsello & Hayes, 2024; Golightley, 2020; Mater, 2022), there are currently limited quantitative studies investigating the long-term impacts and well-being of youth after they have been released from residential treatment. Moreover, it is unclear from the current literature what specific aspects of the TTI experience might be contributing to well-being outcomes in adulthood as well as what protective factors may be helpful for individuals following these experiences. The present study aimed to examine potentially morally injurious event exposure experienced in the TTI and its association with adult well-being.

Secondly, this study sought to understand whether meaning-making moderated this association. It was hypothesized that there would be a negative association between PMIEs and adult well-being, and that this association would be moderated by meaning- making, such that greater integration of negative TTI experiences would be correlated with reduced impacts of PMIEs and elevated levels of well-being.

Results from this study did not provide evidence in support of the original hypotheses. Our analyses found that there was not a significant association between reported TTI-related PMIE exposure and reported well-being in adulthood. Additionally, no interaction effects were found between meaning-making and PMIEs, suggesting that meaning-making was not a significant moderator of the relationship between PMIEs experienced during the TTI and adult well-being. Notably, however, meaning-making was found to have a statistically significant association with well-being. Specifically, our findings suggest a negative association between meaning-making scores and well-being levels, such that individuals who indicated greater difficulties with meaning-making often experienced lower levels of well-being in adulthood. In contrast, successful integration of stressful TTI experiences into existing world schemas was associated with higher degrees of self-reported well-being. This effect remained constant across all levels of PMIE exposure, suggesting the capacity of meaning-making to operate independently and irrespective of our original PMIE predictor.

The non-significant association found between PMIEs and well-being is inconsistent with existing literature which suggests that PMIEs are associated with lasting negative symptoms and considerable compromises to healthy functioning (Currier et al., 2014; Haight et al., 2022; Litz et al., 2009; Roth et al., 2022). In the context of child welfare settings, research has investigated these PMIE-related consequences in youth under institutional care, describing distress and challenges to well-being as a result of moral violations inflicted by social institutions (Haight et al., 2022; Soffer-Elnekave et al., 2023). However, results from our study failed to support these previous findings, providing no significant association between participants’ PMIE exposure during the TTI to their later life well-being.

One potential explanation for these null effects can be attributed to our study’s emphasis on well-being as opposed to specific markers of mental health and psychopathology. The current moral injury literature provides extensive evidence for the impacts of PMIE exposure on the development and maintenance of psychiatric conditions including depression, anxiety, and posttraumatic stress disorder (Forkus et al., 2019; Hoffman et al., 2018; McEwen et al., 2021; Nazarov et al., 2015; Roth et al., 2022). The present study instead focused on the holistic construct of well-being, which captures participant attitudes related to self-worth, social relationships, life satisfaction, and broader worldviews. Thus, this study’s focus on the concept of well-being, which assesses health across multiple dimensions, may not be directly impacted by PMIEs or be shaped differently by external factors in the same way as measures that target specific mental health outcomes. Finally, because our well-being measure comprises a range of individual, social, and environmental dimensions, it is possible that PMIEs may contribute to some areas but not others. As a result, there may be impacts of PMIEs that are not detectable when well-being is assessed through a composite score, as was done by this study.

Nonetheless, our study did find evidence for a negative association between meaning-making difficulties and self-reported well-being, which is consistent with the existing literature (Park, 2010; Ryff, 2014; Tavernier & Willoughby, 2012). Specifically, our results indicate that, regardless of the frequency and intensity of a participant’s exposure to PMIEs during their TTI involvement, individuals with high levels of meaning-making reported higher levels of well-being. This supports prior theory regarding the reparative potential of life-story narratives, conceptualized as “the connected stories we tell ourselves to make sense of our experiences” (Soffer-Elnekave et al., 2023, p. 149), to rectify distorted perceptions of stressful life events and offer a feeling of internal clarity and coherence (Ferrajão & Oliveira, 2015; Gray et al., 2012; Soffer-Elnekave et al., 2023). Additionally, multiple studies confirm that adaptive meaning-making is a powerful predictor of personal as well as psychological well-being (deRoon-Cassini et al., 2009; García-Alandete, 2015; Tavernier & Willoughby, 2012).

In accounting for the lack of a moderation effect of meaning-making, one explanation could be that meaning-making is a universally adaptive tool that contributes to well-being generally, regardless of prior PMIE exposure (Park, 2010; Ryff, 2014; Tavernier & Willoughby, 2012). For example, Tavernier and Willoughby (2012) found in a sample of Grade 12 students that well-being was significantly associated with positive adjustment following a turning point, defined as “a significant life event that changed the way you thought about something or how you behaved” (p. 1061). In this study, turning points were assessed irrespective of moral transgressions or PMIEs and could range from relationship conflicts to the loss of a loved one. This suggests that meaning-making confers a healing influence on well-being globally, not solely in response to adversity but across general life transitions and personal growth journeys. In the context of the present study, meaning-making was found to be effective for TTI survivors who achieved well- being, regardless of their PMIE exposures during treatment. Thus, our findings establish meaning-making as a potential source of resilience that can help to inform therapeutic approaches to support youth recovering from adverse TTI experiences.

Strengths and Limitations

One strength of the present study is its conceptualization of well-being holistically and across numerous dimensions of functioning. This consideration allows for the PMIEs experienced during TTI involvement to be evaluated within broader contexts of wellness and flourishing as opposed to being isolated to mental health problems specifically.

Furthermore, this study examined the consequences of PMIEs as they are experienced by adolescents in the TTI, a topic of research that remains largely unexplored despite garnering much media attention in recent decades. Thus, this study can inform future research towards elucidating the TTI experience and investigating pathways that may contribute to youth adverse outcomes or resilience.

Nevertheless, several limitations should be noted. First, the study’s assessment of well-being using Diener et al.’s (2010) Flourishing scale may have been insufficient to capture a detailed assessment of well-being. Although the 8-item summary was valuable in addressing healthy functioning across various flourishing indicators, a more detailed instrument with more refined subscales might be beneficial in isolating specific PMIE effects on each well-being item. Due to this limitation, the absence of a significant association found between PMIEs and well-being may be more reflective of our outcome definitions and method of measurement as opposed to an indication that PMIE have no impact.

Second, this study emphasized meaning-making as a primary indicator of well- being while neglecting other potentially significant protective factors. For instance, moral injury research has highlighted the powerful influences of social connection, activism, and self-compassion and forgiveness in healing from morally transgressive events (Forkus et al., 2019; Mater, 2022; Nash & Litz, 2013; Soffer-Elnekave et al, 2023).

Therefore, by only examining a single resilience factor, such as that of meaning-making, it may have been difficult to discern alternate pathways that buffer the effects of PMIEs and contribute to well-being. However, because meaning-making was found in the present study to be a valuable protective tool broadly, future research should strongly consider including this measure as a protective factor in conjunction with additional buffering agents against PMIEs.

Finally, due to the self-report and retrospective nature of our study, it is possible that participants exhibited recall bias and may misremember or under-report specific events of their TTI experience. To address this limitation, future longitudinal research may be helpful in assessing PMIEs at or near the time of TTI involvement to improve predictions of well-being in adulthood.

Future Directions

Given that the TTI remains a critically under researched but seemingly consequential source of potential distress, future research should direct investigations towards understanding the pathways linking negative TTI experiences to survivor outcomes. Moral injury remains a compelling mechanism by which this association may occur, though it could potentially be examined using a more comprehensive measure of well-being to detect direct PMIE effects. Furthermore, there is limited research to date investigating the consequences of PMIEs on well-being. However, evidence within the moral injury framework calls attention to specific markers of internal distress and moral conflict (i.e., shame, guilt, loss of trust, spiritual crises) that may be suggestive of more permeating impacts of PMIEs beyond mental health diagnoses (Litz et al., 2009; Nash & Litz, 2013; Jinkerson, 2016; Roth et al., 2022). Thus, future research should examine the impacts of PMIEs on well-being and adaptive functioning holistically rather than focusing narrowly on psychopathology.

Conclusion

Although the results of this study did not support our hypothesis regarding an association between PMIE exposure and well-being, available qualitative reports of the TTI experience suggest compelling experiences of moral violations that are consistent with the moral injury literature (Chatfield, 2019; Corsello & Hayes, 2024; Golightley, 2020; Mater, 2022). Future research should continue to explore this association in order to better understand youths’ experiences in TTI programs and identify mechanisms that may be contributing to negative survivor outcomes.

Despite the absence of evidence for an interaction effect between PMIEs and meaning-making, this study did find a significant association between meaning-making and adult well-being. This suggests the healing capacity of meaning-making to restore disjointed perceptions of stressful life events in a way that provides harmony and coherence to the individual. Future investigative efforts should continue to expand the search for potential sources of resilience (e.g., support networks, social activism, self- forgiveness) that may help to mitigate against potentially distressing TTI experiences and support youth’s recovery following release from residential treatment.

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