9 STUCK How to Conduct a “Focused Family Session” Ron, I don’t understand it. I’m trying to find a referral for a friend’s teenage daughter. Either they only see kids and won’t involve the parents, or they only see families and won’t see the kid alone. I thought we’d gotten further than this in the field. —An extremely experienced professional in a major, urban–suburban hub Slowly you turn yourself from a bridge into a well-worn path. Your office has become the town’s center, a place where park benches still exist. Copyright © 2005. Guilford Publications. All rights reserved. D uring the course of work with adolescents, there are times when it is absolutely essential to meet with the family, instead of with the child or parents alone. This is troublesome for many therapists. For the most part, we are trained to work individually with children or do guidance with parents or see families as a whole. Our narrow specialization drives families crazy. Having personally done and supervised thousands of initial interviews, I’ve learned that one of the biggest complaints patients have is a sense they are being forced into the teaching model of a training facility or the orientation of a private practitioner. This is maddening to prospective clients—approximately half terminate prematurely and find what they want elsewhere. Within many agencies, the family Taffel, R. (2005). Breaking through to teens : Psychotherapy for the new adolescence. Retrieved from http://ebookcentral.proquest.com Created from touromain-ebooks on 2019-12-15 18:59:05. 213 214 BREAKING THROUGH TO TEENS is divided according to modality. When assigned as a “family” case, few of the treating therapists are equipped to see kids alone; if it is considered a “child” case, few of these therapists can handle the family in a room together. Almost none can move between modalities, keeping all relationships intact. What a perfect metaphor: Fragmented homes, already pulled between first and second families, now find themselves in a field that replicates the disconnection that got kids into trouble in the first place. The relational–behavioral approach is a way to address this fragmentation, challenging the distance between parents and kids while strengthening both kids’ and parents’ competence. Paraphrasing Winnicott, the 21st-century helping professional must create a flexible container: see kids alone, see parents alone, and feel competent to conduct what I call “focused family sessions” when needed. This is a difficult balancing act. In a disconnected world, however, it is necessary to integrate modalities. The information you receive from parents and kids and the way you use this information in conjoint meetings challenges family members to make significant changes in their behavior. This creates connections and family relationships previously considered impossible. Copyright © 2005. Guilford Publications. All rights reserved. Why a Focused Family Session? Talking in individual meetings is not enough. Dylan complains about his “crazy” mother. He describes to me how they get into fights over his grades and increasingly strident demands to go out with friends during the week. Interactions at home escalate, sometimes into physical standoffs. Recently, Dylan loomed over his mother with a baseball bat in hand, screaming he’d use it (not a real threat) if she pressed on. They are obviously stuck. When I work with Dylan alone I challenge him to make concrete changes around the house. His mother might not be so hysterical if he approached her less provocatively, or in a respectful way that eased her mind, at least slightly, about the kind of privileges he was demanding. At the same time, parent sessions did not lead to changes either. Dylan’s Taffel, R. (2005). Breaking through to teens : Psychotherapy for the new adolescence. Retrieved from http://ebookcentral.proquest.com Created from touromain-ebooks on 2019-12-15 18:59:05. 9. Stuck 215 Copyright © 2005. Guilford Publications. All rights reserved. mother,Yvette, still pounced like a tigress when he was slow to cooperate. She couldn’t stop focusing on his disorganized room. Yvette exploded almost every time he pushed for a later curfew, once rushing from the bathtub naked to block him at the front door. Often, child and parent are like a dysfunctional couple who can’t transfer what is discussed in the room to acting differently at home. The inability to create individual or systemic change leads kids down a dangerous path. For example, Frederick, 14, talked at length in our sessions about his father’s ferocious temper, his mother’s attempts to play peacemaker, and his own efforts to stand up for himself. Frederick and I tried to figure out how he might handle these scenes in a better way. I also met with Mom and Dad, as I regularly do, to try to get them to manage anger differently. Very little shifted—family life was temporarily quiet, then new explosions always flared up. Meanwhile, outside the house, Frederick spent more time playing at the edge of danger. Pushing the envelope, he slept around, stayed out later, drank more, and went to after-hour clubs and extremely sketchy areas of town. Frederick became unmotivated in school, which had always been a sustaining involvement. The situation was stuck. The cycle of explosion, peacemaking, remorse, truce and explosion kept recurring. In such mired-down cases—after I have met with an adolescent for some time alone and with parent(s), separately—it is necessary to have a “focused family session” before a major crisis occurs. What Are Focused Family Sessions? Focused family sessions, as I have developed them, synthesize family systems theory, even as most sessions are individual ones with the adolescent or parents. The “focus” in focused family sessions is essential, so that the therapist can maintain control of family meetings and protect empathic connections with both teen and parent. Fears of unmanageable eruptions during conjoint sessions, stony Taffel, R. (2005). Breaking through to teens : Psychotherapy for the new adolescence. Retrieved from http://ebookcentral.proquest.com Created from touromain-ebooks on 2019-12-15 18:59:05. 216 BREAKING THROUGH TO TEENS silence on a teen’s part, and vicious scapegoating in all directions discourage therapists from entering into this territory. In hundreds of consultations with families of adolescents, I have heard complaints by both parents and teens who say past family sessions were episodes of unprocessed venting, huge disappointments or events that shook their faith in the entire change process. It is such a difficult balancing act to manage individual as well as family sessions, it’s no wonder few training facilities offer this approach (check the brochures or websites of programs around the country). To begin, use the following guidelines for focused family sessions: ♦ The frame of the session is extremely specific—to shift a single stuck interaction or issue. Success is more attainable when the frame is limited. ♦ Goals are defined ahead of time, thereby lessening surprises for kids and parents. ♦ The fact that you will temporarily ally with the other “side” is predicted. This is done in order to protect empathic connections for future individual meetings. Copyright © 2005. Guilford Publications. All rights reserved. The overarching purpose of a focused family session is to help parent(s) and teen shift one troublesome, repetitive interaction between them. That’s it! The goal is not to figure out how the entire family dynamic needs to change or how each member might improve communication or how to resolve transgenerational issues, and so on. The Choreography of Change My narrow definition of a family session evolved from work I originally did over 20 years ago at the Philadelphia Child Guidance Clinic. I was then trained in structural family therapy with Salvador Minuchin and Virginia Goldner, and later in family systems therapy with Betty Carter. Structural family therapy teaches us that Taffel, R. (2005). Breaking through to teens : Psychotherapy for the new adolescence. Retrieved from http://ebookcentral.proquest.com Created from touromain-ebooks on 2019-12-15 18:59:05. Copyright © 2005. Guilford Publications. All rights reserved. 9. Stuck 217 changing the interaction in one area of family life allows individuals to move beyond symptomatic behaviors; they begin to differentiate in healthier ways. Structural family therapy had its most profound impact in the ’70s and ’80s. It produced dramatic videotapes of sessions so charged that reestablishing empathetic connections in subsequent individual meetings would be quite a challenge. For example, in one famous videotaped session, Mother and Father became sufficiently frustrated with their anorexic teen that they literally shoved a frankfurter down her throat—at the therapist’s urgings that Mom and Dad take charge. This shocking intervention, a kind of therapeutic performance art, restructured the entire hierarchy: The sick child was no longer in charge of her parents. This girl could now begin to eat for herself, according to what these family therapists believed. Another dramatic videotape involved a family in which the two adolescent boys were out of control—defying their parents and in trouble with police. In the taped session (considered then to be a breakthrough), Dad physically wrestled one of his teenage sons to the floor. From that session, as was the case with the anorexic girl, the family pattern significantly shifted. Kids reconstituted because parents were now in charge and the children were not. Even then I never believed that most of the time one session had the stand-alone power to entirely rearrange the course of family life or of child development (see my article “Revolution/Evolution: Feminism Forces Us to Reconsider Our Expectations about Dramatic Cures,” The Family Therapy Networker, 1986). Actually, I learned during my externship at Philadelphia Child Guidance how much behind-the-scenes help was offered to kids and families—individual sessions, parenting, and psychoeducational input. These important change agents were left on the cutting room floor. Not dramatic enough for audiences, but a critical part of the paradigm that I valued even more as I learned about all the quiet attention families received. So, despite dramatic videos, one family session doesn’t usually do the trick. It is truly powerful, however, if after a dysfunctional dance is challenged during family meetings, the therapist continues to see family members to strengthen different ways of dealing Taffel, R. (2005). Breaking through to teens : Psychotherapy for the new adolescence. Retrieved from http://ebookcentral.proquest.com Created from touromain-ebooks on 2019-12-15 18:59:05. 218 BREAKING THROUGH TO TEENS with each other. The power of structured interventions is exponentially increased when transgenerational issues can be dealt with before or after focused family sessions. Even if a specific interaction cannot be dislodged in a focused family meeting, it almost always has a transgenerational etiology that may be addressed later on. Interestingly, my training in systemic family therapy (à la Betty Carter) emphasized how work could be done in sessions in which family members talk just to the therapist in the room. These two vastly different perspectives are wonderful complements to each other—if you are able to conceive of your role as a bridge between the teen and adult worlds. Preparing for Focused Family Sessions Copyright © 2005. Guilford Publications. All rights reserved. In order to protect existing empathic connections, it is necessary to prepare both adolescent and parent for a focused family session. Once a family interaction gets underway, each “side” can feel totally abandoned by you. The family format seems strange to clients used to seeing you alone. The empathic connection of the private session is now fraught with potential for you to be experienced as favoring the other. In addition, clients often land in your office because of out-of-control dynamics. Naturally, both parent and teen are afraid (or secretly hope) that similar escalations will take place in the family meeting: “Now, you’ll really see how crazy my mother is; now you’ll finally understand how impossible my kid is.” They’re often right; family sessions can get wildly out of control, so I prepare in the following ways: First, define ahead of time exactly what the topic will be. To one boy and his parents I said: “We’re going to talk about curfews— nothing more.” To a girl and her mother I said, “The topic is going to be the fights in the morning about what clothes you’re wearing. That’s it.” At the beginning of the family session, I remind both what we’ll be talking about. It’s important to limit the scope in this way. John Gottman, noted researcher on the “science of communi♦ Taffel, R. (2005). Breaking through to teens : Psychotherapy for the new adolescence. Retrieved from http://ebookcentral.proquest.com Created from touromain-ebooks on 2019-12-15 18:59:05. 9. Stuck 219 cation,” (Observing Interaction, 1997) is right. Relationship fights are so volatile, they instantaneously move into a physiologically inflamed laundry list of hot-button issues. At the start of the session, remind both parents and kids that they will probably feel unhappy about your role. I say to my teen client, “Listen, at some point during this meeting you’re going to feel I’m taking your parent’s side. Don’t worry. It’s just temporary, to find what works better for you and them.” To parent(s): “At some point, you’re going to feel like I’m taking your child’s side against you. It’s for the purpose of moving the session ahead. Try to remember that I’m not abandoning your perspective.” ♦ Remind everyone that whatever happens during the session, you will have a chance to talk in private meetings. This “to-be-continued” approach takes the heat off everyone, including professionals, and it is the truth. No one should enter a focused family session worrying that it will make or break the relationship. This is the therapeutic equivalent of that mythical “birds and bees” discussion about sex. In real 21st-century life such sex-talks rarely happen just once; rather, minidiscussions on the topic occur many times over. In the same way, real change usually occurs over time. For focused family sessions to work, the hope for instant transformation needs to be lessened, or disappointment is sure to follow. ♦ Copyright © 2005. Guilford Publications. All rights reserved. Enactments and Focused Family Sessions The specific structural technique to use in focused family sessions is “the enactment.” Family members, if prodded to discuss a conflictual issue, invariably act out their most important dynamics. While we all may not have been formally taught this principle, we are certainly familiar with it. Enactments happen in our lives all the time. Borrowed originally from interpersonal psychoanalytic theory, “enactment” is another way to say that family communicational patterns are so ingrained they spontaneously appear no matter how determined we are to avoid them. Taffel, R. (2005). Breaking through to teens : Psychotherapy for the new adolescence. Retrieved from http://ebookcentral.proquest.com Created from touromain-ebooks on 2019-12-15 18:59:05. 220 BREAKING THROUGH TO TEENS ♦ Foster an interaction between parents and child over a stuck issue, previously identified in individual sessions. The topic must be one that is currently “alive” to all parties. It may be curfew, friends, verbal abuse, drugs, alcohol, back talk, homework, keeping the room clean, how parents and kids listen to each other, and so on. Your goal is to start parent and child talking to each other (not to you) about one concrete issue. For example, you might say, “Discuss with your son the chores you’d like done. This is an area you’ve all described as a problem.” The authority with which you can lead is the relational traction you’ve gained from previous sessions with parent and teen alone. Prepare family members for a moment or two of self-consciousness. Even if they have known you for years, most people are selfconscious when asked to discuss personal matters in front of a non-family member. Awkwardness needs to be addressed. Say, “This will seem strange at first. But I guarantee in a few minutes, it will feel much more natural.” Normalize by referring to the many other experiences you’ve had with enactments (remember, in your personal as well as professional life these interactions go on all the time). Or, if you can’t think of specific examples, be honest and say, “I’d like to try a technique I’ve just learned.” ♦ To start the interaction, make yourself as invisible as possible. There are several ways to do this. Don’t make eye contact with family members, since this leads to greater self-consciousness. How? Lean back, literally face another direction, or look down at your notes. The boundary expressed through your body language communicates that whatever goes on is the family’s doing, not an artificial exchange created by being in your presence. Copyright © 2005. Guilford Publications. All rights reserved. ♦ After it gets going, artificial as it may feel or as much as a parent or child initially objects—the strength of the “dance” is so powerful you’re quickly into the thick of it. Whenever one has a strong relationship—and what is more intense than a parent–teen showdown—the interaction gets going almost exactly the way it happens around the house. As you listen, your role changes. Taffel, R. (2005). Breaking through to teens : Psychotherapy for the new adolescence. Retrieved from http://ebookcentral.proquest.com Created from touromain-ebooks on 2019-12-15 18:59:05. 9. Stuck 221 A Quick Enactment Guide Observe the most concrete behaviors, the basic steps in the family’s dance . Don’t look for hidden motivation. Ask yourself questions that begin with words such as “what,” “who,” and “where.” Do not get yourself stuck on asking “why” or “when.” The following are some examples of what to look for. ♦ Tone of voice—respectful, contemptuous, and so forth. A niceguy dad complains that his boy, James, is an inexplicable wise guy in school. Mom is also concerned about her son’s negative attitude with other adults, with whom he constantly finds fault. During the enactment, this very nice man surprisingly speaks to his son in a derisive tone, especially when the boy disagrees with him. “I’ve never heard anything so ridiculous,” he says. Dad’s attitude infuriates his son and, in turn, the boy shouts, “Yeah? . . . You don’t know anything either!” further aggravating the father. Loudness—Who drowns out whom? In the Marion family, everyone had to yell to be heard. Katie, a fifth grader who had trouble standing up for herself in school, was unable to speak during the enactment. As everyone screamed at each other over every possible issue, Katie could not get a word in edgewise. In just a few minutes, it was clear where she had learned to be so reserved. ♦ Reactivity—the quickness and intensity of family members’ responses to each other. Parents had complained about disagreements over the kids. They then demonstrated their endless fighting when the counselor got them to discuss a time for the next appointment. They were so inflamed that the counselor told me, “It was as if I didn’t exist in the room.” Copyright © 2005. Guilford Publications. All rights reserved. ♦ Listening—Who listens? Who does not? Dad was a wonderful listener while the family discussed differences of opinion. Mom, on the other hand, lectured to their oppositional and sullen daughter. The more Dad listened, the more Mom said he was being too soft-hearted and launched into another lecture. During this inter♦ Taffel, R. (2005). Breaking through to teens : Psychotherapy for the new adolescence. Retrieved from http://ebookcentral.proquest.com Created from touromain-ebooks on 2019-12-15 18:59:05. 222 BREAKING THROUGH TO TEENS action, Mom, who was just as concerned about her daughter’s welfare, became “the bad guy” compared to ever-patient dad. Relatedness—Who’s talking to whom? Who’s left out? A tough-guy father interrupted loudly and repeatedly barged into the conversation I got going about curfew for his adolescent son. Despite his ineffectiveness, Dad prided himself on being the family’s teacher of life lessons. As the enactment went on, this tough guy was slowly pushed to the periphery. No one talked about anything without going through Mom; certainly no one listened to Dad as he barked and sputtered from the sidelines. ♦ Leadership—Who speaks first? In some families, the person who speaks first during the enactment is a paper tiger. In others, this person sets the tone of the entire discussion. The latter was the case in the Johnson family. Whatever mood Dad was in seemed to set the stage for any discussion that followed. Enactments were merely a reflection of dad’s predominant mood. ♦ Closure—Who gets in the last word? Can a conclusion be reached? With Annie, a 14-year-old who was in trouble because of acting out in school, the enactment between her and her mom was very telling: Annie always had to get the last word in. Unfortunately, so did her mother. Keeping the enactments down to several minutes was next to impossible since, just like at home, they could never end their arguments. Each just got madder at the other and more determined to have the last world. ♦ Copyright © 2005. Guilford Publications. All rights reserved. Empathic Punctuation ♦ Punctuation is your empathic feedback about the dance parent and child get caught up in. While not originally presented in this way by structural family therapists, punctuation reestablishes the empathic connections you have spent individual sessions creating, connections you may temporarily lose during the heat of the family’s exchange. This eye on empathic traction, while pushing for change, is essential in a relational–behavioral approach. Taffel, R. (2005). Breaking through to teens : Psychotherapy for the new adolescence. Retrieved from http://ebookcentral.proquest.com Created from touromain-ebooks on 2019-12-15 18:59:05. 9. Stuck 223 Here are some illustrations: Copyright © 2005. Guilford Publications. All rights reserved. Fifteen-year-old Amy and her mother Jolie came to a focused family session. I had been seeing both in individual sessions for several months. The troublesome issues for this mother had to do with her daughter’s staying out late and being maddeningly secretive. I said, “Amy, talk to your mom about having a later curfew.” Immediately, their interaction made it clear that Jolie was intensely provoked by Amy’s silence or obfuscations. Mom began communicating with her daughter primarily by asking a lot of demanding questions. Of course, the more she grilled Amy, the more her daughter clammed up. Amy became deeply sullen and, if possible, even less present. When the nature of the interaction is clear, you can punctuate—offer feedback to both sides. In this case, I said, “Amy, you have a lot more power over your mother than you or I may have realized. Your clamming up is driving Mom crazy and getting her to ask one question after another.” To Mom: “Now I understand even better how your frustration makes you want to pull your hair out— but endless questions don’t seem to be getting you anywhere.” Another example: In our private meetings, Dylan complained that his mother, Yvette, “got hysterical” when things weren’t done her way. Mom repeatedly complained how stubborn her adolescent son was: “It’s like talking to a brick wall.” So, when individual sessions didn’t change the dance, I called for a focused family session. I asked Dylan and Yvette to talk about keeping his room neater, a conflict both had separately mentioned. As they started interacting, it became immediately clear that Mom jumped into sweeping generalizations, “If you can’t keep your room clean, if you don’t have that kind of basic sense of responsibility, what does that say about your whole character? As you get older, how are you going to maintain a job? Any boss you have isn’t going to stand for this.” Dylan, in turn, was no slouch. He became sharply belligerent, calling her almost every name he could think of—“You’re a lunatic. You’re crazy. You’re worse than any parent I’ve ever met. You get absolutely insane over these stupid little things.” In the way he talked to her, he became exactly what she had accused him of being—thoughtless and irresponsible. Taffel, R. (2005). Breaking through to teens : Psychotherapy for the new adolescence. Retrieved from http://ebookcentral.proquest.com Created from touromain-ebooks on 2019-12-15 18:59:05. 224 BREAKING THROUGH TO TEENS Empathic punctuation: Mother and son needed to see what they were doing in this exchange. I said, “Mom, you’re letting Dylan get you so upset, I can really see how his whole future is flashing before your eyes. Dylan, the more you keep calling your mother names about how “off the wall” she gets, the angrier she becomes. Soon, she’ll be grounding you for life.” The point about punctuation is that you must empathically address each participant. In the dance that is taking place, point out both parent’s and teen’s behavior. This is a departure from traditional structural family therapy. We were trained to unbalance stuck dances, the idea being that with enough pressure—repetition, directives, urging, even shaming—some family member would change a step in the dance. In focused family sessions, however, you are a bridge, and maintaining empathic balance is incredibly important. You need to hold the connection with family members who have come to trust you in individual sessions. You need to think about future sessions, protecting what you’ve already built. Copyright © 2005. Guilford Publications. All rights reserved. ♦ Address different family members with respect. Try not to sound authoritarian or, especially, act the part of the self-important professional. This is easier said than done. After all, a lot of family therapy arose from an era informed by Harry Stack Sullivan and the supervisees of Eric Fromm, the interpersonal psychoanalyst. Therapists were expected to decisively “nail” people with precise interpretations. (Actually, Salvador Minuchin himself was quite a contradiction. I’ve met several of his ex-patients, who uniformly commented on his brilliance and empathic kindness toward them—“What a nice guy,” each fondly remembered.) Many professionals, however, still don’t realize their legacy and have a hard time keeping away from flashy but subtly disrespectful communication. This is especially important if you are going to resume individual sessions after a focused family meeting. Provocative pronouncements such as “Your child has you wrapped around her finger” may be true, but the humiliation and shame such statements create can rupture a parent’s relationship with you. I learned this lesson years ago. Once, sitting with a family, I Taffel, R. (2005). Breaking through to teens : Psychotherapy for the new adolescence. Retrieved from http://ebookcentral.proquest.com Created from touromain-ebooks on 2019-12-15 18:59:05. 9. Stuck 225 Copyright © 2005. Guilford Publications. All rights reserved. was struck that during the enactment each person seemed to protect the feelings of another family member. Instead of commenting on how sensitive they were toward each other, I came up with the pithy observation that their exchange reminded me of the way communication might sound in a well-mannered “protection racket.” This was right on the money, but it was delivered in a curt, sarcastic tone that severed my connection with the family. Such statements make for dramatic showmanship and temporary satisfaction about being tough, but they often mark the last time we will see a family. Compare the statement “Your child has you wrapped around her finger” with “Your child is incredibly tenacious. It’s no wonder that she has you wrapped around her finger.” Direct but balanced feedback is exactly what helps family members continue to feel understood. It prepares them for the idea that change is about everyone working on something. In this case, after commenting on the child’s tenacity, it’s easier to move toward directives that will be experienced empathically: “Since your daughter is so tenacious, we need to figure out ways that can help you to be more in charge. Because of her strong will, you might have to work harder than other parents.” I will never just say to Mother, “You’re acting in a way that’s ineffective,” or to a teen, “You’re being absolutely dismissive of your parent”—without tying each remark, in some way, to the other’s place in the interaction. Keep in mind the following rules about feedback: ♦ The problem is almost never one person’s fault. ♦ You are not blaming anyone as being single-handedly responsible for difficult interactions. ♦ You do your best to see the situation from everyone’s point of view. ♦ Each person is part of a system that is interdependent— therefore everyone has to change a little. The better the balance, the more both parent and child can stay connected to you and move on to the next step in the ses- Taffel, R. (2005). Breaking through to teens : Psychotherapy for the new adolescence. Retrieved from http://ebookcentral.proquest.com Created from touromain-ebooks on 2019-12-15 18:59:05. 226 BREAKING THROUGH TO TEENS Copyright © 2005. Guilford Publications. All rights reserved. Empathic Feedback That Gets Through Unbalanced Balanced “You don’t understand your child.” “Your child is challenging and complicated. It’s not surprising how difficult she is to understand.” “You’re yelling at your parents too much.” “Your mom’s stubborn, but yelling doesn’t seem to be getting through, either.” “You criticize your child a lot of the time.” “I know you’re frustrated and that easily turns into criticism; it’s difficult to know what to do with him in the moment.” “You need to listen better to your parents.” “It’s always hard when there are two tough parents like these. You’ll have to learn to listen to one at a time.” “As his parents, you’ve got to be more of a united team.” “Your family’s so busy, it’s just about impossible for the two of you to discuss and think through decisions. . . . ” “Your father’s not crazy, you just have him wrapped around your finger.” “Your father does get a little crazy; in part it’s because you know exactly which buttons to push.” sion—figuring out how to do something, just one thing, a little differently. Moving Toward Change Create small change. Focused family sessions are not about change on a grand scale. Rather, I push both adolescent and parent to alter Taffel, R. (2005). Breaking through to teens : Psychotherapy for the new adolescence. Retrieved from http://ebookcentral.proquest.com Created from touromain-ebooks on 2019-12-15 18:59:05. Copyright © 2005. Guilford Publications. All rights reserved. 9. Stuck 227 a very specific aspect of the dance. I want to challenge each in the session. And, à la Salvador Minuchin (also, let’s not forget our strategic family therapy heritage—Haley, Madanes, Hoffman, and others), change in the moment can sometimes be the beginning of change in the entire family system. Most child professionals I have supervised ask people to take steps that are simply too big. We push them to be different from who they are; we forget belief systems that predate us and extend way into the past. Sadly, we do all this primarily because many of us suffer from a kind of “clinical narcissism.” Too many of us have the view that clients exist only in the moments we see them. I experienced this painful phenomenon first-hand when one of our children needed to be evaluated. He endured, as did we, an “arena evaluation.” After an hour observing him, the team was ready to make their final, life-altering suggestions about our son. It was a traumatizing and enlightening experience, one which I described in an article in The Psychotherapy Networker (“Honoring the Everyday,” 1995). Supervisors of family therapy would watch 30 seconds of a session and draw sweeping conclusions about parents’ entire character structure. Because of this tradition, it may be hard to imagine what people are like when we’re not around. Especially with difficult parents, the complexity of everyday family life often eludes us: The family has more loving aspects than we can possibly imagine, or deals with more extraordinary adversity than we can immediately understand. To create change means that we see mothers and fathers accurately enough so that we do not ask too much (or too little) of them. This relational-attunement is necessary to transform a difficult parent into one whose mind is open enough that new behavior is possible. Here are a number of examples taken from focused family sessions in which I pushed for small changes from both teen and parent, while trying to maintain connections throughout. My comments are always informed by what I have learned during private sessions before, and the awareness of needing to reestablish meetings afterwards. Taffel, R. (2005). Breaking through to teens : Psychotherapy for the new adolescence. Retrieved from http://ebookcentral.proquest.com Created from touromain-ebooks on 2019-12-15 18:59:05. 228 BREAKING THROUGH TO TEENS Copyright © 2005. Guilford Publications. All rights reserved. Challenging Kids Dylan talked to his mother in starkly disrespectful ways—making her even “crazier.” I said: “Dylan, I know how important it is to you to sound older—the kids in your grade are merciless toward anyone who sounds reasonable—but, I don’t think you’re getting through to your mother. In fact, it makes her so upset she treats you more like a child. If you want to get what you want, and I think you do, you need to talk without calling her names.” In this way, I respected Dylan’s context, but asked him to experiment with different way of speaking, not because it was morally right (though I believe it was), but because his behavior ensured not getting what he wanted. Frederick, the adolescent who was inching ever closer toward dangerous behavior, taunted his father, Jack, when he reacted contemptuously about Frederick’s choice of friends. In a family session, Frederick responded to his father’s objections with comments like “You’ve got a problem,” “You’re old,” “You can’t understand anything I say about my friends anyway,” “I wish I had another father,” “You don’t belong in this family.” It was no surprise that Jack could not help but react aggressively. Veins in his neck and his forehead bulged. Deeply hurt, Dad’s reaction was to become even more aggressive. Then Frederick paid even less attention to what he was saying. I gave Frederick this challenge: “It’s hard for me to ask you to forgive your dad’s temper, but remember I’m on your side here. Even so, I want you to talk to him in such a way that you sound like the good friend you can be to others, and not like a child who’s having a tantrum” Reminding Frederick what a truly good person he could be to his friends assured Frederick that I was not abandoning him. This allowed me to bluntly challenge him to change his steps in the dance. * * * Rice, the girl who refused to take a shower and was increasingly belligerent in school, came to a family session with her Taffel, R. (2005). Breaking through to teens : Psychotherapy for the new adolescence. Retrieved from http://ebookcentral.proquest.com Created from touromain-ebooks on 2019-12-15 18:59:05. Copyright © 2005. Guilford Publications. All rights reserved. 9. Stuck 229 mother. At home, battles erupted nightly. Rice adamantly defended why she shouldn’t have to bathe—the teacher said they didn’t have to shower that much, few of her friends took many showers, and so forth. Her mother’s response to these excuses was something like “You get dirty and smelly. I don’t want to live in a house with somebody who takes a shower only once a week,” and so on. The arguments always escalated, sometimes accompanied by nearphysical confrontations. Talking about showers in a focused family session might sound like a silly issue for treatment, but the violent interaction these two got into was no small matter. It was important to challenge each to approach this ”dance of anger” (Harriet Lerner, 1985) differently. I said to Rice: “I know you don’t want to take a shower every night. I know how much you can’t stand getting your skin wet, how sensitive it is. But, it seems like the more excuses you make, the more insistent your mom gets about the whole thing, and you know how stubborn your mother can be. You need to listen to her for a minute, without coming up with an excuse.” This was my challenge to Rice—to be quiet, if just for a few seconds. I protected our empathic connection by validating her experience of Mom being an incredibly strong-willed, rigid person. I used the information from private sessions to stay connected with Rice, even as I pushed her to change. Alvin wanted to drive the family car. His father, Arnold, believed Alvin wouldn’t be entirely truthful about very serious issues: whether he would drive while drinking; whether he would chauffeur other kids around, even if he was too tired or drunk; and how fast would he drive. His fear was understandable, inflamed by the recent deaths of four neighborhood kids when, after a keg party, one of the boys wrapped the car around a tree. In talking about all this, Alvin attempted to be Mr. Smooth, coming up with superficially clever, made-for-TV arguments: “Well, you know I never touch a drink during the week, so I don’t know why you’d worry about me driving. I can give you my full-faith, absolute, sacred guarantee: There’s no way I’d touch an ounce of liquor if I’m out with the car.” Taffel, R. (2005). Breaking through to teens : Psychotherapy for the new adolescence. Retrieved from http://ebookcentral.proquest.com Created from touromain-ebooks on 2019-12-15 18:59:05. 230 BREAKING THROUGH TO TEENS To this, Arnold would reply: “How can you say that? What difference do the weekdays make? You’re going to parties on the weekends all the time; I know you go to bars with other kids. How can you promise you’ll never touch anything?” Alvin responded with 10 reasons why such a situation was completely ludicrous. Drinking during the week showed real alcohol dependence, so obviously, he didn’t have a problem; his friends looked out for each other—they didn’t want him to get busted, and on and on. The more he tried to “sell” these ideas, the more nervous dad got. In trying to change Alvin’s part of the interaction, I presented this challenge: “Alvin, you’re sounding like a potentially successful lawyer. I have faith that one day you’re going to make tons of money. But can you see that the more you try to impress your father with these arguments, the less he seems to trust you? So, what I’d like you to do is talk more slowly. Give yourself and him time to think.” Previous sessions with Alvin helped me understand his deep desire to succeed, to make big bucks, and to impress. Clearly, I used this empathic grasp, even as I pushed him to drop the “con artist” façade. Copyright © 2005. Guilford Publications. All rights reserved. * * * Ruth, 13½, wanted to go to a loft party. The precursors to “raves,” loft parties typically involve several hundred teens with absolutely no adult supervision. Kids arrive from all parts of town and pay a cover charge to have unfettered access to each other and free-flowing substances. The more Ruth’s parents asked her about the party, the more vague she became. Ruth would not say where it was, who was going, when it would end, and so on. I said: “Ruth, the vaguer you are, the less chance you’ll get to go to this party or others that I know are coming up. Even though I like you so much, I’m not sure I’d even let you go, and it’s clear that your parents are getting more and more upset. You want them to trust you about a lot of things, so you’re going to have to be more specific about the details of what’s involved.” My appeal to Ruth was to understand her desire for greater privileges, which she’d expressed many times in our sessions. I could completely side with her parents about this party, Taffel, R. (2005). Breaking through to teens : Psychotherapy for the new adolescence. Retrieved from http://ebookcentral.proquest.com Created from touromain-ebooks on 2019-12-15 18:59:05. 9. Stuck 231 as long as I recognized her need to be treated in a more mature, trusting way. Challenging Parents In troubled families, the dance is dysfunctional from both sides of the generational divide. Obviously, parents need to be pushed. Here are ways I challenged parents in three of the enactments described earlier. Again, keep in mind the importance of maintaining an empathic connection, so individual meetings in the future will still be possible. To Dylan’s “insane, hysterical” mother, I said: “As a parent, I totally understand your frustration. But you do sound hysterical, like we get at home with our kids. I know it’s hard, because you’d like the automatic respect your own parents got. I’m asking you to lower your voice, though. Speak softer and a little lower—let’s see what happens.” My identification as a “fellow traveler,” another harried parent of a 21st-century teen, was not lost on Dylan’s mother who secretly believed she was an ineffective mess, totally to blame for her son’s difficulties. Copyright © 2005. Guilford Publications. All rights reserved. * * * Frederick’s father, Jack, became so agitated while talking to his son, he visibly stiffened in his seat. He got up, and began looming over Frederick in a physically intimidating way. At that point I said: “We know each other so well by now. When Frederick talks to you, I can almost feel your reactions. Pay attention to how much your whole body is starting to tense up. As Frederick talks, try to be aware of your body. It’s a simple exercise many parents of teenagers need to learn. The more aggressive you get, the more disrespectful and babyish he’s going to behave. And, I know from your history that’s not what you want for Frederick.” Again, meeting with Jack several times before this session gave legitimacy to my empathic remarks. I did know him well. I knew how hurt he was beneath that aggressive stance and how much he wanted to avoid the decades-long estrangement he had endured with his own father. Taffel, R. (2005). Breaking through to teens : Psychotherapy for the new adolescence. Retrieved from http://ebookcentral.proquest.com Created from touromain-ebooks on 2019-12-15 18:59:05. 232 BREAKING THROUGH TO TEENS * * * To Rice’s mother, I said: “Arlene, everyone, including me, admires how quick your mind is and how logical you are. But rational arguments aren’t working. I want you to try to talk to Rice without using logic to convince her. Use your imagination. Cut a deal if you have to. I know how creative you can be in your work negotiations.” In sessions before this enactment, I had many times commented on Arlene’s intellectual acuity. Arlene didn’t let my challenge upset here because she truly believed I admired her tenacity. This empathic recognition enabled her to take my suggestion seriously, without rupturing our connection. Putting It Together Following are summaries of extended dialogues from two of the families described earlier. In them you will recognize the basic principles of a focused family session: protecting and referring back to already established relationships, pushing for very specific change, aiming for greater effectiveness in family members—all the while nurturing your connection for subsequent private sessions. * * * Copyright © 2005. Guilford Publications. All rights reserved. FREDERICK: (to Jack, his father) You’re a real bully! Why are you always pushing Mom around like that? You’re always bossing her. DAD: Well, it’s my right. You’re not married to her, I am. When you get married, then you can treat your wife the way you want to. Anyway, she’s not complaining. FREDERICK: I’ll never be like you. I can’t stand the way you act. I hate the way you are around the house. Jack, upset and angry, starts to get out of his chair and walk over to where Frederick is sitting. The scene looks threatening. Mom starts to rise at the same time, moving to block her husband from going over to Frederick. Taffel, R. (2005). Breaking through to teens : Psychotherapy for the new adolescence. Retrieved from http://ebookcentral.proquest.com Created from touromain-ebooks on 2019-12-15 18:59:05. 9. Stuck 233 THERAPIST: (to Mom) I know how you worry, but please, Sherry, let them handle this. “Frederick, you can say whatever you want outside this room. But I want you to try to talk to your father another way here. I know the many ways you talk so well in other situations. I want you to try to speak toward him in a way that doesn’t sound like a disrespectful kid who’s just trying to get his goat. And Jack, I’d like you to move back. Frederick isn’t a little boy anymore, the one you miss so much, even though he sounds like one right now. Standing over him, it seems as if you’re trying to remind him that you’re still Big Daddy. I’d like you to talk to Frederick in a way where you don’t have to stand up over him. A long pause follows. Not a word is said. Jack is back in his seat; Frederick sits glowering. Eventually they speak again: FREDERICK: When you stand over me like that, I forget everything good you ever did for me. All I do is hate you. DAD: Yeah, like you ever remember anything I do for you in the first place! Copyright © 2005. Guilford Publications. All rights reserved. THERAPIST: Frederick, what you just said now sounded different from the way you were talking before, more like the way you’ve described other relationships to me. Jack, I see you’re getting upset again. I want you to try to calm yourself down. You don’t have to be so big. Talk to Frederick from the quieter side you’ve shared with me privately. DAD: All right . . . all right . . . all right. (With each “all right,” Jack seems to be calming himself down. Then, in a lower voice:) Frederick, what do you mean when you say that? [This is the first time Jack has ever asked his son to clarify what he’s talking about.] FREDERICK: Well, I hate you so much that I forget you do a lot of things for me. (At this point, Frederick’s eyes fill up.) DAD: Like what? FREDERICK: Like, you’re the only father who drives me and my Taffel, R. (2005). Breaking through to teens : Psychotherapy for the new adolescence. Retrieved from http://ebookcentral.proquest.com Created from touromain-ebooks on 2019-12-15 18:59:05. 234 BREAKING THROUGH TO TEENS friends around all the time, and brings us places. Mostly mothers do it, but you bring me to my friend’s houses. DAD: You always treated me like the chauffeur. I never knew it mattered to you or that you even noticed. THERAPIST: Frederick, it’s true, you can manipulate your father and make him feel useless. Even though I know what he does secretly matters to you. FREDERICK: (smiling wearily) Well, I know how I can get to him. THERAPIST: Jack, you stand up and try to display your raw power. It’s almost like you’re challenging Frederick to fight you. Please talk to him about your anger, like you’ve talked to me about it before. DAD: (thinking for a long while) I want you to be tougher. I don’t want you to get scared. I want you to stand up to people. I almost wish you’d stand up and just, you know, clock me one. So, I could feel like I did my job, that I made you tough enough for the world out there. (long pause; again in a lower voice) Frederick, I love you. I just wish you didn’t make me so mad. Copyright © 2005. Guilford Publications. All rights reserved. Frederick is annoyed by this last comment from Jack (because Dad’s blaming him for Dad’s own anger). He starts to get provocative again. They’re suddenly at the edge of another physical fight; Dad moves forward in his seat, Mom moves forward in hers. THERAPIST: Jack, just keep talking. Don’t move forward. You caught it and controlled it just in time. You were about to get up. I know how well you can work with people. You don’t have to use raw muscle power to make Frederick tougher. And, Frederick, with the way friends respect you, you don’t have to keep provoking your dad just to prove that you can push him around. FREDERICK: Dad, I don’t want to push my girlfriend around the way you do us. And you know what? I don’t want to work all the time, like you do. I wish that you would just listen Taffel, R. (2005). Breaking through to teens : Psychotherapy for the new adolescence. Retrieved from http://ebookcentral.proquest.com Created from touromain-ebooks on 2019-12-15 18:59:05. 9. Stuck 235 to things I say to you, instead of worrying about making me tougher. I wish you would take just a couple of minutes to listen, without feeling you have to teach me to become like you. JACK: You think I work too much? . . . I never said a word to my own father. He never said much to me. I barely saw him around the house, and, when he did talk to me, he was always teaching me, too. Trying to toughen me up, I guess. FREDERICK: (in response to his father’s frankness about his own youth) I know I make you feel like you’re a servant. I take Mom’s side on purpose just to get you crazy. I can’t say I’m never going to do all that again. Maybe if you just stop trying to teach me all the time to be the way you think I should be, maybe I could feel a little different about you. It’s quiet in the room now. Keep in mind how many times I’ve referred back to our private meetings, how much I’ve pushed, while protecting empathic connections. Frederick and his father are looking down. Nothing dramatic happens. Jack doesn’t get upset; he’s just nodding. Mom looks almost relaxed, for the first time. We can all feel the change from the beginning of this interaction. Father and son are talking to each other and listening in a slightly different way. This was a focused challenge for each to change a step of a destructive dance; and, their connection to me has survived the meeting. Copyright © 2005. Guilford Publications. All rights reserved. * * * Jolie, a single mother, is raising her youngest child alone. Amy is a junior in high school and is supposed to be thinking about college. The family has very little money and careful planning will be necessary. But, meanwhile, Amy’s close to failing in school. She’s dyed her hair jet black, gotten her tongue pierced, adopted a new Goth look, and become part of a wild crowd. In addition, she’s coming home later and later, some nights not at all. The live issue around which I focus the enactment is curfew. Taffel, R. (2005). Breaking through to teens : Psychotherapy for the new adolescence. Retrieved from http://ebookcentral.proquest.com Created from touromain-ebooks on 2019-12-15 18:59:05. 236 BREAKING THROUGH TO TEENS JOLIE: No matter what, I still love you. But why do you get into so much trouble all the time? I don’t understand you. You promise me you’ll be home by 2:00, and then there’s this big excuse when you show up hours later. AMY: Yeah, well, if you paid more attention to me you would understand what’s going on. JOLIE: What are you talking about? I do everything for you. I always ask you questions about your friends and what goes on in school and about your work. But you don’t answer me. THERAPIST: You’re not getting through to each other. Amy, I know you’re great at having your own mind and doing things your own way. Jolie, you’ve always been terrific at plugging ahead in life, despite the obstacles. But you’re clearly not getting through. Try again. JOLIE: You’re always so busy. You never have time to talk, anyway. AMY: Well, I am busy, because I don’t want to turn into a slug like you. Copyright © 2005. Guilford Publications. All rights reserved. JOLIE: (very defensive) What are you talking about, a slug! I do plenty! (She reels off a long list of things she does for the house, for Amy, for herself.) THERAPIST: Jolie, you defend yourself so quickly. It’s not necessary after what you’ve accomplished with your life. I don’t think you deserve going on the defensive like this. And Amy, you’ve developed that glare into an art form! It’s so perfect, you could be on MTV with it. (Amy smirks at this.) Go back to talking about your curfew. Jolie, try not to be so defensive. Amy, see if you can cut out the glare for a minute, no 10 seconds. AMY: Well, look, Mom, you’re so dull, nothing ever goes on around the house. So sure, I want to be with my friends. (Jolie says nothing.) If I go away to college, what are you go- Taffel, R. (2005). Breaking through to teens : Psychotherapy for the new adolescence. Retrieved from http://ebookcentral.proquest.com Created from touromain-ebooks on 2019-12-15 18:59:05. 9. Stuck 237 ing to do? You don’t have a life, what are you going to do? (another long pause) JOLIE: Well, it will be hard. It’s been just the two of us for a long time. I try to show an interest and ask her questions, but she doesn’t answer and she flares up at me. THERAPIST: Jolie, you’re sounding the same as before. Try to talk in a way that doesn’t sound so defensive. And Amy, you’ve got that glare on your face again—and I know your mother secretly matters to you. AMY: I think you want me home early because you’re so bored, because you don’t have your own life. It’s not for any other reasons, it’s not for all those things you say, like my safety. You know the group I’m in. They’re not as wild as they seem. Nobody’s ever gotten into bad trouble. Nobody’s been arrested. Nobody’s even been hurt. You just want me around the house for you. THERAPIST: OK, Jolie, I understand this is hard. But I’ve heard a lot about your life in our meetings, a lot more than you’re saying to your daughter here. Copyright © 2005. Guilford Publications. All rights reserved. JOLIE: (with a burst of feeling) OK. You know what? I like it when you’re here. But to be honest—and I don’t want to hurt your feelings—here’s the truth: I also like it when you’re gone. It’s me time. I can focus on me. It’s quiet, I play the music I like, I watch my shows. I don’t just think about you. So, if I’m going to be honest, sometimes it’s OK when you’re not home. . . . In fact, I actually look forward to it. AMY: (The glare on her face suddenly disappears. She gets tears in her eyes.) But you always act like you don’t have a life at all. JOLIE: You’re right, I don’t have as much of a life as I’d like. But I’m not shriveling up either. And I feel like I’m actually starting to get one, a life, I mean. THERAPIST: Can you tell Amy more about how you’ll do when Taffel, R. (2005). Breaking through to teens : Psychotherapy for the new adolescence. Retrieved from http://ebookcentral.proquest.com Created from touromain-ebooks on 2019-12-15 18:59:05. 238 BREAKING THROUGH TO TEENS she leaves, actually if she leaves—some of what you’ve shared with me. Amy, see if you can listen without interrupting or staring her down. JOLIE: You’re worried I won’t make it if you go off to college. AMY: (after a long pause) You’re right. I think you’re going to get sick. Or maybe you’ll just sit around and not do anything. I bring the only life to this house. If I leave, you’ll turn into a nothing. JOLIE: (clearly thinking hard) Look, Amy, I can’t promise you how I’m going to feel. But in my heart, I know I’m going to survive. I’ve been through much worse. And, I’m going to be OK. (Amy looks skeptical.) THERAPIST: I’m very familiar with Amy’s skepticism, I don’t think she really believes you. JOLIE: Listen, I’ve been through the divorce. I had no job. I got a job. I went back to school and I got a degree. The business closed down and I found another job. (She’s now crying.) I’m going to make it, no matter what happens with you. You’ve got to stop worrying about me! For the first time, Amy is listening with rapt attention. I can see she’s taking it in. The “truths” that I’d learned from individual sessions were now in the space between them. Copyright © 2005. Guilford Publications. All rights reserved. The Focused Family Session: Loose Ends ♦ If the troublesome interaction changes within the first few minutes, the meeting can end. Don’t feel you must fill up a 45-minute or a onehour session. Your goal is to change the choreography, to alter the interaction around one specific issue—because that one change could help parent or child relate differently to each other. ♦ Predict “normal” setbacks after the session. Say, “The way you were the past few minutes sounds different. But, remember, you’ll Taffel, R. (2005). Breaking through to teens : Psychotherapy for the new adolescence. Retrieved from http://ebookcentral.proquest.com Created from touromain-ebooks on 2019-12-15 18:59:05. 9. Stuck 239 probably go back to your old way of doing things. This dance has been going on for a long time. At least in the room today, you were able to do it differently for a few minutes.” Take what you saw during the enactment—what worked better and what underlying patterns emerged—and use them in private sessions afterward. Frederick, for example, needed to work on not being provocative. (This happened not just toward his father; Frederick often antagonized friends around him.) Amy’s secret caretaking of Mother was her modus operandi within the second family. Amy continuously fretted about whether a friend was going to stay with a boyfriend, or whether another friend was getting too deeply into drugs. Her reflexive caretaking was getting in the way of academic demands and her own needs with peers. The experience together stays alive for future private sessions, and creates ongoing challenges for each side afterwards. ♦ * * * Copyright © 2005. Guilford Publications. All rights reserved. Focused family sessions close a circle. Do you remember the special sense of familiarity with old friends, whose parents you also knew as a child? That “neighborhood” feeling is exactly what happens when you bring everyone together. You’ve immersed yourself with teens in their world; you’ve immersed yourself with parents in their concerns. Now, during a focused family session, you’ve immersed yourself in both sides of the generational divide. Slowly, you’ve turned yourself from a bridge into a well-worn path. Your office has become the town’s center, a place where park benches still exist, a place where parents and children, despite all their struggles, can still come to be with each other. Taffel, R. (2005). Breaking through to teens : Psychotherapy for the new adolescence. Retrieved from http://ebookcentral.proquest.com Created from touromain-ebooks on 2019-12-15 18:59:05. WEBC05 01/25/2015 2:29:41 Page 141 5 Substance Use Disorders in Adolescence Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. Rebecca Hall and Anna Lembke “ ‘Crash Kills  Contra Costa Youths. Two injured as pickup, -wheeldrive vehicle collide; beer containers found at accident scene.’ ” Eight young teenagers and adults from the age of  to  were killed in a head-on collision when they swerved into oncoming traffic while traveling about  mph, none of them wearing seat belts. One victim’s brother was stunned: “ ‘I don’t know how it happened. We always have a designated driver. It was a freak accident. I love my brother, man. I loved all of them. They were good people.’ ” A dolescent alcohol and drug use is a major public health problem in the United States. Drugs and alcohol contribute to a range of negative developmental outcomes, including mental health disorders, dropping out of school, delinquency, and incarceration. In , % of drivers who were involved in a fatal car crash between the ages of  and  had been drinking alcohol, with motor vehicle fatalities comprising over  Steiner, H., & Hall, R. E. (2015). Treating adolescents. Retrieved from http://ebookcentral.proquest.com Created from touromain-ebooks on 2019-12-15 19:02:29. WEBC05 01/25/2015  2:29:41 Page 142 TREATING ADOLESCENTS one-third of all deaths age  to . Substance use is also associated with attempted and completed suicide—the third leading cause of death in this age group. Health care providers play a key role in the prevention and treatment of adolescent substance use problems. In this chapter we provide a brief overview of the epidemiology, risk factors, natural history, screening, diagnosis, and treatment of substance use disorders. We define substances as any and all drugs of abuse, including alcohol. ADAPTIVE SIGNIFICANCE Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. Humans are well versed in learning what behaviors improve their odds of survival. By activating neuroreceptors in the brain, these survival behaviors become associated with emotions that motivate us to either repeat or avoid them. In addition to the basic human necessities that stimulate this reward system—food, sex, warmth, positive social interactions—certain plants and chemicals have the same neurologic effect, causing the brain to develop a need so strong for these substances that it can eclipse all else. Chemicals that can “hijack” the brain in this way are considered substances of abuse. EPIDEMIOLOGY For most adults with substance use disorders, the problem began as teenagers or young adults. Approximately .% of people in the United States are addicted to drugs or alcohol, and % of adolescents aged  to  have a substance use disorder. Forty-nine percent of graduating high school seniors have used an illicit drug at some time in their lives. Between ages  to , American Indian and Alaska Native youths have the highest rate of substance use, followed by mixed race youths, white youths, Hispanic youths, black youths, and Asian youths. Alcohol is the most commonly used substance by adolescents—% of graduating high school seniors have had at least one alcoholic drink, and % of seniors have been drunk at least once. Those enrolled in college full time are more likely to drink alcohol and binge drink than those not in college. Though cigarette use has declined since the mid-s, it is also Steiner, H., & Hall, R. E. (2015). Treating adolescents. Retrieved from http://ebookcentral.proquest.com Created from touromain-ebooks on 2019-12-15 19:02:29. WEBC05 01/25/2015 2:29:41 Page 143 Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. Substance Use Disorders in Adolescence  still an area of concern: % of adolescents have smoked a cigarette by their senior year, and % of seniors report being current smokers. Marijuana is the most commonly used drug among youth. In  one in  high school seniors reported using marijuana every day, or nearly every day. Synthetic marijuana (Spice or K-) is created in the laboratory to mimic chemicals in the cannabinoid family, and is used by .% of eighth graders, .% of th graders, and .% of th graders. Choice of substance typically varies by demographic and age. College students, for example, most commonly present with alcohol use disorders, marijuana use disorders, nicotine use disorders, and/or cocaine use disorders, while the top three substances of abuse for eighth graders are marijuana, inhalants, and synthetic marijuana. As teens get older they are more likely to use all categories of substances except for inhalants, which is the only category with a reverse pattern, declining in use after eighth grade. This may reflect the availability of inhalants for younger teens, which are often over the counter household products like nail polish remover, glue, gasoline, whipped cream dispensers, butane, and solvents. In the past decade, nonmedical use of prescription drugs was the fastest rising category of abused drugs among youth, particularly the nonmedical use of pain relievers, such as hydrocodone products (e.g., Vicodin) and oxycodone products (e.g., Percocet). In , .% percent of high school seniors misused a prescription drug. Adolescents most often get these drugs from a friend or family member’s prescription. CARDINAL SYMPTOMS Drug use typically progresses in stages, from less serious substances to more serious, and from legal to illegal. Experimentation is the first stage of use. A teen experimenting with a substance does so in a recreational circumstance to learn what intoxication feels like, but without the intention of continuing. Experimental use should not be condoned or trivialized by adults. Alcohol and cigarettes are often tried first, followed by marijuana and cocaine, hallucinogens, heroin, and opioids. The next stage is limited use, during which a teen uses substances for pleasure when available and in relatively lowrisk, predictable situations, such as on weekends with friends. This stage is Steiner, H., & Hall, R. E. (2015). Treating adolescents. Retrieved from http://ebookcentral.proquest.com Created from touromain-ebooks on 2019-12-15 19:02:29. WEBC05 01/25/2015  2:29:41 Page 144 TREATING ADOLESCENTS followed by problematic use. A teen using a substance problematically does so in high-risk situations, for emotional regulation purposes, or his use is associated with a negative event like being suspended from school or being arrested. During this stage the teen may begin to have family conflicts, academic problems, and peer group changes. Next is a substance use disorder. Once a teen reaches this stage, the substance use has become a significant problem, interfering with functioning. This stage is characterized by out of control use, compulsive use, and continued use despite consequences. The earlier teens begin experimenting with substances and the faster they move through these stages, the more at risk they are for developing a substance use disorder. The following case example illustrates this progression. Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. Case Study : Sally Fifteen-year-old Sally moved from the Midwest to California with her mother after her parents divorced. Her mother’s time was consumed with settling into a new job and a new city, and Sally was often left on her own. Prior to the move, Sally had been using alcohol and marijuana on weekends with friends, and she was smoking about a pack of cigarettes per day. Sally had a difficult time fitting in at her new school, until she met Joe. They started dating, and she began drinking with him at parties. They started smoking marijuana together as well. Joe then introduced her to crack cocaine, and then she experimented with crank. Along the way she tried PCP and LSD, but did not like them enough to continue. She was now using cocaine regularly. Her grades started to drop, and she developed nasal lesions. Despite her awareness that cocaine was affecting her health and academics, she felt unable to reduce her use. Sally had progressed to a substance use disorder. DIAGNOSIS If a patient screens positive for risky substance use, how can we differentiate risky use from a substance use disorder? We use DSM criteria to make this distinction. The revised edition of the DSM published in  (DSM-) Steiner, H., & Hall, R. E. (2015). Treating adolescents. Retrieved from http://ebookcentral.proquest.com Created from touromain-ebooks on 2019-12-15 19:02:29. WEBC05 01/25/2015 2:29:41 Page 145 Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. Substance Use Disorders in Adolescence  combined substance abuse and substance dependence into the single diagnosis of substance use disorder, which is measured on a continuum, with the added qualifiers of mild, moderate, and severe. Each substance is addressed separately, and called a use disorder. For example, addictive behavior involving alcohol is called an alcohol use disorder (DSM- diagnostic codes: mild ., moderate ., and severe .). The DSM- defines a substance use disorder as involving two or more of the following symptoms within a -month period: () attempting to cut back on substance use without success, () consuming more of the substance than planned, () spending a lot of time and energy getting, consuming, and recovering from using the substance, () experiencing intense desire to consume the substance, often referred to as craving, () failing to fulfill major life obligations due to substance use, () continuing to use the substance despite consequences, () giving up or reducing important activities due to substance use, () using in dangerous situations, () developing tolerance, and () experiencing withdrawal. According to the DSM- guidelines, if the patient endorses two or three items on the list, then she has a mild substance use disorder, four or five items and she has a moderate substance use disorder, and six or more items and she has a severe substance use disorder. Clinically, a more severe substance use disorder can take a variety of forms depending on which criteria the patient meets. Although the DSM does not use specifiers for quantity or frequency of substance use, there is an ever-growing body of evidence demonstrating that the higher the quantity and/or frequency of alcohol use, the higher the risk of poor health outcomes, such as gastrointestinal-related illness, pancreatic disease, liver disease, trauma, and death. Developmental differences between adults and children must be taken into account when applying these diagnostic criteria to young people. Because alcohol is illegal for those under , when adolescents drink alcohol it requires a level of energy and effort to obtain that adults do not face. This factor can skew criteria like “spending a significant amount of time obtaining the substance.” Adolescents also usually drink less often than adults, but do more binge drinking. Withdrawal and tolerance can be problematic diagnostic criteria, because withdrawal typically does not Steiner, H., & Hall, R. E. (2015). Treating adolescents. Retrieved from http://ebookcentral.proquest.com Created from touromain-ebooks on 2019-12-15 19:02:29. WEBC05 01/25/2015  2:29:41 Page 146 TREATING ADOLESCENTS occur until after years of use, and some adolescents will bypass the tolerance phase by jumping straight to drinking larger amounts. We also need to take social and environmental pressures into account when assessing young people. Rather than compulsive use, substance use in an adolescent may be more an indicator of an inability to resist social and peer pressures. This is true for all patients, but adolescents are particularly vulnerable to social and environmental pressures. Many of the diagnostic criteria therefore assume a different meaning in this population, and the particular nuances of this age group should be evaluated when considering a substance use disorder diagnosis. Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. RELATED DIAGNOSES TO BE RULED OUT AND CONCURRENT PATHOLOGY One of the major challenges in diagnosing a substance use disorder is differentiating it from primary mental disorders. Psychiatric symptoms caused by substance use can mimic primary mental disorders, which often do also occur concurrently. Robust scientific evidence also demonstrates that substances can cause psychiatric disorders. For example, cannabis can trigger an acute psychotic state, and frequent, heavy cannabis use is associated with a higher risk of psychosis, such as schizophrenia. However, it is still unclear if marijuana can induce a psychotic disorder that would not have developed otherwise. Refer to Chapter , Schizophrenia, Psychosis, and Autism Spectrum Disorders, for more information. On the other hand, having a mental illness other than addiction is predictive of having a co-occurring substance use disorder. In a study of  adolescents in drug treatment programs, % had at least one comorbid mental disorder, most often disruptive behavior disorders (Chapter ). Other commonly cooccurring disorders are mood disorders (Chapters  and ), anxiety disorders (Chapter ), ADHD (Chapter ), bulimia nervosa (Chapter ), and learning disabilities (Chapter ). Youth with substance use problems are also at greater risk for suicidal behaviors (Chapter ). One way to understand the high rates of comorbidity between substance use disorders and other mental illnesses is the self-medication hypothesis, which states that efforts to “treat” the underlying psychiatric Steiner, H., & Hall, R. E. (2015). Treating adolescents. Retrieved from http://ebookcentral.proquest.com Created from touromain-ebooks on 2019-12-15 19:02:29. WEBC05 01/25/2015 2:29:41 Page 147 Substance Use Disorders in Adolescence  disorder lead to substance abuse. Although having a mental illness may indeed be a risk factor for developing a substance use disorder, it is only one of many risk factors (see later section on lifetime trajectory), and the selfmedication hypothesis should be invoked cautiously in clinical practice. Encouraging the “self-medication” justification for substance use can further a patient’s denial and lead to overdiagnosis of primary mental disorders and undertreatment of substance use disorders. Adolescents are aware that using substances will elicit disapproval. Presenting their substance use as a reaction to sadness, rather than their sadness as a reaction to their substance use, can be an effort to avoid judgment or to rationalize substance use in their own minds. In general, clinical attention should be paid to both disorders concurrently. The following case illustrates the dilemma of differentiating a primary psychiatric disorder from substance-induced symptoms. Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. Case Study : Charles Charles, an -year-old Asian American male, began drinking alcohol and smoking marijuana when he was . Over the next  years his drinking increased, and he began using cocaine. He entered our clinic as a college freshman, where he lived in a fraternity and “partying” with friends represented the majority of his social life. He reported that he looked forward to little else throughout the week. At the first visit, Charles stated that his drinking had increased over the past  months. At times he would intend to drink only one or two alcoholic beverages, but once he started drinking he was unable to stop. He often drank until he blacked out. Despite attempts to curtail his binge drinking, he was not able to cut back. He currently used marijuana a few times per month. He stopped using cocaine a month ago, prior to which he had been using heavily on weekends. He typically smoked a few cigarettes per day, and an entire pack when drinking alcohol. Charles was originally referred to us by the campus health center, where he had presented with complaints of depression, anxiety, and Steiner, H., & Hall, R. E. (2015). Treating adolescents. Retrieved from http://ebookcentral.proquest.com Created from touromain-ebooks on 2019-12-15 19:02:29. WEBC05 01/25/2015  2:29:41 Page 148 TREATING ADOLESCENTS Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. sleep disturbances that had persisted for the previous  months. He reported that the past few weeks had been particularly difficult, with increased levels of sadness and often sleeping until the middle of the day. He had begun to have academic difficulties and thoughts of suicide. Charles also reported mood swings, in which he would feel energetic and increasingly talkative for a few days at a time. During these periods he slept very little and engaged in risky behaviors, like unprotected sex. His last episode like this was  month ago. When asked about his history of mood swings, Charles reported that his moodiness began in high school. However, his ups and downs did not affect his academics or overall functioning at that time. Charles stated that he believed that he had begun drinking alcohol in order to “self-medicate” his depressive symptoms. Charles clearly meets the criteria for alcohol use disorder, nicotine use disorder, and possibly cocaine use disorder and marijuana use disorder, reporting symptoms such as craving substances, taking more than intended, an inability to reduce use, significant amount of time spent using, failing to fulfill academic obligations, risky behavior while using, and possibly experiencing withdrawal symptoms. The question this case poses is: “Does Charles, in addition to having a substance use disorder, also have a mood disorder?” Charles’ history of depression and hypomania suggest a bipolar affective disorder. However, many teenagers experience some mood fluctuations during high school, and given that Charles did not experience any impairment in functioning during that time, these ups and downs may have been within the normal limits. His substance use history indicates that these symptoms may actually be substance induced, rather than a primary mental disorder. For example,  month prior to his first visit with us, he stopped cocaine and simultaneously began feeling more depressed. Ergo, withdrawal from the cocaine could be the cause of his current depressive symptoms. His last use also coincided with feeling hypomanic, suggesting that intoxication with cocaine or alcohol could be to blame for Charles’ manic symptoms. Steiner, H., & Hall, R. E. (2015). Treating adolescents. Retrieved from http://ebookcentral.proquest.com Created from touromain-ebooks on 2019-12-15 19:02:29. WEBC05 01/25/2015 2:29:41 Page 149 Substance Use Disorders in Adolescence  An observed prospective period of abstinence is the best way to differentiate a substance-induced psychiatric disorder from an independently occurring psychiatric disorder in the context of substance abuse. The DSM- recommends that a patient be abstinent from substances for a minimum of  weeks in order to determine if psychiatric symptoms are substance-induced. Clinicians must often make a treatment plan without knowing if the symptoms are substance-induced or due to a primary mental disorder. A lifetime timeline can be helpful in this process, which includes the major life events, such as academic performance, major family events, trauma, the onset of substance use, and the onset of psychiatric symptoms. Insurance limitations can complicate this process, as sometimes treatment for a substance use disorder is only covered if the patient also has a primary mental disorder. However, inaccurate diagnoses motivated by these insurance policies ultimately do not benefit the patient or our understanding of these disorders. Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. LIFETIME TRAJECTORY OF SUBSTANCE USE DISORDER Understanding social, environmental, and familial contexts is crucial in understanding why an adolescent uses substances, and in turn, how to create an effective treatment plan. For a more complete discussion of different theories of what contributes to the progression of substance use, please refer to the Handbook of Developmental Psychiatry (Steiner, ). Access to substances is the biggest risk factor for adolescents and the strongest determinant for what substances they choose. Perceived risk is also an important risk factor. The high prevalence rate of both marijuana and prescription drug use may be reflective of the belief that these substances are safer than other drugs. Because these drugs are also used for medical purposes, many teens use these substances under the false impression that they are not dangerous. Age of onset of substance use is another important risk factor for developing a substance use disorder. Those who use alcohol at age  or younger are more than  times as likely to develop alcohol use disorder as an adult. Other risk factors in youth for developing a substance use disorder Steiner, H., & Hall, R. E. (2015). Treating adolescents. Retrieved from http://ebookcentral.proquest.com Created from touromain-ebooks on 2019-12-15 19:02:29. WEBC05 01/25/2015  2:29:41 Page 150 TREATING ADOLESCENTS include early aggressive behavior and impulsivity, lack of emotional regulation, lack of parental supervision and monitoring, parental and peer substance use, and poverty. Protective factors include individual self-control; good parental monitoring; academic competence; school anti-drug use policies; and strong parental, community, and neighborhood attachment. Charles, who we introduced earlier in the chapter, illustrates how developmental factors can contribute to substance use in teens. Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. Case Study  Coninued: Charles’ Developmental History Charles grew up in an upper-middle-class home. His home life was tumultuous, with a father who abused alcohol and a mother who suffered from an eating disorder. Both worked long hours, and Charles was often home alone. His parents argued regularly throughout his childhood and were in the process of separating. School had always been Charles’ source of relief from the anxiety of his home life. He excelled academically and had a large peer group, including a girlfriend, with whom he drank alcohol and experimented with drugs. Now in college, Charles spends as much time as he can in the dorms with his friends in order to avoid home, including during school vacations. A variety of factors contributed to a developmental pathway that resulted in Charles’ addictive behavior, including limited parental monitoring and a stressful home life that may have impacted his ability to develop coping skills or regulate his emotions. His primary social support was a deviant peer group, which in combination with his parents’ addictive behavior, likely normalized his own substance use. The most notable protective factor in Charles’ history is his academic achievement. Understanding the factors that may have led to his substance use disorder allows us to develop a stronger case conceptualization and will help to guide treatment decisions aimed at getting Charles back on a positive developmental pathway. Steiner, H., & Hall, R. E. (2015). Treating adolescents. Retrieved from http://ebookcentral.proquest.com Created from touromain-ebooks on 2019-12-15 19:02:29. WEBC05 01/25/2015 2:29:41 Page 151 Substance Use Disorders in Adolescence  EVIDENCE-BASED TREATMENT INTERVENTIONS The adolescent substance use disorders treatment guidelines recommended by the American Academy of Child and Adolescent Psychiatry in  are now considered outdated. However, practice parameters can be a useful tool and providers should keep track of any updated guidelines. (http://www .aacap.org/AACAP/Resources_for_Primary_Care/Practice_Parameters_and _Resource_Centers/Practice_Parameters.aspx) Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. Prevention Programs Effective prevention programs should aim to both address the developmental factors and change long-term problematic environmental conditions. Schoolbased prevention programs are a worthwhile endeavor, given that a young person spends a significant amount of her daily life at school. Addressing adolescent psychopathology also helps to prevent early onset of substance use. Despite the billions of dollars that have been spent on substance use prevention programs, studies have shown that life-skills training and drug refusal skills programs are not overwhelmingly effective. When the typical adolescent is bombarded with hours of TV, media, and video games that promote drugs and alcohol, combined with parental/peer modeling, it is no wonder that programs that last only a few hours do not exert a significant effect on his substance use. Pharmacotherapy and Other Biologically-Based Interventions Pharmacotherapy has been used to treat substance use disorders in adults, however, there is a significant lack of pharmacotherapy research on substance use disorders in adolescents. Our treatment discussion here, therefore, focuses on behavioral and psychosocial interventions. That being said, evidence is beginning to show that treating co-occurring psychiatric disorders pharmacologically improves substance use treatment. Clinicians should be aware that substance use can increase the chances of overdose with some psychotropic medications. If there are concerns of potential abuse of these medications, adult supervision of the medication administration should be considered. The current emphasis on concurrent, Steiner, H., & Hall, R. E. (2015). Treating adolescents. Retrieved from http://ebookcentral.proquest.com Created from touromain-ebooks on 2019-12-15 19:02:29. WEBC05 01/25/2015  2:29:41 Page 152 TREATING ADOLESCENTS integrated treatment is in contrast to the former widely held belief that substance use disorders should be treated first, followed by treatment for any residual disorders, or vice versa. Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. Psychosocial Treatment A substantial amount of research is currently being undertaken to develop treatments for alcohol use disorders among adolescents, including guided self-change therapy, brief motivational therapy, cognitive behavioral therapy, and family therapy. So far, social-based treatments that focus on family and school environments are the most effective for adolescents with substance use disorders. Involving the family is crucial—family therapy has been shown to be more effective than couples therapy, individual therapy, family psychoeducation, peer counseling, life-skills training, education, and disciplinary actions. Work with families should be approached with a “nonblaming” attitude, rather than confrontation. This stance reduces the chance that families and patients will give up on treatment. Family therapy that involves the community is also an effective strategy. Opinions on group treatment programs remain divided, as there is evidence that group programs can negatively affect outcome by introducing the patient to a deviant peer group. This is especially true in youths with a co-occurring conduct disorder, which is quite common in this population. Other studies show that group treatment programs can be beneficial. With more deviant youth, however, it may be more beneficial to consider other treatment options, such as family-based treatment. Motivational interviewing, a nonauthoritarian technique that encourages an adolescent to assume responsibility for her actions and teaches how to make positive changes, has shown evidence for reducing problems related to alcohol use and can be administered in the primary care setting. We provide more discussion about this technique in the following Clinical Practice section. CLINICAL PRACTICE: PRACTICE-BASED EVIDENCE Screening Screening, brief intervention, and referral to treatment (SBIRT) for substance use is recommended for all adolescents. Many resources exist in Steiner, H., & Hall, R. E. (2015). Treating adolescents. Retrieved from http://ebookcentral.proquest.com Created from touromain-ebooks on 2019-12-15 19:02:29. WEBC05 01/25/2015 2:29:41 Page 153 Substance Use Disorders in Adolescence  journals, books, and online for how to conduct SBIRT with adolescents. To highlight some of those details here, the CRAFFT is a six-item questionnaire that screens adolescents aged  to  for risky alcohol and drug use. It can be a helpful way for a primary care physician to determine if a more in-depth conversation about substance use is warranted. Those who have a score of  or more are high risk and should receive follow-up assessment. Administering the survey on paper or by interview without a parent or guardian present can maximize honest responses. Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. Interview and Assessment Many of our patients arrive at our clinic seeking help for problems other than substance use, such as depression and/or anxiety. They are most often referred to us from the inpatient service, student mental health service providers who suspect a substance use disorder, or they are brought to the clinic by their parents. Helping these patients to understand that they have a problem with substance use can be a significant challenge. They can be resistant to the idea that their symptoms are related to their substance use, or that their substance use is an issue. This resistance must be managed carefully, and the first interview is an important step. We first gather a detailed history, including history of any substance use, behavioral addictions (gambling/sex), current and past nonaddiction psychiatric issues, a complete review of medical systems, psychiatric evaluation, developmental/social history, family substance use, and family psychiatric history. We use CURES (Controlled Substance Utilization Review and Evaluation System), which is the California prescription drug monitoring program, to access a patient’s controlled substance history. This system allows us to know what controlled substances are being prescribed to the patient by other providers, as a way of screening for a possible prescription drug use problem. Also, if the patient reports highrisk sexual behaviors, we offer testing for HIV and other STIs and provide education on safer sex practices. The way in which this information is gathered can be quite important. Due to the tendency for patients to justify their substance use with “selfmedication” language, it can be useful to first focus on the patient’s Steiner, H., & Hall, R. E. (2015). Treating adolescents. Retrieved from http://ebookcentral.proquest.com Created from touromain-ebooks on 2019-12-15 19:02:29. WEBC05 01/25/2015  2:29:41 Page 154 TREATING ADOLESCENTS substance use history and gather a detailed account of age of onset, any patterns of remission and relapse, past treatments, and any periods of sobriety before discussing the patient’s psychiatric history. When both areas have been independently explored, we then discuss any possible relationship between substance use and psychiatric symptoms. By separating these two lines of questioning, the clinician is able to gain a more accurate picture. Confidentiality issues must be addressed at the initial interview. Adolescents will be more likely to be honest about their substance use if they know that the information will not be shared. They should be assured confidentiality except when there is a threat of harm to self or others. Reporting and informed consent laws vary from state to state, and the clinician should consider both local and federal laws before initiating any treatment plan. Adolescents should be encouraged to inform their parents of their substance use. Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. Treatment Contracting Once we have finished the initial assessment, we will involve the patient in discussing which diagnostic criteria are relevant to her and what treatment will be agreed on. If the patient is particularly resistant to the idea that she may have a substance use disorder, we will temporarily withhold any definitive diagnosis and suggest that the patient try a trial period of abstinence in order to give us both more information. We then go over the results together. This maintains a collaborative approach and minimizes the tendency for patients to lie about their substance use. Treatment We encourage a therapeutic alliance that emphasizes listening and collaboration, rather than paternalism or blaming. We find that when working with adolescent patients, it is very important not to re-create the didactic relationship that they may have with concerned parents or teachers. Rather than insist that they should not use substances, which can trigger resistance, we ask the patient to think through what the pros and cons of their Steiner, H., & Hall, R. E. (2015). Treating adolescents. Retrieved from http://ebookcentral.proquest.com Created from touromain-ebooks on 2019-12-15 19:02:29. WEBC05 01/25/2015 2:29:41 Page 155 Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. Substance Use Disorders in Adolescence  substance use are, and adopt a “wondering aloud” approach. We are looking for the patient to think about what impact his substance use has had on his life. It is important to listen carefully to what the patient believes are positive outcomes from his substance use, as this will then open up the conversation about what may be negative about his substance use. We then move into a discussion about what factors may be contributing to the substance use. Social factors are often big players in adolescent substance use. These are important to address in order to maximize the patient’s chances of recovery. When substance use is a major shared activity with friends, it can be a frightening thing for a young person to abstain. Removing the common activity can weaken those relationships. We encourage having an open conversation with patients about how abstinence would affect their relationships and ask them to think through which of their friends and/or family might be supportive of stopping or reducing substance use. This conversation should include suggestions about what organizations or communities do not emphasize substance use, such as athletics, study groups, or religious groups. It is also important to address the issue of normalization. When an adolescent is embedded in a social network that uses substances, it can create the feeling that drinking alcohol or using drugs is not a big deal. Normalization combined with low perceived risk makes marijuana use disorder an especially tricky problem to address with adolescents—we often hear patients say, “everyone does it, and it’s not even illegal in some states.” We handle this situation by educating on the dangers of marijuana, explaining that although it may be legal in some states, the bottom line is that it is still an illegal substance in California. We help the patient to understand that although it may seem like everyone else uses substances, too, this is not actually the case. Often, a patient is quite surprised that they consume significantly more than the average adolescent their age. When initiating a treatment plan, we encourage both abstinence from substance use and reduction. If a patient is resistant to the idea of stopping his substance use altogether, we focus on changing behaviors to minimize harm and the consequences from using substances, like encouraging cutting back or trying edibles instead of smoking marijuana. In addition Steiner, H., & Hall, R. E. (2015). Treating adolescents. Retrieved from http://ebookcentral.proquest.com Created from touromain-ebooks on 2019-12-15 19:02:29. WEBC05 01/25/2015 Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved.  2:29:42 Page 156 TREATING ADOLESCENTS to reducing harm, small steps like these can allow the patient to begin to see the positive effects of reducing his substance use, which fosters motivation to take more steps toward the ultimate goal of abstinence. With this approach, concrete progress points and goals should be discussed. Withdrawal symptoms, such as delirium tremens and seizures, can be a real barrier to abstinence for some patients. We warn patients of the possibility of withdrawal symptoms and use the Clinical Institute Withdrawal Assessment for Alcohol Scale, Revised (CIWAR) to assess a patient’s risk of developing alcohol withdrawal syndrome. Those who experience troublesome side effects as they abstain or reduce their substance use may benefit from medication to ease the process. This can help patients stay motivated. If outpatient medication is not sufficient, we may recommend hospitalization during acute withdrawal. Toxicology screens can be helpful in some circumstances, but the results should be used as a discussion point, not as a definitive data point around which decisions are made. An agreement about the confidentiality of results needs to be made with the adolescent before testing. Some families will use home toxicology screens as part of a contract to stay sober. However, if a patient tests positive during treatment, we would use this information as the beginning of a conversation about what is going on, not as data for incrimination. These tests give limited information, as they are not % accurate and do not give any information about when a substance was taken. Psychiatric symptoms must be continually monitored throughout treatment. Patients find it reassuring to learn how substance use can cause psychiatric symptoms and how abstinence can resolve these symptoms. Often by providing this education, we are able to avoid prescribing medication. If psychiatric symptoms persist beyond a -week trial period of abstinence, a primary mood disorder and the appropriate treatment should be considered. If a patient enters our clinic already on medications for a mental disorder but is still experiencing psychiatric symptoms, we will avoid making any adjustments to medication until after the -week period of sobriety or reduction. Let us return to the case of Charles to illustrate how we approach the treatment process in our clinic. Steiner, H., & Hall, R. E. (2015). Treating adolescents. Retrieved from http://ebookcentral.proquest.com Created from touromain-ebooks on 2019-12-15 19:02:29. WEBC05 01/25/2015 2:29:42 Page 157 Substance Use Disorders in Adolescence  Copyright © 2015. John Wiley & Sons, Incorporated. All rights reserved. Case Study  Continued: Charles�...
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