ASA8285 - SECTION 7: TREATING ADOLESCENT ALCOHOL AND OTHER DRUG USE
Working with Parents and Guardians
One of the most influential factors in an adolescent’s life is the family system including the family of origin and the various other family and guardian systems and subsystems that operate through an individual’s life. A growing body of research has identified family related factors as important influences in the development and maintenance of substance abuse problems.
Family biology and family dynamics not only contribute to an individual’s risk for development of AOD use problems, but the family can also provide protective and recovery factors. The family can also play a significant role in getting adolescent into treatment.
Engaging adolescents and working with their parents presents extraordinary clinical challenges for most counselors and treatment personnel. Parenting is a joint outcome of three interrelated processes: having a positive relationship with an adolescent, being effective in managing behavior including setting clear standards for a child’s behavior, and monitoring and attending to behavior in a consistent manner.
Patricia Hersch (1998), in her book A Tribe Apart, notes that in all societies, adolescents have learned how to become adults by observing, imitating, and interacting with adults around them, but the evidence shows that today’s adolescents spend very little of their time interacting with their parents and other adults. Most adolescents are not so much pulled away from adults by their peers as pushed toward these groups by families where there is an overabundance of conflict and interpersonal disengagement.
Usually by the time parents and their children come to counseling or treatment, the adolescent’s AOD problems have escalated and the parents have lost significant control. If there is more than one parent, it is common for the parents to be split in how they each parent the adolescent. If there is a single parent, it is common for the parent to be too permissive.
In addition, the adolescent is probably in some trouble at school, in the community, and possibly the legal system as a result of his/her AOD use. Families usually do not seek counseling because of their adolescent’s problem with AOD. More frequently families come to counseling because their adolescent is having problems at home, school, and/or in the community, problems that may be influenced by the adolescent’s AOD use problems.
While many parents want help, they can be threatened by their children having a special relationship with another adult. Some parents have little or no interest in becoming involved in the therapy process, rather, they want the counselor or the treatment program to “fix” their child and return them to the family without their AOD use and associated problems. Many other parents, however, want to be involved in the counseling or treatment process including being involved in family counseling sessions.
Most counselors and treatment personnel recommend that the family or guardians need to be involved in some meaningful way for the treatment to be successful. It can also be very useful to involve other professionals in the counseling or treatment process including teachers and school counselors, probation officers, and department of social services as well as other individuals in the adolescent’s life including other family members, other adults, and peers.
The Harvard School of Public Health’s Project on the Parenting of Adolescents identifies what they call the five basics of parenting adolescents (Simpson, 2001).
1. Love and connect: Teens need parents to develop and maintain a relationship with them that offers support and acceptance, while accommodating and affirming the teen’s increasing maturity.
2. Monitor and observe: Teens need parents to be aware of, and let teens know they are aware of, their activities, including school performances, work experiences, after-school activities, peer relationships, adult relationships, and recreation, through a process that increasingly involves less direct supervision and more communication, observation, and networking with other adults.
3. Guide and limit: Teens need parents to uphold a clear but evolving set of boundaries, maintaining important family rules and values, but also encouraging increased competence and maturity.
4. Model and consult: Teens need parents to provide ongoing information and support around decision-making, values, skills, goals, and interpreting and navigating the larger world, teaching by example and ongoing dialogue.
5. Provide and advocate: Teens need parents to make available not only adequate nutrition, clothing, shelter, and health care, but also a supportive home environment and a network of caring adults.
When their children are involved with AOD, most parents experience both a sense of helplessness and desperation. Their helplessness leads parents into denial, and their desperation leads parents into battles for control. Some parents, feeling helpless in trying to control their adolescent’s behavior, become enablers or rescuers whereby they shield the adolescent from experiencing the full consequences of their AOD use and associated behaviors. Other parents engage in spirited battles for control of their adolescent’s behavior.
When it comes to confrontations over control, many adolescents are willing to go to very extreme lengths to win the battle including causing harm to themselves and to others. It is usually impossible to stop an adolescent from experimenting with AOD simply by adults using their force of authority. Parents need to find ways to provide their children with guidance and information on how to handle these complex situations.
A good way for parents to communicate to their children that while they disapprove of their AOD use, they are most concerned about their safety and health. One way to do this is to have a strict policy on drinking and driving. Parents can say to their child:
“If you are out and the only ride you can get home is with someone who has been drinking or using drugs, or if you’ve been drinking or using drugs, call us and we will come and get you or you can call a cab and we will pay for it, no questions asked, no punishments. While we are concerned about you drinking and using drugs and being around people who are drinking and using drugs, we also want you to be safe. On the other hand, if you are caught by the police for drinking or drug related behavior, or the school or someone else contacts us about your drinking or drug use, then you will have to face the consequences of the court system, the school, and others and we will punish you for your behavior.”
It is important to empower the parents by validating parents' past efforts, acknowledging that parenting can be difficult, but giving parents hope by helping them to develop new family management techniques. Parents often need to be reminded that it is normal for adolescents to struggle with their parents and that AOD experimentation and some other problem behaviors are normal for most adolescents.
The basic goal in working with parents is to teach them good parenting skills. Parental monitoring is the foundation of positive family management. Parents need to develop a coordinated parenting style that is not too authoritarian or based too much on trying to be their friend. While parents need to feel that they can have a significant influence on their adolescent’s behavior, they also need to realize that they cannot control everything in their adolescent’s life.
While parents may feel they have relatively little control over their children’s attitudes and behaviors, what parents can learn to control is their reactions to their child’s attitudes and behaviors. Effective parenting involves learning what to take on and what to ignore or accept for now. Parents in conflicted families are often locked into battles with their children over control of issues which are not important or are not winnable. Parents need to learn how to “choose their battles” and focus their energies on the behaviors and attitudes that put their children at real risk of physical and emotional harm either now or in the future (Treadway, 1992).
When conflicted families come for counseling, it can be difficult for them to articulate what is going well and not well in their family life. An effective exercise in helping parents to begin being specific about what they like and dislike about their current family situation is the use of the “miracle question.” The “miracle question” is presented to the parents and the children as follows:
“Suppose one night while you are sleeping, there is a miracle and the problems that brought you into counseling were solved. When you wake in the morning, what will be different that will tell you that this miracle has taken place?”
Each family member is asked to describe the perceived changes and their feelings in detail. Their responses can identify things that the family is current doing that are working, identify common family goals and individual family member’s goals, and ways to achieve these goals. This exercise can also provide families with a sense of hope and optimism.
The basic strategy for working with the parents of adolescents who are abusing AOD is to teach them the use of creative consequences. Most adults who seek help for their AOD abuse usually have “hit bottom” that is, they have experienced significant negative physical, psychological, social, and/or economic consequences as a result of their AOD use. Most adolescents have not experienced these symptoms or they will not acknowledge them.
Developing meaningful negative consequences for AOD use, in essence, “raises the bottom” for the adolescent. Adolescents do not have to agree that their AOD use is a problem, rather, they only have to realize that continuing the behavior is more trouble than it is worth. Parents need to clearly define stopping AOD abuse as a rule and design a set of meaningful consequences that are severe enough to make the adolescent choose giving up AOD abuse over suffering the consequences. This is most effectively done through the development of a written contract between the parents and the adolescent (Dishion & Kavanagh, 2003).
Most families have a very difficult time developing and enforcing meaningful contracts. Sells (1998) identifies six primary reasons why parents have difficulty in setting clear rules of consequences:
1. Rules and consequences are not clearly operationalized before a rule has been broken
2. Rules are optional rather than mandatory
3. There are too many rules to master at any one time
4. Consequences are not effective enough
5. Parents do not follow through on a consistent basis or they change rules or consequences in midstream
6. Rules and consequences are not written down in a contract format
Contracts work best when the rules and responsibilities are discussed and created with the counselor’s input during a series of family meetings. There should be rules and responsibilities for all the family members, not just for the adolescent who is exhibiting problem behavior. To begin, parents can say to their child the following:
“Your drug use has affected your living at home, your progress at school, and your behavior in the community. Since we cannot completely control your decision to use or not to use drugs, we will control the environment we live in by setting limits and consequences for your behavior at home, at school, and in the community. The purpose of these limits is to protect you while you learn to control your own behavior.”
The best strategy is to develop agreements - rather than make rules - and to develop consequences - rather than punishments. A rule says you have to do this and there is a punishment if you do not obey the rule, while an agreement is an arrangement that is negotiated and agreed to by all parties and there are consequences for honoring or not honoring the agreement (Kirshenbaum & Foster, 1991).
Sells identifies a number of strategies for constructing effective agreements and consequences:
1. Getting the parents to agree upon the top three behaviors that they want to improve
2. Getting parents to convert unacceptable behaviors into clearly operationalized rules (rules that do not need explanation and without the adolescent pleading his/her case)
3. Constructing effective consequences to reduce or eliminate extreme behavioral problems (what each consequence will be, how it will be monitored, who will deliver it, when it will be enforced, and how long the consequence will last)
4. Showing parents how to put together a written contract (but ultimately the parents should come up with both rules and consequences)
5. Incorporating the adolescent’s expertise in setting his/her own consequences (with the understanding that the parents will decide what ultimately goes into the final contract)
6. Getting parents to follow through on a consistent basis (do not say anything to your teen that you can’t or don’t want to do, and do everything you say you are going to do)
7. Consideration of family dynamics (can the parents put aside their differences for the greater good of solving their teenager’s behavioral problems)
The agreements should be spelled out in a written contract signed by the affected parties. There should be positive consequences for obeying agreements and negative consequences for disobeying agreements. Agreements can be renegotiated only after they have been discussed, and agreed upon by the family.
Agreements need to be enforced 100% of the time in an unemotional manner and parents need to give praise when agreements or expectations have been achieved. As the adolescent increasing complies with the agreements in the contract, the contract can then be less restrictive as the adolescent begins to build family trust and responsibility.
Parents need to be prepared for the fact that most adolescents will initially react very negatively to an increase in family structure, but they still need to be as consistent as possible. There should also be discussions with parents that with some adolescents even when a good family system is in place, their behavior may not change or it may even get worse.
If families have tried to implement these changes and they have not worked or the family is not able to consistently implement them, then they may want to consider more severe consequences such as calling the police, probation, or school officials or sending the adolescent to an inpatient treatment facility. However, parents need to realize that using these additional resources in most cases will still mean that they need to make changes in their family dynamics to produce effective, long-term, change.
Working with Adolescents in Therapy and Treatment
Working with adolescents presents counselors and treatment personnel with unique challenges. Young adolescents can become easily overwhelmed by their feelings and many of their problems result from their inability to deal effectively with these feelings. It is often difficult to get at the underlying problems because many adolescents mask their true feelings with anger, apathy, or acting out. In turn, adults often overreact to adolescent behavior because they assume that the adolescent’s actions are intentional.
The adults’ overreactions create additional problems for adolescents and their responses range from defiance to withdrawal (Vernon, 1999). Most adolescents do not volunteer for counseling or treatment, rather they are encouraged or required to get help from family, friends, school officials, employers, child welfare services, or the legal system. So engaging and motivating adolescents becomes a top priority. In working with adolescents there are a number of important factors that impact counseling and treatment.
First, many counselors assume that they can work with adolescents since all of us were adolescents at one time and many of us, have been, or are, parents of adolescents. However, working with adolescents is a treatment specialty in its own right that requires special training and clinical experience. Working with adolescents and their parents can bring up memories of one’s own childhood and one’s own parenting, so it is important for counselors to deal with any counter-transference issues they may have with working with this population. Reading what other counselors are doing and getting feedback from other counselors can be very helpful in this regard.
It is also important not to assume that you understand the adolescent’s world especially if there is a significant age difference. It may be tempting to say: “When I was your age,” or “I once had a similar experience,” but many adolescents feel no one, especially an adult, has experiences similar to theirs. Adolescents need an objective, nonjudgmental listener who validates their experiences as important and tries to understand them.
If you are going to regularly work with adolescents you should become familiar with the important influences in their lives such as television shows, movies, video games, sport figures, and fashions and trends so that you can use this information to not only better understand their world but also so that you can reference it is your counseling. Many counselors have found that one of the best strategies to adopt when working with adolescents is to use the same techniques that one would use to understand a client from a different racial, ethnic, or cultural background - letting them educate you about their experiences and world view.
Second, for counseling and treatment to be effective, it is important to involve the adolescent’s parents or guardians and other significant people in the adolescent’s life. Most counselors who work with adolescents would recommend involving some or all of these people directly in the counseling and treatment process, especially the parents or guardians. Getting written permission to speak with the adolescent’s teachers and counselors, legal system personnel such as police and probation officers, psychiatrist and other medical personnel, social welfare and child services personnel, and friends can be very important in the total treatment process.
It is important to discuss with adolescent clients and the other people involved directly or indirectly in counseling or treatment, the limits of confidentiality (i.e., danger to self or others, child abuse, elder abuse, and the possible need to speak with other people about the case). The counselor also needs to establish a clear policy with the adolescent, his/her parents, and any other people about information they receive from each other and how this will be handled. It requires delicate skills by the therapist to make all of these people feel they are involved in the therapy process while maintaining the trust of each party, especially the adolescent.
Third, when most adults come to therapy they have a general expectation about what is involved in seeing a counselor. Most adolescents have little knowledge of what actually happens in a therapy session, or if they have some knowledge, they are often very reluctant to participate by sharing their thoughts and feelings with a strange adult. Confidentiality needs to be explained in language that the adolescent can understand. For example, a counselor might say:
“What we talk about here, I don’t tell anyone. Everything you say is confidential. This means that I don’t talk about what we talk about with other people. If anyone asks me about what we talk about, including your parents, I first check with you to see if you want me to tell them anything. But the law requires that there may be times when I have to tell someone else if I believe you are a danger to yourself or if you could hurt someone else. If I believed you are or were being abused or hurt or someone was putting you in danger, then I’d have to tell that to someone who could do something about it such as the police or child protective services. Otherwise, what we talk about is kept confidential. So what do you think about this? Do you have any questions?”
Fourth, adolescents often do not respond well to many of the counseling approaches and techniques that work with adults. Counselors will need a broader set of relationship building skills and therapy techniques that are specifically suited to the needs of adolescents including using other materials and techniques (i.e., paper, art activities, games, music, writing exercises, role playing, drama exercises), doing therapy in places other than an office (i.e., walks, playing sports, driving around listening to music, in a restaurant or park), doing counseling in different formats (i.e., other than one hour sessions once a week), and involving other individuals (i.e., peers, teachers, coaches, other counselors, other adults). Counselors need to be aware of the adolescent’s age and developmental stage and tailor their interventions accordingly.
Fifth, while counselors need to develop trusting relationships with the adolescent, they should also remember that they are counselors and not the adolescent’s friend or parent. Many counselors find it difficult to not want to rescue adolescents and second-guess their parents, teachers, and other adults.
Many counselors find it is easy to lose their objectivity especially when they develop a connection with an adolescent. In an effort to bond with the adolescent, it is important not to explicitly or implicitly endorse antisocial attitudes or behavior, AOD use, other problem behaviors, or undermine the adolescent’s parents or school or court personnel. While trying to be their friend may work initially, it will hurt the therapeutic relationship in the long run when the counselor needs to confront or correct the adolescent. Trying to be a substitute parent will only undermine the work the counselor needs to do with the adolescent’s parents or guardians.
The therapeutic relationship is a unique relationship that both the counselor and the adolescent need to clearly understand and experience, maintaining objectivity and good boundaries. With adolescents, developing this unique, trusting, relationship will take time.
Sixth, in most cases, counselors cannot assume that when adolescents come to therapy they want to address their AOD use and associated problems. Most adolescents are under significant pressure to at least drink, as well as use other drugs. AOD use is a rite of passage for most adolescents.
Admitting that one has an AOD use problem and coming to counseling may be important to other people in the adolescent’s life, but it is not necessarily important to many adolescents, even to adolescents who have gotten into some serious trouble as a result of their AOD use. Being in counseling reminds many adolescents of their dependent relationships with their parents, teachers, and other adults which they often find intolerable.
Many adolescents interpret seeing a counselor is that people feel they cannot deal with their life successfully without someone else’s assistance at a time when they are trying to establish their independence. Many adolescents who are required to go to counseling will say it is their parents that need the counseling, not them. Therefore, it is important for the counselor to be able to engage adolescents by developing an individualized rationale for treatment with each adolescent so that they can come to understand that there is something in it for them.
Focusing on where adolescents are in terms of the “stages of change” (DiClemente, 2003), that is, how motivated they are to make meaningful changes in their lives and using such techniques as “motivational interviewing” (Miller & Rollnick, 2002) have proven very effective in working with adolescents. A section on motivational interviewing is offered later in this training.
Seventh, most adolescents feel that no one listens to them, therefore, they usually have strong expectations that an adult will respond to them with corrective advice or at least some judgment. If a counselor meets these expectations in the first few contacts with the adolescent, developing a personal bond will be very difficult. The basic goal of most therapy with adolescents is to help them with their communication and problem-solving skills (Dishion & Kavanagh, 2003). A good initial strategy is to help the adolescent understand that he/she has something to gain from being involved in therapy. The best approach to take is to ask adolescents to teach you about their world.
A counselor might say:
“I’d like to understand the things in your life that you wish were different, that you would like to change, and see if we can figure out some ways to make them different” or “Our purpose together is to try to find some ways to make your life better in a way that makes sense to you. It appears that while you have some valid concerns, you are not communicating these concerns in such as way that people are listening. Maybe I can help you find more effective ways of communicating these concerns so that others may hear what you have to say and respond to you more favorably.”
It is important for the counselor to create an environment where adolescents feel heard and understood.
Eighth, with most adults, an effective counselor can usually see evidence of steady growth or improvement (with some setbacks), but with most adolescents their process of growth seems less steady. For example, it is common for adolescents to frequently not to show up for sessions, to forget what was talked about in the last session, to exhibit wide emotional changes during and between sessions, and to go from active involvement to disinterest, even resistance, during and between sessions.
Working with adolescents often involves what can be called “therapeutic moments.” These therapeutic moments or windows are based upon forming a good therapeutic relationship so that the adolescent begins to feel comfortable with, and learns how to talk about, personal issues and hear constructive feedback from the counselor and other people in the adolescent’s life.
Finally, counselors should keep their interpretations to a minimum because this may make the adolescent feel that the counselor and others feel their behavior is foolish or unwarranted. Counselors should be “educated guessers” where they offer suggestions, possible explanations, and other responses that are all very much like interpretations, but they do not appear as threatening or critical to the adolescent. The counselor can confront, challenge, or give advice, but this should be given without implying judgment or control.
Responses such as “It sounds like you feel” or “If you could have things just the way you want them, my guess is that” make the adolescent feel less defensive. Your goal as a counselor is not to solve the adolescent’s problems, but to help adolescents make responsible choices on their own. Most adolescent are much more comfortable with counseling that is oriented around problem-solving, skill-building, and just being heard than understanding the deep psychological reasons for their behavior.
In conclusion, working with adolescents can present many significant challenges. David Treadway’s titled his article on working with adolescents and their families, Hanging on for Dear Life (1992). While the challenges are great, the rewards are also significant. One of the advantages of working with adolescents is that they are often less committed to their AOD using lifestyle than most adults. Therefore, when they are ready and committed to changing their attitudes and behaviors they can make rapid and meaningful changes in a relatively short period of time.