How to Work With Youth Engaging Adolescents in a Treatment Process: Avoiding Arrogance and Irrelevance Charles Huffine, MD

How to Work With Youth

Engaging Adolescents in a Treatment Process: Avoiding Arrogance and Irrelevance

Charles Huffine, MD

Adolescence as a Social Developmental

Process To understand the clinical tasks it is critical to understand adolescent development.Adolescence is a recent phenomenon historically

End of Adolescence can only be defined sociallyAssumption of Adult Responsibilities

Neurodevelopmental events do not bracket adolescence

Goals of Adolescent Developmental Process:Creation of a personal identity

Education in support of a personal identity

Ability to exercise choices in ones life consistent with one’s identity


Process To understand the clinical tasks it is critical to understand adolescent development.Adolescence has changed each generation making intergenerational understanding hard.

Social development involves stress.More if one can’t compete as prettiest, strongest, smartest, coolest

More if one is subject to poverty, discrimination

More if one has a mental illness

Symptom Expression in adolescents reflects social distress through behavior that has social communicative value.


Process Evaluation and Treatment must support the adolescent developmental process.One must quickly assess where an adolescent is developmentally in clinical encounters.

In treatment one must be aware of the task of developmental support at all times.

Adolescents must incur some risk for healthy development; a parents job is to reduce risk.

Over allying with parents is easy for therapists and understandable, but it can kill a treatment.


Process

The Nature of AdolescenceAs a Social PhenomenonMakes the Practice of

Adolescent Psychiatry a Subset of

Community Psychiatry(if practiced correctly)

Initial Interviews with Youth

Before the Interview What you learn before you see your new patient. Talk to referral sources; parents, schools, etc.

Read referral material. Be skeptical of what you’ve heard and read.


Meeting Your New Patient/Client Meet with Parent(s) (or

Alternative Adult) and the Patient First: Make introductions, go over why referred.

Very short: under 5 minutes. “Kick parent out,” graciously, with humor.

Follow up with parent after appt, or by phone, deal with crises, confidentiality

Accept meeting youth alone if there are reasons.


Meeting Your New Patient/Client

Let youth in on who you are:

Loosen up, don’t fear making

dumb or funny comments.

Be genuine, share yourself.


Meeting Your New Patient/ClientStart with broad questions or

comments: i.e.“Whuz-up?”,“So that’s your Mom!” Look for immediate reactions. Have no agenda in first minutes. Goal is to find out who this person is. Give many clues to youth on who you are.

This is not about your CV or family life


Meeting Your New Patient/Client Begin practicing the

strength based approach Leave the “problem behavior” alone for a while - actively turn away from the referral issues.

Find out what the kid likes to do, who their friends are

Find a way to genuinely enjoy the kid who is in front of you.


Meeting Your New Patient/Client Most youth will warm up and

talk if you give them a chance. Expect cautious responses for 10 -15 minutes while they check you out.

Once they’re allying with you, you can nudge and prod if you are: focusing on strengthsattending to the youth’s agendarespecting cultural issues

Some youth are difficult to engage


Reaction Styles and responses:1. Very shy Kid

Be Empathetic, talk actively and speculate.

Pick up cues, give space to talk, validate

2. Kid with verbal flood,own agenda: Let the youth go, actively listen. Keep eye contact, lean towards them. Punctuate with “Oh, my God’s!”

3. The kid who Stonewalls: Be verbal, don’t leave silences,jabber, foolishly,note silliness as a flaw

Inject referral agenda, “this is what they’re saying about you - I don’t know if its true.”

Speculate wildly, let kid correct you!


Reaction Styles and responses: General Points on interviewing

teens: Declarative statements are gifts, make few demands with questions.

Use youth friendly language. Clarify confidentiality off the cuff, make no big deal about it - middle or end of the first session.

Strut your stuff: show your sophistication regarding what goes on in the world of teens - non-critically and understated.


Latter 1/3 of the interviewCleaning Up Loose Ends:

Deal with referral questions. Survey of life domains:

Peer relations, social savvy. Indirectly get at S/A issues.Touch on school (OK?, sucks?)How family works for them.Deal with any specific agency needs.


Latter 1/3 of the interviewMental Status/Diagnostic Refinement: Depression/Anxiety:

Common issues for youth.Are symptoms frequent and clear?Do they add up to syndrome?

Not often considered diagnoses:Brain functioning: LD/FASD.Signs of trauma; abuse?Impulsive, erratic, irritable?

• Never diagnosed ADD/ADHD.

• Juvenile Bipolar.

• Attachment Problems.

Make no diagnostic conclusions on 1st appt.


Latter 1/3 of the interview When you have assessed Suicide Risk: Be cool headed and serious

Panicky decisions can make things worse Many youth find “contracts” a joke, others get dependent on them, others are helped

Your relationship is the best safety device

Be clear that self harm is NOT suicide. If severe (immediate and lethal),and you must break confidence, do it while with youth in the room, can bring parent in.


Latter 1/3 of the interviewFormulation/Summary:

Make sense of story, share with youth.

Reemphasize confidentiality.

Ask “Did it go OK?” Make contract for future.

A Few Points On Working with Parents

Parents are partners, not patients You have NO contract to treat parents.

Meet On first Appointment, get agreement to Let Relationship with kid develop before “Big Meeting.”

Be available by phone for early crises

Get clear quickly about confidentiality.

Have a Big Meeting to get background after seeing the kid 3 - 4 times.

Make referrals when necessary for parent support or treatment

Ongoing Psychotherapy

Opening a sessionLetting youth take the lead: Open with a friendly but non-biased word:i.e. “Whuz-up,” “ Its Monday.”See if kid talks about an issue or not.

Allow for warm up time.


Content of Sessions Slow Uptake Session:

Jabber a bit, tell a story. Don’t allow long silences.

Judge timing intuitively, look for angst.

Avoid pestering questions.Deal with anxiety of lack of structure.

Avoid topical focus or direction initially.


Content of Sessions Slow Uptake Session:

Let the session evolve without agenda.OK to pick up old threads later. OK to have a low energy or fluff hour.

Be playful, be clear that strengths emerge in play, resiliency is enhanced.

Be respectful of where the youth is at at this time and join them there.

If there is a big issue it WILL emerge.


Content of Sessions Big Issue Session: Climb into it with the kid with avengence:

Get Overwhelmed. Keep one’s bearings.Lots of exclamations, outrage, humor.

Indulge with youth in projections:

Do it with note of absurdity.Be playful.Lots of “They suck,” “Dumb.”

Feel what it is to be powerless.


Content of Sessions Big Issue Session:

Begin the sorting process with client. Clarify, organize for youth.Look for reactions from youth.

•Be sure that the youth is with you.•Test one’s ideas with youth openly.

Gather general principles, realities.•Compare and contrast with past.•Recall old stories.


Content of Sessions Big Issue Session: Begin the sorting process with client:Look at options. Begin to make a plan.Offer methods such as:

• Mindfulness, Meditation• Creative Dissociation

Help youth avoid escape behaviors:Self harmSubstance abuse


Content of Sessions The Cardinal Rule Most Cited by Youth:

•= Youth parody of counseling•Instead, find feelings in behavior, indirectly in words•Comment on their feelings in youth friendly terms: “it sucks.”

Avoid saying: “How did you feel about that?”

Issues in Therapy with Youth

Therapists Style Need to understand one’s own persona: Know one’s strengths and aptitudes:Not everyone can work with teens.

Observing ones own limits.Play to one’s own strengths with youth.

Male and female perspectives:Work at cross gender competence.

Be a good role model of gender.


Therapists Style One’s own Persona: Issues of

Language - Slang

Do not censor or correct what you

hear youth say or the way they say

it.

Let youth inform you on slang.

Become a student of youth slang.

Use slang only if it is natural

for you, or if you mirror youth

with “quotes.”


Therapists Style One’s Own Persona: Issues of Language - ProfanityMost youth use profanity naturally.

Youth will test you with its use.Decide if it is your style to mirror.If yes, use only as youth does.If no, be subtle and don’t judge.

Profanity in service of the work.Natural speech for youth.Language = youth culture.


Therapists Style Need to understand ones own persona:Don’t try so hard

Youth Pick up phonies in two seconds.

When you respect the youth in the session the youth will respect you.

Relax and have fun with a kid Be open to grow and develop.

Let youth teach you to treat them.


Therapists GoalsBeing Useful:

Look for tangible things you can do.Solve a current problem with parents.

Intercede with school.Letters to write on youth’s behalf.

Use such issues as bridging parents/youth.


Therapists Goals Being Useful: Staying practical:

Ground oneself in realities of family.•Understand income constraints.•Understand transportation issues. •Appreciate personal limitations.

Be willing to advocate with systems.•Be a good advisor to parents/kid.•Always present realities of system.

Be creative, practical, in problem solving.


Therapists GoalsDefine our Roles with Youth:

Youth generally do not value treatment.Prior bad experiences.Model of being taught, sick of it.Wary about all adult agenda’s.Therapists as agents of parents.Therapists as agents of cops.


Therapists Goals Define our Roles with Youth:

Youth are starving for adult attention.Cut through the kid/therapist barriers by shifting to a strength based approach.

Role of Mentor, best model:• Youth own you as theirs.

• Youth take liberties with you.

• Youth demand care taking.

• Normal adult roles with a youth.


Therapists Goals Define Our Role With Youth:

Adore youth you are working with.It is OK to love kids.It is artificial to prohibit love.Youth expectations:

Most youth demand being adored, do adorable things and if you don’t notice your weird.

Some youth can’t tolerate being cared for, give them space and let this problem be solved slowly


Therapists Goals

Defining Our Role With Youth Limit Setting as presumptuous

Principle of defining ones own limits.

Communicate what you need.•Not for patient’s own good

•What drives you nuts is not OK.

•You have adult worry rights.


Therapists Goals Help Youth find new perspectives: Offer overviews with new insight. Reduce uptightness of issues, use humor.

Future pace, drag youth into planning.

Work on personal identity:Help kid discover their “reputation.”Push strengths. Define needs.


Therapists Goals Help Youth find new perspectives: Support “parent management.”

How to manipulate positively.How to accept/see parents love.Help youth see the “good deal.”

• Get lots of goodies for free.• Less responsibility.

Translating parent perspective.How to “out-mature” parents.


Therapists Goals Help Youth find new perspectives: Identifing psychopathology as a clue to needs.Explain to youth in relatable terms.

Explain treatment possibilities.Be straight about risks.Let youth warm up to ideas/action.


Therapists Goals Help Youth find new perspectives: Be aware that radical changes are occurring in a youth. These are a function of both treatment and growth.

Note and celebrate, be subtle, cool. • Don’t pounce on it and slather.

• Acknowledge good work.

• Place in perspective of strengths.

Thank You

For more discussion and a copy of slides write or e-mail:

Charley Huffine, MD

3123 Fairview Ave. E.

Seattle, WA 98102

[email protected]

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How to Work With Youth Engaging Adolescents in a Treatment Process: Avoiding Arrogance and Irrelevance Charles Huffine, MD