This is the fourth in a series of four articles on adolescence.
I remember the parents well – a middle aged couple, they were very sad and communicated a sense of helplessness. The mother completed their story in a tone of resignation and pain: “The worst is that we cannot reach him anymore. We have become strangers to him.”
Their 14 year old son, a freshman in high school, spent the nights with friends smoking pot or at home listening to music and playing videogames. He missed more and more days at school and had become physically aggressive towards his two younger brothers. Then there were days of high energy during which he was able to complete homework and receive excellent grades. Most attempts on the part of the parents to speak with him resulted in torrents of abusive language or made him retreat into his room and barricade the door.
Traumatic family experiences with adolescents vary greatly in specific details. They have in common that the most profound pain and suffering of parents and other family members consists in the increasing collapse of their relationship with the adolescent and, therefore, in the erosion of the cognitive and emotional basis for communication with the teenager.
Families speak of their shock when their teenager acts violently towards other family members or seems intent on destroying herself or himself through self starvation, cutting, or extreme risk taking.
For other parents words do no longer penetrate the fog and distance generated by drugs. Extreme mood swings or incoherent ”conversations” with imaginary figures that do not make any sense present the family with a youngster that they do not seem to know at all. The trauma intensifies when parents go through this process alone out of shame and embarrassment.
What are parents to do? Teenagers rarely seek therapy on their own. In fact, many times the parents’ attempts to induce or coerce the youngster to speak with a school counselor or to see a psychiatrist and take medication either result in increasing the symptomatic behavior or have only short-term calming effects.
In order to put together a thorough assessment of the situation a family therapist will take a broader view than just being concerned with the teenager alone. The work may start with a series of consultations with the family or the parents alone, if necessary in the family’s home. The goal of the initial phase of therapy is to assist the parents (or other responsible adults in the family) to overcome their helplessness and to take charge of the recovery process. Despite the appearance of a total relational breakdown, parents are encouraged to trust, nurture, and strengthen the remnants of the relationship with their teenager and to set a firm structure for the teen’s life in the family.
The plans for a comprehensive psychotherapeutic approach may include, in addition to family sessions, some individual sessions with the teenager, parent meetings, school consultations, psychiatric evaluations for possible medication treatment, and family support from close relatives or family friends, who can serve as emergency standby. It is vital that any divisions among the professionals are avoided and the family therapist continues to be entrusted by the family with guiding and integrating the therapeutic process.
Safety is a primary concern, of course, when adolescents act out-of- control, behave in a violent manner toward family members, or put themselves in serious danger. Family therapists have developed strategies that may spare the family and the teenager the stigma of psychiatric hospitalization.
For most kids who are found to be abusing drugs the peer context has to be considered in any treatment intervention. Parents often struggle with setting limits or crossing borders, partly because a sense of entitlement is so widespread among teens and the peer culture is a powerful influence. Guidance by the family therapist and support in a group with other parents may strengthen the parents’ resolve to take decisive action. It may be the turning point of therapy when the teenager joins a positive peer group context, such as a therapeutic school away from home.
The effectiveness of family therapy in the treatment of the most traumatic family experiences such as having an adolescent diagnosed with “mental illness” (bi-polar disorder, severe depression, schizophrenia) is well established by research, provided the therapeutic approach is comprehensive enough. As family, adolescent, and therapists search to comprehend the teen’s crisis they may need to consider multiple dimensions such as early childhood trauma, genetic factors that impact the bio-physiological maturation of the adolescent, gender related differences, intergenerational family patterns and cultural legacies as well as specific stress factors in the environment of the family. A holistic approach to the family trauma of adolescent “mental illness” can replace the apparent need for long-term use of psychotropic medications.
Relationship focused treatment of adolescents that uses the family as a resource is a viable alternative to more narrowly focused individual psychotherapy or psychiatric intervention. In an intense healing process it moves the complex interaction between internal bio-physiological processes, individual experiences, and interpersonal relationships toward the adolescent’s individual and social integration, maturation and well being.