Here's the handout from my workshop at Counselor Camp 2001. I'm presenting a very similar workshop (it even has the same title!) in November at the Association for Experiential Education's 2011 International Conference. That workshop will focus more specifically on integrating narrative therapy and experiential education with this population.
Overcoming the Stuckness
Six Keys to Facilitating Change with Substance Abusing Teens
Presented by David Flack • Counselor Camp 2011
Teens are teens. They aren’t adults and they aren’t children. That seems obvious, right? Obvious or not, though, it is essential to remember when working with this age group. Adolescence is a discrete developmental stage that focuses on the tasks of developing identity, autonomy, intimacy, sexuality, and achievement. With substance abusing teens we often see distorted, funhouse mirror versions of these normal developmental tasks. With co-occurring teens, that mirror can be even more distorted.
It is normal for teens to question, rebel against, and ultimately reject the plans of authority figures, including the most well intentioned drug counselors. That means our clients are doing exactly what they should be doing, just in maladaptive, problematic ways. Yet, we often label them non-compliant, oppositional, or treatment resistant.
What Else Do We Know About Our Clients?
• Teens rarely enter treatment by choice. Since establishing autonomy is an important task of adolescence, when teens are mandated or pressured to attend treatment, there is a predictable conflict that frequently results in reactance.
• Substance-abusing teens typically exhibit rigid thinking habits. If we use confrontational or directive approaches, we’ll stop being allies and become adversaries. This won’t be useful for anyone!
• Most of our clients have complicating factors. 80% of substance-abusing teens have a mental health challenge; 70% have a history of trauma. If not addressed, these challenges can become insurmountable obstacles to change.
With these points in mind, I’ve developed Six Keys for facilitating change with substance-abusing teens. These Keys are a “mash up” of motivational interviewing, stages-of-change, narrative therapy, and existential psychotherapy. I think of them as the “C” in CBT — a way to assist adolescent clients in overcoming rigid thinking, getting unstuck, and moving forward.
First Key: Everyone is motivated by something.
When starting treatment, teens often deny any problems related to alcohol, marijuana, or other drugs. When this happens, many helpers quickly label them as resistant. This can be a self-fulfilling prophecy. In other words, if you expect resistance then you’ll probably get it.
When given an opportunity, even the most reluctant clients are likely to identify something that motivates them to engage in treatment — often legal, school, or family problems. These may not be the motivators we want for our clients, but change requires meeting clients where they’re at, not where we want them to be.
Help clients find their “hook” by using the Five R’s of Motivational Interviewing:
• Relevance. Why is change important?
• Risks. What are the risks of changing? What are the risks of not changing?
• Rewards. What will you gain from change?
• Roadblocks. What are the obstacles to change?
• Repetition. Review these at each session.
Second Key: Change requires leaving your Comfort Zone.
Our clients are stuck in seemingly endless loops of maladaptive behaviors. Our task is to assist them in getting unstuck, not behave better, fulfill external mandates, or stop using. Hopefully those things happen, but they’re side effects of getting unstuck. When we start thinking about our task this way, we’re better able to help clients discover how to leave their Comfort Zones.
In the Zone
• Comfort Zone. Most people spend most of their time in their Comfort Zone, where risks and challenges are minimal, but so is change or learning.
• Challenge Zone. When you leave your Comfort Zone, you enter your Challenge Zone. This is where learning and change occurs.
• Crisis Zone. In the Crisis Zone, stress is too high for effective learning.
Risking Change
Leaving your Comfort Zone is risky. However, it is necessary if change is going to occur. Three ways to assist clients in taking this risk are:
• Acknowledge the risk. Increased awareness is one of the first steps to changing any behavior. Spend time talking with clients about the risks involved in change and ways to move forward anyway.
• Explore good risks vs. bad risks. Their behavior might suggest otherwise, but most substance-abusing teens are risk adverse. Bad risks have become commonplace in their lives, but they actively avoid taking good ones.
• Provide opportunities to practice safe risk taking. I’ve had clients try belly dancing, glass blowing, rock climbing, snowshoeing, and more. Adventure outings and other experiential activities also provide ways to practice risk taking.
Super-stuck Teens
This is a term I use for those clients who are simply unwilling to leave their Comfort Zone. For these teens, The Known — no matter how bad — is inherently better than The Unknown. Super-stuck teens are overwhelmed by existential anxiety. This can be defined as stress or anxiety rooted in our awareness of personal freedom and the responsibilities that accompany choices.
Teens with chaotic histories, unstable environments, and past traumas are most likely to become super-stuck. Super-stuckness can also occur with “timid” teens, clients who have poor self-esteem, and youth with traits of anxiety or depression, even if sub-clinical.
In my experience, super-stuck teens will likely spend a longer-than-usual time in the Contemplation and Preparation Stages of Change (see Third Key). They require extra patience, increased empathy, and counselors focused on relationships over compliance.
Third Key: Change is a process, not an event.
Even when it seems that change was instantaneous, we’re really seeing the end result of a process. The Stages of Change is a transtheoretical model that identifies five steps:
• Pre-contemplation. I don’t have a problem.
• Contemplation. Maybe I have a problem.
• Preparation. I have a problem and am thinking about what to do.
• Action. I’m doing something about my problem
• Maintenance. My new behavior has become habit.
It is important to remember that movement through these stages isn’t always linear. The most obvious example of this is Recycling (or Relapsing). When attempting any kind of change, relapse into old behaviors can be a necessary part of the process and a valuable teachable moment.
When relapse happens, we tend to blame a lack of skills, situational factors, or client unwillingness. These may be the extenuating circumstances, but I propose that relapse happens because we push our clients into Action too quickly. Recovery isn’t a race! We need to set our abstinence agendas aside and give our clients the time they need to move through all the Stages of Change.
Fourth Key: Expect ambivalence.
Ambivalence can be defined as simultaneously believing two seemingly contradictory ideas. In the case of substance-abusing teens: I want to fix my problem and I want to keep using. As we know, teens typically enter treatment because of legal, school, and family pressures, but don’t think they have a problem with alcohol, marijuana, or other drugs. Is it any surprise they’re ambivalent?
Helping clients resolve their ambivalence requires exploring both the pros and cons of using. However, drug counselors often focus solely on the problems. Our clients know they have a problem. They don’t need us telling them over and over. If anything, doing so may be invalidating and reaffirm their apparent inability to make change.
Resolving Ambivalence
As we know, substance-abusing teens have rigid thinking habits. These habits reinforce their ambivalence by keeping them stuck in extreme thinking. Resolving ambivalence requires them to think beyond the extremes. In addition to exploring the pros and cons of using, some strategies for helping with this are:
• Engage clients in activities and discussion on balance, the Middle Path, and similar concepts.
• Explore all-or-nothing thinking.
• Whenever possible, use continuums, spectrums, and scaling questions.
• Assist clients to develop critical thinking and mindfulness skills.
Fifth Key: Changed lives require changed stories.
The stories we tell about ourselves and our experiences define how we act, think, and feel. They determine how we make sense of our past, present, and future, how we interpret the information of our lives, and how we interact with the world.
Substance-abusing teens have lives filled with problem-saturated stories. These tales of stuckness, maladaptive behavior, and treatment failures have become the defining stories for their lives. These stories are constrictive, leaving our clients trapped in an ever-shrinking Comfort Zone, with fewer and fewer options. As helpers, we need to provide opportunities to create new, more hopeful stories.
Externalizing the Problem
• Instead of having a problem or being a problem, assist clients to view problems as existing outside themselves.
• Externalizing the problem removes pressures rooted in blame, shame, and defensiveness.
• We can take this even further by encouraging clients to think of their problems as characters in their stories.
• You can assist clients to externalize their ambivalence by presenting the idea of both an Addictive Voice and a Rational Voice.
Seek Exceptions
• Clients build and sustain problem-saturated narratives by ignoring times when The Problem wasn’t in control.
• Seeking exceptions involves assisting clients to identify those ignored times.
• Explore these exceptions in great detail. Much can be learned from them.
• Identifying exceptions assists clients to discover the skills they already possess but have been ignoring because The Problem was in control.
Re-authoring
• Once exceptions have been identified, clients can start re-authoring their problem-saturated stories.
• Re-authoring involves giving clients the opportunity to create new, more empowering stories.
• Anything that involves clients successfully leaving their Comfort Zone and experiencing exceptions to their problem-saturated narratives can provide useful material for these new stories.
Sixth Key: Maintain a playful approach.
I conceptualize the challenges faced by some adolescent clients as developmental debt. Various developmental theories exist, but most have some things in common. For example, most include stages of development that are linked to age ranges. Also, most include a task that needs to be accomplished in order to move to the next stage.
Traditional perspectives on development suggest that if a task isn’t successfully completed, then the person becomes stuck at that stage. While that may have been accurate when these developmental models were created, it seems to me this is no longer true. Instead, sociocultural and biological factors keep pushing individuals forward, even if developmental tasks are unresolved or only partially completed.
With every push forward, these individuals become less likely to successfully complete the next stage, resulting in an ever-growing developmental debt. Think of it like a credit card that never gets fully paid off. Not only will you always have a balance due, but you’ll also get further and further behind each month.
Maintaining a playful approach is one way to meet our “in debt” clients where they’re at both emotionally and cognitively. Also, play and playfulness creates an environment that allows these teens to start paying off some of that debt. In other words, a playful approach provides opportunities for our clients to go backwards in order to catch up.
Activities from the Workshop
The following activities and exercises were part of the workshop: Chiji Mingle, Endless Loop, Chiji Zones, Mega Jenga, Gutter Ball, Brainstorm Posters (The Good, the Bad, and the Ugly), and Whack 'Em.
Further Reading
• The Art of Changing the Brain, by James Zull
• Changing for Good, by James Prochaska, John Norcross & Carlo DiClemente
• Elusive Alliance, edited by David Castro-Blanco & Marc Karver
• Interviewing for Solutions, by Peter de Jong & Insoo Kim Berg
• Motivational Interviewing, by William Miller & Stephen Rollnick
• Motivational Interviewing with Adolescents & Young Adults, by Sylvie Naar-King & Mariann Suarez
• Pathways to Change, by Matthew Selekman
• The Primal Teen, by Barbara Strauch
• Real Boys, by William Pollack
• Reviving Ophelia, by Mary Pipher
• What is Narrative Therapy?, by Alice Miller
Showing posts with label adolescent development. Show all posts
Showing posts with label adolescent development. Show all posts
Monday, September 19, 2011
Saturday, February 21, 2009
Riskier Risks
I’ve recently re-read The Primal Teen, by Barbara Strauch, to help me prepare for an upcoming workshop I’ll be presenting. In the book, Strauch presents findings from several studies showing that the human brain undergoes “dramatic changes around puberty and early adolescents” ( p. 15).
These changes include a thickening of the outer layer, which then thins suddenly and significantly. This thickening is thought to be the result of an “overproduction” of brain cells. Many scientists believe that during this overproduction, “the brain may be highly receptive to new information” (Strauch, p. 15).
While this overproduction is happening during adolescents, there is also a significant amount of synaptic pruning, explaining that sudden thinning. Strauch states that “some dendrite branches and their synapses develop and thrive simply because they’re used the most and grab the most neurochemical juice” (p. 17). On the other hand, less used or unused branches and synapses tend to get pruned.
Life experiences determine which synapses get used and which do not, thereby “impacting the brain’s essential architecture” (Strauch, p. 17). Siegel conceives of the mind as separate from the brain, stating, “The human mind emerges from the activity of the brain, whose structure and function are directly shaped by interpersonal experiences” (p. 1). He continued, “Experience can shape not only what information enters the mind, but the way in which the mind develops the ability to process that information” (p. 16).
However, while experience is shaping the brain during adolescence, “it remains more exposed, more easily wounded, perhaps much more susceptible to critical and long-lasting damage than most parents and educators or even most scientists had though” (Strauch, p. 21).
Taking Risks
It seems to me, based on my experience working with high-needs teen, that this critical time of brain development is also a time of risk-taking and impulsive behavior. In other words, while the brain is at most risk, the likelihood of risk taking is highest. Strauch states, that high impulsivity is “one of the world’s stereotypes about teenagers that just happens to be true” (p. 24). This is true, at least partly, because the frontal lobes, part of the brain that is used to resist impulses, is not yet fully developed in an adolescent’s brain (Strauch, p. 26).
So, all teens are impulsive. That’s not really news. However, this developmental appropriate impulsiveness can manifest itself in extremely different ways.
What is different between “Alex,” a seventeen year old neighbor kid who is on the soccer team, vice president of his class, and planning to attend UW next fall, and “Carl,” a seventeen year old client who has an extensive criminal record that includes auto theft and drug dealing, a history of unsuccessful chemical dependency counseling, and an alphabet soup listing of mental health diagnosis including ADHD, PTSD, and ODD?
Oh, if you saw Carl on the street, you’d think he was in his early 20s, not 17. If you talked to him, though, you’d think he was about 13. It is also important to know that when Carl was four years old, his family was living in their car when he witnessed the death by overdose of both parents. He’s spent most of his life being shuffled between group homes or on the run.
Is the differences between neighbor kid Alex and Carl a case of use-it-or-lose-it synaptic pruning? Carl’s past experiences have certainly had significant influence on his current multi-dimensional challenges, but it seems to me there must be more.
When asked, Carl describes his past risky behaviors—from stealing cars to having unprotected sex—by stating that such behavior “gives me a rush you just can’t believe.” Strauch cites several studies that suggest risk-taking in teens is developmentally necessary, a way to test boundaries and explore autonomy. In addition, adolescent risk taking involves “complex interactions across several brain systems of motivation and reward, including those that involve the neurotransmitter dopamine—one of the key brain chemicals that carry and influence the messages between nerve cells” (Dahl, qtd in Strauch, p. 92). However, not all teens steal cars, deal drugs, become meth addicts, and end up as my clients—even when they have pasts similar to Carl’s.
Could the answer be that Carl has an imbalance in dopamine that compels him to take riskier risks? Could the answer be that having physically matured earlier than his peers he has a particular vulnerability because his brain is “an engine without a driver” (Dahl, qtd in Strauch, p. 96). The answer to these questions would seemingly suggest very different treatment strategies.
If Carl has a chemical imbalance, medication would probably be an appropriate treatment approach. If he simply needs to mentally catch up with his physical development, perhaps he simply needs to be kept safe until this happens. That might suggest he needs a more structured environment, as his current home environment is clearly not preventing him from engaging in risky, even life-threatening, behavior. Or, maybe he just needs better choices of risky behavior. Could activities such as hang gliding, snow boarding, mountain climbing, and auto racing “cure” Carl?
Riskier Risks
All teens do not become chemically dependent car thieves. However, it does seem to me that, in general adolescents today take riskier risks than in the past. I hypothesize that there are three inter-related reasons for this. First, adolescence starts earlier than ever before, with the onset of puberty at eleven or twelve in many cases. That means youth are younger when physical development begins and their drive for autonomy surfaces. However, the onset of cognitive development, especially problem solving abilities, has remained consistent. This leads to physical maturity without cognitive maturity. I have certainly witnessed this with Carl and other clients.
Second, adolescence ends later, both physically and culturally, generally not ending until the early 20s (or even later). Combined, these factors have led to a significantly longer period of time spent within The Danger Gap, that space where physical development has raced significantly ahead of cognitive development.
Finally, there's the third reason: risks lurking within that Danger Gap are riskier today than ever before. A few examples: the THC levels in marijuana are now as high as 25-30%, making it more addictive than in the past; other substances of abuse, such as meth and crack, are highly addictive and readily available; youth are less supervised then ever before, and this lack of supervision starts at an earlier age.
Siegel wrote, “Experience, gene expression, mental activity, behavior, and continued interactions with the environment are tightly linked in a transactional set of processes” (p. 19). These processes that begin at birth continue into adolescence and beyond. Perhaps it is these early experiences that influence how a teen will respond to the ever-growing Danger Gap. Perhaps for Carl, his early life experiences have created synaptic connections that compel him to engage in the highest risk behaviors available to him.
If this were the answer, it would seem a combination of treatment strategies is most appropriate. In other words, keep him out of danger while he continues to cognitively develop, encourage participation in “appropriate” risky behavior, but also expose him to experiences that allow new, more adaptive synaptic connections to be nurtured.
Works Cited
Siegel, D. (1999). Developing Mind, The. New York: Guilford Press.
Strauch, B. (2003). Primal Teen, The. New york: Anchor Books.
These changes include a thickening of the outer layer, which then thins suddenly and significantly. This thickening is thought to be the result of an “overproduction” of brain cells. Many scientists believe that during this overproduction, “the brain may be highly receptive to new information” (Strauch, p. 15).
While this overproduction is happening during adolescents, there is also a significant amount of synaptic pruning, explaining that sudden thinning. Strauch states that “some dendrite branches and their synapses develop and thrive simply because they’re used the most and grab the most neurochemical juice” (p. 17). On the other hand, less used or unused branches and synapses tend to get pruned.
Life experiences determine which synapses get used and which do not, thereby “impacting the brain’s essential architecture” (Strauch, p. 17). Siegel conceives of the mind as separate from the brain, stating, “The human mind emerges from the activity of the brain, whose structure and function are directly shaped by interpersonal experiences” (p. 1). He continued, “Experience can shape not only what information enters the mind, but the way in which the mind develops the ability to process that information” (p. 16).
However, while experience is shaping the brain during adolescence, “it remains more exposed, more easily wounded, perhaps much more susceptible to critical and long-lasting damage than most parents and educators or even most scientists had though” (Strauch, p. 21).
Taking Risks
It seems to me, based on my experience working with high-needs teen, that this critical time of brain development is also a time of risk-taking and impulsive behavior. In other words, while the brain is at most risk, the likelihood of risk taking is highest. Strauch states, that high impulsivity is “one of the world’s stereotypes about teenagers that just happens to be true” (p. 24). This is true, at least partly, because the frontal lobes, part of the brain that is used to resist impulses, is not yet fully developed in an adolescent’s brain (Strauch, p. 26).
So, all teens are impulsive. That’s not really news. However, this developmental appropriate impulsiveness can manifest itself in extremely different ways.
What is different between “Alex,” a seventeen year old neighbor kid who is on the soccer team, vice president of his class, and planning to attend UW next fall, and “Carl,” a seventeen year old client who has an extensive criminal record that includes auto theft and drug dealing, a history of unsuccessful chemical dependency counseling, and an alphabet soup listing of mental health diagnosis including ADHD, PTSD, and ODD?
Oh, if you saw Carl on the street, you’d think he was in his early 20s, not 17. If you talked to him, though, you’d think he was about 13. It is also important to know that when Carl was four years old, his family was living in their car when he witnessed the death by overdose of both parents. He’s spent most of his life being shuffled between group homes or on the run.
Is the differences between neighbor kid Alex and Carl a case of use-it-or-lose-it synaptic pruning? Carl’s past experiences have certainly had significant influence on his current multi-dimensional challenges, but it seems to me there must be more.
When asked, Carl describes his past risky behaviors—from stealing cars to having unprotected sex—by stating that such behavior “gives me a rush you just can’t believe.” Strauch cites several studies that suggest risk-taking in teens is developmentally necessary, a way to test boundaries and explore autonomy. In addition, adolescent risk taking involves “complex interactions across several brain systems of motivation and reward, including those that involve the neurotransmitter dopamine—one of the key brain chemicals that carry and influence the messages between nerve cells” (Dahl, qtd in Strauch, p. 92). However, not all teens steal cars, deal drugs, become meth addicts, and end up as my clients—even when they have pasts similar to Carl’s.
Could the answer be that Carl has an imbalance in dopamine that compels him to take riskier risks? Could the answer be that having physically matured earlier than his peers he has a particular vulnerability because his brain is “an engine without a driver” (Dahl, qtd in Strauch, p. 96). The answer to these questions would seemingly suggest very different treatment strategies.
If Carl has a chemical imbalance, medication would probably be an appropriate treatment approach. If he simply needs to mentally catch up with his physical development, perhaps he simply needs to be kept safe until this happens. That might suggest he needs a more structured environment, as his current home environment is clearly not preventing him from engaging in risky, even life-threatening, behavior. Or, maybe he just needs better choices of risky behavior. Could activities such as hang gliding, snow boarding, mountain climbing, and auto racing “cure” Carl?
Riskier Risks
All teens do not become chemically dependent car thieves. However, it does seem to me that, in general adolescents today take riskier risks than in the past. I hypothesize that there are three inter-related reasons for this. First, adolescence starts earlier than ever before, with the onset of puberty at eleven or twelve in many cases. That means youth are younger when physical development begins and their drive for autonomy surfaces. However, the onset of cognitive development, especially problem solving abilities, has remained consistent. This leads to physical maturity without cognitive maturity. I have certainly witnessed this with Carl and other clients.
Second, adolescence ends later, both physically and culturally, generally not ending until the early 20s (or even later). Combined, these factors have led to a significantly longer period of time spent within The Danger Gap, that space where physical development has raced significantly ahead of cognitive development.
Finally, there's the third reason: risks lurking within that Danger Gap are riskier today than ever before. A few examples: the THC levels in marijuana are now as high as 25-30%, making it more addictive than in the past; other substances of abuse, such as meth and crack, are highly addictive and readily available; youth are less supervised then ever before, and this lack of supervision starts at an earlier age.
Siegel wrote, “Experience, gene expression, mental activity, behavior, and continued interactions with the environment are tightly linked in a transactional set of processes” (p. 19). These processes that begin at birth continue into adolescence and beyond. Perhaps it is these early experiences that influence how a teen will respond to the ever-growing Danger Gap. Perhaps for Carl, his early life experiences have created synaptic connections that compel him to engage in the highest risk behaviors available to him.
If this were the answer, it would seem a combination of treatment strategies is most appropriate. In other words, keep him out of danger while he continues to cognitively develop, encourage participation in “appropriate” risky behavior, but also expose him to experiences that allow new, more adaptive synaptic connections to be nurtured.
Works Cited
Siegel, D. (1999). Developing Mind, The. New York: Guilford Press.
Strauch, B. (2003). Primal Teen, The. New york: Anchor Books.
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