|AWARD PAPER: BALINT AWARD PAPER
|Year : 2018 | Volume
| Issue : 1 | Page : 11-15
Concerned parents, belligerent adolescent: Providing support to distressed parents
Department of Psychiatry and NDDTC, All India Institute of Medical Sciences, New Delhi, India
|Date of Web Publication||29-Mar-2018|
Dr. Siddharth Sarkar
Department of Psychiatry and NDDTC, All India Institute of Medical Sciences, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
Societal changes have brought about transformation in the family dynamics in India. The youth of today is exposed to a wide variety of influences, and their tendency toward experimentation makes them vulnerable to get into unpleasant situations. Adding to that, issues related to use and abuse of substances sometimes bring them into contact with mental health professionals. Parents come with high expectations that the treatment provider would provide “treatment” that would miraculously mend the ways of the belligerent adolescent. The treatment provider may find himself or herself sandwiched between a poorly motivated, somewhat deviant adolescent and concerned parents who press for a lasting solution. The progression of therapeutic encounters presents certain challenges to the mental health professional. In this case discussion, I would like to present few issues and challenges and put forth some reflections about an adolescent with substance use and behavioral problems brought by family members. Over time, the stance of the therapist changed from attempting to “reform” the adolescent to providing support to the distressed parents. At the same time, the potential ways of dealing with such a situation are explored further.
Keywords: Adolescent, personality disorder, substance use disorder
|How to cite this article:|
Sarkar S. Concerned parents, belligerent adolescent: Providing support to distressed parents. Indian J Soc Psychiatry 2018;34:11-5
|How to cite this URL:|
Sarkar S. Concerned parents, belligerent adolescent: Providing support to distressed parents. Indian J Soc Psychiatry [serial online] 2018 [cited 2018 Jun 22];34:11-5. Available from: http://www.indjsp.org/text.asp?2018/34/1/11/228783
| Introduction|| |
Adolescence is the period of an individual's development which is fraught with experimentation and handling uncertainties., The individual grows not only chronologically and physically but also psychologically and in experience. Adolescence can be a tumultuous period as the youth exhibits some degrees of belligerence in the process of establishment of their identity and individuality. Transitioning Indian society with greater emphasis on individualism and gradual dissipation of authority structures provides another contextual dimension in which assertion of adolescent individuality manifests.
However, in some circumstances, the behaviors exhibited by the adolescent can be quite distressing to the parents. Experimentation with psychoactive substances does occur in adolescence, and sometimes such experimentation progresses to the development of substance use disorder. Furthermore, many adolescents exhibit an exaggeration of assertion of their independence. This challenges the authority of the parents. Moreover, when the adolescent engages with deviant peers, does not follow a career objective or vocation, has poor compliance to family rules, and exhibits erratic affective and impulse control, the concerns of the exasperated parents become substantial. With growing awareness about mental health issues, acceptance of treatment for mental health problems, and expansion of mental health services, parents consider taking help of mental health professionals as a viable option for getting their adolescent children “treated” for deviant behaviors by the mental health-care team. However, the expectation of the parents is high (justifiably so), putting the mental health professional at a difficult prospect. Here, I discuss the case of an adolescent and deliberate upon the patient–physician–caregiver dynamics in this context.
| The Case|| |
Mr. A, an adolescent male, was brought by his family members with concerns of cannabis abuse and exhibiting odd and possibly psychotic behavior. The referral was precipitated by a fight at home where he apparently injured a family member and spoke irrelevantly afterward. The adolescent came into the consulting room and sat down. He was disinterested in the interview and appeared a little disheveled. He talked very coherently, told about his use of substances which included regular tobacco use, regular cannabis use in the past (which now had stopped), and occasional alcohol use. Previously, he had also experimented with hallucinogens. There was a history of a brief psychotic episode a couple of years back, which was managed in an inpatient setting with antipsychotics. However, the patient did not demonstrate features of psychosis on the initial examination. The patient complained that his parents were not making efforts to understand him, and they were stifling him. The parents complained that he did not follow any schedule, had dropped out of college studies, was argumentative, abused substances and created ruckus at home, did not take care of his grooming and dressed odd, listened to some strange music, and had peers who were a bad influence. The parents wanted him to become a “better person,” and they expressed their anguish that over time, the behavior of their adolescent child had been deteriorating. They wanted some treatment which would eliminate the problematic aggressive behaviors, deter him from substances of abuse, make him a better person, and bring back the atmosphere of peace and tranquility at home.
The parents further narrated that the problems had worsened gradually over the past few years. They had consulted several doctors and complied with their treatment but with short-lasting benefits. No one had provided satisfactory results, as the patient had gone back to his erratic behaviors in some time, with or without treatment. The longest time period of being “well” was when the father took the initiative to monitor and control his behaviors and a guard was hired to keep him in check at home. Several alternate and complementary treatments were also tried as the parents did not want any stone to remain unturned. The successes with such interventions too were limited. Yet, the parents were determined to bring about a positive change in his life and sought consultation.
The patient was coherent, though appeared disinterested in seeking any help or changing his way of life. He did not think that there was any problem with him. He reluctantly agreed to forsake the use of cannabis for now (though not leave it forever), failing which admission might be considered for him. He also said that the parents needed counseling and not him. Behavioral contracting was attempted with him, to which the patient agreed. It was decided that a threat to self, threat to other family members, or use of illicit substances would necessitate inpatient treatment. Family members were encouraged to consider using positive reinforcements contingent on good behaviors. They were reluctant, yet considered it as an option. They were quite keen on restricting the interaction with deviant peers and wanted the patient to follow the discipline of the family to the rulebook. They wanted treatment providers to ensure that. I had fingers crossed, as aggressive behaviors in the familial context arising out of interpersonal conflicts seldom resolve completely.
| The Initial Euphoria, Short-Lasting Though|| |
The parents went out with hope for the adolescent and came back after a couple of weeks. Although overall things were in order, on one occasion, the patient had become aggressive toward the family members. They allowed a cooling period, and he was apologetic for his uncalled behavior. The patient did report that he had anger issues and he needed to control his anger. At the same time, he wanted provocation from the family to be limited. Options were explored about how he could control his anger. Plans about his career and vocation were enquired about, though the patient did not offer any concrete ideas.
A couple of weeks later, the patient was brought by family members in a somber mood. He did not want to talk. He had been violent toward the family on a trivial issue. He declared that he did not want any treatment and that the family members should mind their manners. Since he had breached his therapeutic contract and family members felt threatened by him, they had planned to send him to a “rehab” center. They arranged for admission of the patient and got him admitted there. The family members went to meet the patient at this center, where he expressed regret for his behavior and asked family members to take him home. They agreed and he came home.
After coming home, he was better for a few days and followed through what his family members requested of him. He was in control of his anger and took care of his grooming. Family members attempted to engage in constructive pastime and nudged him toward music as he was interested in it. However, again his behavior started to gradually deteriorate, and he would get easily angered when family members would restrict him going out, monitor what he did with internet access, and asked him to wake up on time and bathe. After a few days, the patient again got aggressive and neighbors had to be called to resolve the issue. One of the family members got injured after being hit by the patient. The patient was brought back again.
| A Recurring Issue|| |
Over the course of the first couple of months, certain themes became clear. There was quite a discrepancy between what the family members wanted and what the adolescent had to offer. The adolescent felt stifled as he felt parents were monitoring and controlling him, while the parents feared that something worse might happen if the adolescent was let loose. They had realized this through previous bad experience with him when he had run away from the home. In addition, parents were quite disapproving of patient's lifestyle and wanted it to change. The parents wanted some stable solution about “constructing” his life and were seeking help from several quarters. The adolescent was poorly motivated to pursue a career or quit cannabis and seemingly deferred the use of substances under coercion. He was not willing to engage in dialog.
With the aim of re-clarification of the diagnosis and formulating a concrete plan of management, a detailed workup was done. A diagnosis of personality disorder (mixed type) with substance use disorder was entertained. The patient found the other therapist who assessed him as relatable and opened up during the interview. A therapeutic working relationship was established between the adolescent and the other therapists. Hence, it was discussed that further sessions could be planned, in which I would cater to the parents and the other therapists would take sessions with the adolescent. A brief admission for direct observation of behaviors and to tide over unmanageability at home was planned but could not be executed. A formal psychological assessment was planned, though it could not be done as the patient outrightly refused. The patient did follow up for a few times with other therapists at the center, while the family members followed up with me. The family members were getting distressed that things were not progressing as anticipated and sporadic instances of violence occurred at home when the patient's behaviors were curtailed. They were concerned that nothing was working for his craving and he demanded cigarettes (a few were given under supervision), and he did think about cannabis. Furthermore, nothing specific was materializing, and he did not have a specific plan for his life. The father was clear that discipline was needed to be inculcated by whatever means necessary, while the mother wanted the therapist to be more active in taking up the challenge of reforming the adolescent.
| The Distressed Parents|| |
Given the situation, my thoughts meandered about discussing the options with the parents. Making it clear that we do not have a silver bullet to take care of craving or change the personality per se, I thought about supporting the parents in exploring the options and deciding for a further long-term course of action. Among the options were (1) leaving the adolescent to his fate and not being bothered about him, (2) confining him in custodial center for a long period of time to mitigate the threat of violence, or (3) keeping him under strict supervision and on a tight leash at home. The family members' expectations were not met and they were not committal about any of these options. They wanted some other better options to be provided which would take care of the problem. Being concerned, they explored other options of help as available and did get some albeit temporary respite to the behavioral problems. Yet, they continued to remain in contact with me, followed up roughly on schedule of 2 weeks to a month, and reported sporadic instances of violence at home and overall no improvement in craving or the life situation.
The break in parents' patience came when the adolescent ran away from home without informing anyone. They asked for guidance. I suggested to keep on looking. He was subsequently found at a friend's place and he admitted to have used cannabis. He was brought by family members, and he offered an apology to them after coming back. The family members were distressed about such an event and apprehended that the adolescent could potentially have been entangled in legal complications. After coming back, no significant problems ensued. However, the family members thought of engaging in some kinds of constructive vocation. Yet, the adolescent did not show any active interest, and he primarily stayed at home. Subsequently, he again ran from home, and family members became concerned again. He was subsequently admitted in a custodial facility by family members. Yet, family members kept me informed about what was going on with him there and urged me find a solution.
| Can We Do Anything?|| |
The case brought forward some vulnerabilities faced by me, the therapist. We are happy to treat patients who need help and express a desire for getting such help. We are happy to cater to the needs of patients who seek our help. We also take initiative in treating individuals who have impaired mental faculties due to psychosis, affective disorder, or organic illnesses. However, forcibly treating individuals with substance use disorders and personality issues is something that does not evoke keenness on our (at least my) part. Yet, in the therapeutic setting, the expectations of the distressed and concerned family members impel us to consider doing something in such cases. Theoretically, we could have offered some other options such as multisystemic therapy or multidimensional family therapy. However, these need services to be developed accordingly and therapy to be delivered in a structured manner. I wondered whether the therapy should better be as case management approach with home visits to intervene in the patients' living situation. I took refuge in statutes of employment which did not mandate going to patients' home for treatment. Furthermore, dealing with the situation, I felt a sense of therapeutic nihilism, about whether anything worthwhile can be done. Here was a patient who was not willing to take charge of his life. How much was I supposed to make better choices and implement them, especially when he was not willing to engage? For substances as well, motivation enhancement works, but whether it was warranted for someone coerced to not take substances, and it does not work in everyone and anyone. I felt incapacitated to provide concrete help to him, and consequently the family.
In this case, I felt snared between the expectations of the parents and unwillingness of the adolescent to change. Bringing the expectations of the parents to a realistic level would be the target, but how to put it across. Telling the parents that we can offer only a little was not what they were willing to take home. They developed a degree of trust and had some hope. Based on theoretical knowledge, personality problems do not change very easily. However, at the same time, they might resolve over time as well. So conveying a total gloomy picture for the future was avoided, though it was conveyed that things would take efforts from the adolescent as well as to change. The good thing was parents kept on coming despite the ups and downs. They shared their concerns, lamented about the situation, and expressed hope about the future. Lending a patient ear and being supportive about their concerns probably made the parents keep coming back and being in touch. Seemingly, this time was the longest that they continued with a team/mental health professional at a place.
| Countertransference?|| |
In hindsight, I guess countertransference did occur from my (therapists') perspective. The belligerent adolescent evoked negative countertransference. He avoided me, and I avoided him in subtle ways. When he was not willing to talk, I talked to the parents. I was happy when another therapist developed a rapport with him, possibly reveling the fact that I do not have to deal with him. I took cover of the books and literature in concluding that this is a “difficult” case and the outcome might not be optimal. But what was the genesis of this reaction? Was the nihilism a manifestation of anger turned inward?. Whether it was the anger that the adolescent did not pay his reverence to therapist as the authority figure, inflicting a narcissistic injury? This could not be vented out to the adolescent or displaced on others. Hence, the anger from such an injury could not be dissipated and possibly manifested as nihilism. I was not enthusiastic to deal with him and did not offer an explicitly optimistic view that things would be better.
The parents in the process evoked mixed feelings. I had made several concessions for them. I gave them my personal phone number. I would spend a substantial time in the busy outpatient, to attempt to clarify all their doubts and make them feel attended to, before the conclusion of the session. I saw them out of turn and facilitated them being seen quickly even when they arrived late for the clinic. From an unconscious level, probably I was treating them like authority figures. I could not be very directive, possibly paying veneration to them. Neither could I set limits onto them. Why did they evoke such feelings? Probably, they asserted themselves as authority figures and clearly conveyed their challenging expectations.
Were these feeling counterproductive? I am not sure. Realizations of the feelings toward the adolescent and the parents did not change approach toward them, or so I would like to believe. Was it some kind of resistance on my part to delve deeper and analyze? Possibly so. However, special consideration for the parents did keep them in the loop of treatment (possibly a rationalization) and provided some hope. Gradually, I have been able to nudge them toward the insight that the situation may not dramatically improve. Yet, they find it difficult to reconcile with such a view that limited success can be gained for their problems despite showing in a medical–psychiatric facility and following through the doctors' orders. Their plea and anger remain toward the medical fraternity for not providing a robust treatment option for their dear child.
| What Could Have Been Done Better?|| |
Hindsight is often a good teacher as we learn from our experiences. Some cases would be challenging. Sometimes, we would not be able to achieve the results desired from us. Sometimes, forcing treatment to an unwilling individual might be construed as colluding with an outsider, being an agent of the powerful. Sometimes, a measured offer of hope can sustain family members' efforts. What could have been done better in the present case would be a matter of speculation. However, appending to hindsight, these speculations may carry definitive probabilities.
Should the boundary crossings, in the form of accommodating for late arrival and spending more time, be avoided? Probably, recognition of such boundary crossings is important, so that they do not progress to a point where the client gets the upper hand in the therapy. Some boundary crossings are likely to occur during the treatment process. The vital issue here would be being cognizant of it, and giving it as a feedback, and analyzing it. In latter instances, I was careful of making them wait till other patients in line were tended to.
Should the patient be referred to someone else when the therapist encounters a feeling of therapeutic nihilism? Referral to another therapist would be a way out when therapist does not feel a good outcome can be provided. But would sending such patients away mean getting rid of difficult cases. Would it be ethical? Referral of cases for which expertise exists somewhere else and for which one feels particularly deficient in the ability to provide help may be justified. However, the present case had been seen and managed by several therapists in the past with inconsequential outcomes as present. Hence, probably turning the patient away to another professional might not have been particularly justified.
Would taking guidance and help from another professional colleague be the right approach? Challenging cases often incite discussion with colleagues. The original Balint group More Details (by Michael Balint and Enid Balint) was formed to discuss challenging clinical situations and get guidance on issues of therapist–patients interactions. Such groups can be immensely helpful. However, whether a case would be discussed with another colleague depends on the individual proclivities (and insecurities) of the therapist. It needs a safe space to discuss, which seem to be lacking in our setting.
Should working toward collaborative systems and getting extra expertise be the correct approach? As professionals, we are supposed to update ourselves and keep abreast of recent developments in the field. Developing additional service based on the need of the patient would have been a righteous approach. However, developing services have to be grounded in pragmatic reality of resources.
Should playing the devil's advocate for the adolescent be the right approach? The index case was the adolescent who felt stifled in the home environment. Would impressing the adolescents' need for personal space to the parents have been the right thing to do? Possibly, a therapist has the opportunity to do so. This was tried to some extent in the initial consultations, but the parents had put their foot down on such a consideration. Although there remains a distinction between personal space and using that for delinquent behavior, advocating adolescents' will to prevail could have exposed one to a slippery slope of extracting more leverage till his/her will prevails always.
Arthur Conan Doyle states that it is easy to be wise after the event, the corollary would necessitate a reflection towards the event to become wise. Having considered several alternatives and approaches as above, probably one or more of the above could have been implemented. Whether it was the correct course of action, or an opportunity lost, or nothing matters, would be subjective judgment and a matter of speculation. Yet, some solace to the parents was the silver lining that could be extracted from this case.
| Conclusion|| |
Each challenging case teaches us something new. It is important to face the challenges to enrich ourselves and to work for the greater good. The concern of parents is an important consideration in the Indian setting, even when the adolescent is emancipated. Sometimes, a thread of hope provides all the needed support to distraught parents who deal with rebellious adolescents.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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