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| Counseling Difficult-to-Reach Chemically Dependent Adolescent Males |
| Feature Articles - Treatment Strategies or Protocols | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Written by Shannon Mayeda, PhD, MSW, CRADC and Mark Sanders, LCSW, CADC | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Tuesday, 26 June 2007 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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A recent New York Times article by Charles Siebert describes an
increase of violence among young male elephants. Siebert states that
studies of elephant behavior reveal that young male elephants have been
dramatically affected by witnessing the massacre of their
communities/families, the death of a parent, the loss of elephant
elders, particularly bull male elephants, who traditionally socialize
young male elephants by modeling how to handle aggression properly.
These losses occur at the hands of poachers, who kill elephants for the
purpose of seeking greater land space and money from the sale of the
elephants’ ivory (Siebert, 2006).
Research quoted in the article states that these younger male elephants are becoming extremely violent; they destroy property (stampede villages), kill people, rape (rhinoceroses), form gangs and develop symptoms of post-traumatic stress disorder (PTSD) in response to their exposure to trauma, abandonment, and loss (Siebert, 2006). This behavior is similar to that of difficult-to-reach adolescent male substance abusers who are often hostile and resistant to counseling, refuse to change, and discontinue counseling services prematurely. This article describes risk factors specific to this population that make it hard to engage them in counseling; and outlines 11 intervention strategies to engage these young men in counseling and to help them to change. Core issues for difficult-to-reach adolescent male substance abusers. Researchers report that difficult-to-reach adolescent male substance abusers present with a number of behaviors, ranging from initiation into destructive peer groups, violence, murder, crime, delinquency, and substance use disorders (Garbarino, 1999). These adolescent males often are challenging to engage in counseling because of a number of core issues, including: Father/son pain. The majority of difficult to reach adolescent males are abandoned by their fathers. For many, this is the first early loss, leading to a great deal of anger and acting-out behavior. Some of these males are numb to their feelings as a result of their fathers’ desertion, making it difficult to open up and express themselves in counseling. It is also believed that abandonment by fathers is a major contributing factor to substance use disorders by males (Sanders, 2006; Real, 1997). Male Depression. There are three features of male depression: 1. the lack of capacity to feel 2. externalization of their pain (“I feel you’re causing me pain, so therefore I have a right to strike out against you.”) 3. feeling of inadequacy without hope – causal factors include parental practices that “rob” male children of an emotional life by discouraging them from crying, being vulnerable and expressing emotions; early abandonment, particularly by fathers; and feelings of inadequacy as a result of not meeting the expectations of their parents, male peers, and academic institutions (Real, 1997). In his book, I Don’t Want To Talk About It, Terence Real asserts, “Depression equals alcoholism in men, and alcoholism equals depression in men.” He states that it is difficult for a male to be an alcoholic without being depressed and that our methods of socializing male children contribute greatly to male depression. Real further states that it is easy for clinicians to miss depression in males, because many males who are depressed do not look depressed. He describes the many masks of male depression, including: • Anger • Rage • Violence • Substance Abuse Depressed males are difficult to reach in counseling because their emotions lie dormant beneath the masks (Real, 1997). The absence of male role models. As mentioned in the New York Times article on elephants, one of the duties of older male elephants is to socialize the younger male elephants and to help keep them in line by teaching them to negotiate the world without violence (Siebert, 2006). In human societies, elder males have historically served a similar role. In addition to modeling responsibility, they also model vulnerability and empathy. All these qualities can contribute to an effective therapeutic alliance. The great majority of difficult-to-reach adolescent males have limited contacts with positive male role models (Sanders, 2006). Other core issues include: • PTSD (a result of exposure to traumatic events) • Conduct disorder • Physical and sexual abuse • Rejection (family, school, society) (Bloomquist & Schnell, 2005; Davis, 2000) • Witnessing violence firsthand (Garbarino, 1999) • Concurrent psychiatric disorder • Early involvement in the criminal justice system Difficult-to-reach adolescent males and the criminal justice system The most “difficult-to-reach” adolescent male often winds up in the criminal justice system. The profile is as follows: males make up 92 percent of the population in the juvenile justice system (Skowyra & Cocozza, 2006); 68 percent of those males are African American/Hispanics (Strom, 2000); 94 percent have an education of 11th grade or under (Strom, 2000). They are getting younger. In 1985, 80 percent entered at the age of 17; and 18 percent at the age of 16. In 1997, 74 percent entered at the age of 17; 21 percent at the age of 26; and 5 percent at the age of 15 or under (Strom, 2000). The statistics regarding youth who meet DSM-IV-TR criteria in the juvenile justice system are staggering. Approx-imately 70 percent suffer from at least one mental disorder. Of those, 79 percent met criteria for a second mental disorder. Depending on the sample, between 58 to 75 percent of juvenile justice system youth met criteria for a substance abuse disorder (Abrams, 2003). Of the youth who meet criteria for one mental disorder, 20 percent of them experience symptoms so serious that their ability to function is severely impaired (Skowyra & Cocazza, 2006). Many of these youth have been witnesses or victims of trauma (Mahoney, Ford, Ko, & Sigfried, 2004). Many have been victims of physical and sexual abuse (National Clearinghouse on Child Abuse and Neglect, 2005). The DSM-IV-TR diagnoses that are most common among youth in the juvenile justice system are Major Depression, PTSD, ADHD, Anxiety Disorders, and addictions. These disorders interfere with reaching developmental milestones, learning, and academic achievements. There is a flagrant lack of adequate mental health services to identify and address the mental heath symptoms and substance use disorders of difficult-to-reach adolescent males. Many find other methods of coping with the negative emotional states that result from experiences of loss and frustration. Turning to alcohol and/or drugs to self-medicate emotional pain is unfortunately commonplace. Intervention strategies for difficult-to-reach adolescent male substance abusers 1. Examine your feelings about difficult-to-reach adolescent males. Many of these males have negative stigma in their families, communities and schools. It is not uncommon for counselors to have a similar negative response to these males. Being aware of, and working through these feelings, perhaps by seeing the victimization of these males (i.e., childhood trauma, abandonment, etc.), which often lies underneath their behavior, can help counselors make empathic connections (Sanders, 2006). 2. Decrease resistance in the first session by: • asking strength-based questions, as opposed to focusing only on what he has done wrong (Rudolph & Epstein, 2000), such as: What do you do well? What skills do you have that have enabled you to endure so much? What is your current or previous life suffering preparing you to do with the rest of your life? What do you like to do in your leisure time? What have you learned from what you’ve gone through? What sources of strength have you drawn from? • being non-judgmental • complementing his style of communication (i.e., being more verbal as a counselor if he is silent; being more silent as he talks) • exuding warmth — this helps to break down barriers of communication (Gladwell, 2005). 3. Move at his pace and join his resistance. When working with resistant clients, it is often helpful to allow them to control the pace and, rather than fighting fire with fire, join their resistance by allowing them to openly talk about not having a problem and needing to be in counseling (Miller & Rollnick, 2002). 4. Use approaches that have proven to be evidence-based with difficult-to-reach adolescent males. Multisystems therapy, functional family therapy, and multidimensional family therapy (Redding, 2000). 5. Provide cognitive behavioral restructuring. Cognitive behavioral therapy has been found to be an effective approach with difficult-to-reach adolescent males. This approach focuses on thinking patterns that precipitate acting-out behavior (Bloomquist & Schnell, 2005; Davis, 2000; Garbarino, 1999). 6. Provide treatment for co-occurring disorders. Research tells us that the majority of these males have a concurrent mental illness (Abrams, 2003), and that many of these youth wind up in the criminal justice system, a system that is often ill-equipped to effectively work with them (USDHHS, 2000). Integrated dual-disorders treatment is the most effective approach (CSAT, 2005). 7. Provide recovery coaches. Recovery management is a new approach to working with individuals with substance use disorders. It is an approach that involves working with clients ongoing in their natural environment where so many of these “real challenges” occur (White, Kurtz, & Sanders, 2006). This approach is ideally suited for difficult-to-reach adolescent males, because of myriad challenges they face in their natural environments while trying to stay sober simultaneously. The approach can involve pairing the youth with a recovery coach — a peer mentor, whose primary credential is not necessarily an advanced degree or certification, but it is the fact that they have “been there.” Their recovery status makes them potential lifestyle consultants (White, Kurtz, & Sanders, 2006) for difficult-to-reach adolescent male substance abusers. 8. Engage in activities that increase endurance, courage, confidence, and discipline. Distance running, chess, martial arts, and other activities have been found to be protective factors and to increase resilience (Bell, 2001). 9. Recommend constant and predictable routines. Many difficult-to-reach adolescent males have experienced a great deal of disruption in their lives resulting from abandonment, trauma, expulsions, and incarceration. It is important for some part of their lives to be predictable. Suggestions to adult caretakers to serve dinner at the same time, have a regular and consistent family outing, the same morning wake-up time, etc., can provide some consistency that is desperately needed (Garbarino, 1999). 10. Provide culturally specific services. As stated earlier, a large percentage of difficult-to-reach adolescent males, particularly those in the criminal justice system, are males of color. Utilizing counselors who are able to make cross-cultural connections with clients and their families and incorporate positive aspects of the clients’ culture into the change process, can be instrumental in engaging young men in counseling (Little, Jackson-Gilfort, Marvel, 2006). 11. Provide therapy that addresses issues of rejection and abandonment. Without this, in the long run, it may be difficult to sustain positive change in these youths without a focus on underlying causes, including issues of abandonment and rejection. In this article we have outlined strategies for working with difficult-to-reach adolescent male substance abusers. We realize that many counselors are perplexed as to how to serve them. We have, therefore, outlined a number of strategies, the idea being that if you try one thing and it doesn’t work, you try something else. If that doesn’t work, you try something else. As long as you have strategies to utilize, you’ll always have a degree of optimism, which is needed in order to help these young men turn their lives around. Shannon Mayeda, PhD, MSW, CRADC is an Assistant Professor at The University of Southern California, where she teaches mental health practice and theory courses in the Master of Social Work Program. She has 26 years of clinical experience assisting adolescents and adults with addiction, severe mental illnesses, and homelessness in the urban and multi-cultural environments of both Los Angeles and Chicago. Mark Sanders, LCSW, CADC, is an international speaker and consulting in the addictions field who has provided training and consultant throughout the United States, Europe, Canada, and the Caribbean Islands. He has had two stories published in Chicken Soup for the Recovering Soul and is co-author of Recovery Management with William White and Ernest Kurtz. References Abram, K., Teplin, L., McClelland, G., & Dulcan, M. (2003). Comorbid psychiatric disorders in youth in juvenile detention. Archives of General Psychiatry 60(11): 1097-1108. Bell, C., M.D. Cultivating resiliency in youth, Journal of Adolescent Health, 29(5), 2001. Bloomquist, M. & Schnell, S. (2005). Helping children with aggression and conduct problems, Guilford Press, N.Y., 2005. Davis, D. (2000). The aggressive adolescent. New York: Haworth Press. 8th Annual Conference on Anger/Trauma and Addiction Recovery.(2006). U.S. Journal Training, April 27-29. CD #756C16. Garbarino, James. (1999). Lost boys: Why our sons turn violent and how we can save them. The Free Press. Gladwell, M. (2005). The power of thinking without thinking. New York: Time-Warner. Gramerzy, N. (1985). Stress-resistant children: The search for protective factors. In J. E. Stevenson (Ed.), Recent research in developmental psychopathology (pp. 213-233). New York: Elsevier Science. Grisso. (2004). Double jeopardy: Adolescent offenders with mental disorders. Chicago, IL: University of Chicago Press. Little, H., Jackson-Gilfort, A., Marvel, F. (2006). An empirically supported and culturally specific engagement and intervention strategy for African- American adolescent males, American Psychological Association, 76(2), 2006, pp. 212-225. Mahoney, K. Ford, J., Ko, S., & Siegfried, C. (2004). Trauma-focused interventions for youth in the Juvenile Justice System. Los Angeles, CA: National Child Traumatic Stress Network. National Center for Mental Health and Juvenile Justice. (2005). The MacArthur Initiative on Mental Health and Juvenile Justice. Retrieved December 28, 2006 from www.ncmhjj.com. President’s New Freedom Commission on Mental Health. (2003). Real, T. (1997). I don’t want to talk about it: Overcoming the secret legacy of male depression. New York: Fireside. Redding, R. (2000). Graduated and community-based sanctions for juvenile Offenders: Juvenile Justice fact sheet. Charlottesville, CA: Institute of Law, Psychiatry & Public Policy, University of Virginia. Rudolph, S. & Epstein, M. (2000). Empowering children and families through strength-based assessment. Reclaiming Children and Youth 8(4): 207-209. Siebert, C.(2006). An elephant crackup? New York Times. October 8. Retrieved from www.nytimes.com/ 2006/10/08/magazine/08elephant.html?ei=5070&en=897ad2e969. Skowyra & Cocozza. (2006). Blueprint for change: A comprehensive model for the identification and treatment of youth with mental health needs in contact with the Juvenile Justice System. Delmar, NY: The National Center for Mental Health and Juvenile Justice Policy Research Associates, Inc. Strom, K. (2000). Profile of state prisoners under age 18, 1985-97: Bureau of Justice Statistics Special Report. U.S. Department of Justice. Office of Justice Programs. Telpin, L. Abram, K., McClelland, G., Dulcan, M., & Mericle, A. (2002). Psychiatric disorders in youth juvenile detention. Archives of General Psychiatry 59(12): 1133-1143. Wasserman, G., Ko, S. & McReynolds, L. (2004). Assessing the mental health status of youth in juvenile justice settings. Juvenile Justice Bulletin (August): 1-7. White, W., Kurtz, E., & Sanders, M. (2006) Recovery management. Chicago, IL: Great Lakes ATTC Monograph. United States Department of Health and Human Services. (2000). Report of the Surgeon General’s Conference on Children’s Mental Health: A Nation Action Agenda. Washington, DC: Department of Health and Human Services.
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