Accessing and Managing the Difficult Adolescent

Les Fleischer, MSW, CSW, Adolescent Division, Hospital for Sick Children, Toronto Diane Sacks, MD, FRCP, Adolescent Clinic, North York Hospital, Toronto

Definition
The term "difficult" is applied to all of those adolescent patients who are "hard to reach". These are the patients who often turn out to be treatment failures (treatment drop outs/chronic problems). While there is always an idiosyncratic component (that reflects the individual personality of the health care provider) that influences whom we define as difficult, it is postulated that there are certain personality constellations, behaviors and style of presentation that most health care providers would define as "difficult". Thus, adolescents who are defined as difficult may present as: angry, hostile, silent, unmotivated, non-psychologically minded, limited, narcissistic, minimizing, blaming, denying, and acting out.

Self-awareness (Countertransference)
The difficult adolescent often evokes a powerful emotional response in the clinician, which can lead to dysfunctional clinician-patient interaction. Health-care provider responses may include withdrawal, passivity, or counterattack. We often feel frustrated, angry, or helpless when working with a "difficult" adolescent. It is essential that health care providers remain in (conscious) control of their behavior, so that their response continues to be therapeutic. Self-awareness and self-observation are critical in order to avoid behaving in a non-therapeutic and helping manner.

Assessment
Developmental Stage

Adolescence is a period in which there is typically conflict around dependency. Adolescents struggle with separation/independence and a task of adolescence is to establish one's own identity. Consequently, most adolescents are ambivalent about treatment. The prospect of receiving help from an adult is often experienced as inviting, and at the same time, frightening. While adolescents strive for independence, they may also look for childhood d ependency. Yet to be dependent is frightening because they fear returning to the child-like state. At the same time, independence, although inviting, evokes anxiety, because it is very frightening to face the pressures of the adult world. Subsequently, all of these conflicts are typically projected on to the therapist who may be experienced as a welcome but frightening figure. Authority (Transference) If the adolescent has had positive relationship with authority figures, he is more likely to view the health care provider as helpful, or as a supportive, somewhat benign figure. If

the adolescent comes from a background of family dysfunction, abuse, or instability, the health care provider may be approached with mistrust or fear. It is anticipated that the adolescent will transfer these conflicts on to the professional. By obtaining information about the adolescent's relationship history with family and authority figures, we are better equipped to anticipate obstacles to the initiation of helping process and potential treatment ruptures.
Manifest/Latent Functions

An old axiom says, the more belligerent, hostile, or bizarre, the external presentation, the more frightened, vulnerable, and helpless the adolescent feels. The manifest behavior usually is obvious and clear. The difficulty is in understanding and ultimately getting to the adolescent's underlying or latent issue (feelings, conflicts, etc.). It is often useful for clinicians to consider how is the underlying anxiety manifested and what is it about?

Treatment Planning
A treatment plan enables to respond more effectively to difficult adolescents. An important question to consider is: given what I know about this adolescent, what are the expected obstacles/difficulties which are likely to occur, and how can I intervene in a way that is more likely to engage the adolescent in treatment? The key to any successful helping process is the development of the relationship. We can only begin to get at the underlying issues and work on problem-solving in the context of a relationship. It is often difficult to engage the difficult adolescent in an helping process and the task of developing an alliance is critical. Ideally, it is hoped that the adolescent will become a partner in the process, so that we have not one, but two people who are interested in charge. When working with the "difficult" adolescent, it is helpful to remember that adolescents are hungry for positive relationships with adults

Techniques/Approach (How to Reach the "Hard to Reach" Adolescent)

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Be open about previous information and contacts and any limits to confidentiality Address the resistance/ambivalence directly Explore emotions/affect before content Listen (to the manifest and latent message) Be empathic Validate feelings Patience Be hopeful, but realistic Develop an alliance/partnership Be curious. Encourage self-exploration/introspection Do not be dogmatic-phrase interventions or interpretations as tentative Maintain limits and boundaries Praise and support when possible Confront when needed Develop an alliance with the family, if possible

16. 17. 18. 19. 20. 21. 22. 23.

Consult & refer know your limitations Don't give up Be reliable and consistent Self-awareness Sense of humor Get special training/supervision Be authentic/genuine Anticipate therapist errors and use them productively.

References
Barish, J. (1940). Engaging the adolescent in Psychotherapy. Adolescent Psychiatry, v.1, 530-536. Giovachinni, P. (1974). The difficult adolescent patient: Countertransference problems. In S. Feinstein and P. Giovachinni (Eds.) Adolescent Psychiatry, v.12 (pp.320-28). Chicago: University of Chicago Press. Katz, P. (1990). The first few minutes: The engagement of the difficult adolescent. In Feinstein, S.C. (Ed.) Adolescent Psychiatry, v.17, (pp. 69-81). Chicago: University of Chicago Press. Mishne, J. (1996). Therapeutic challenges in clinical work with adolescents. Clinical Social Work Journal. 24(2), 137-152. Uribe, V. (1988). Short-term psychotherapy for adolescents: Management of initial resistance. Journal of the American Academy of Psychoanalysis. 107-116.