Substance Abuse Strategies for Kids with Learning Differences
Presented at Courage to Risk: The 16th Collaborative Conference for Special Education,
February 14, 2004, in Colorado Springs, CO.
by Franklin Cameron, Psy.D., LPC, CAC III
While preparing for this presentation-gathering my thoughts as well as my facts-I was also participating in a study activity with a group of Special Education teachers. Together, we were reading Mel Levine's book, A Mind at a Time, a chapter at a time; then meeting in weekly discussion groups. Dr. Levine maintains and argues by means of copious research data and individual case histories that all young learners can be helped once we identify the strengths of their minds as well as the potholes that get in the way of their success or mastery. We can cultivate minds by addressing the weaknesses and strengthening the strengths (p.15).
The point of view, attitude and treatment strategies he describes in the realm of education also have parallels in the realm of counseling. A prominent example of a strength-based therapy is Solution Focused Therapy, which focuses on moments when things went right or clients perceived themselves as functioning well. Therapeutic strategies then focus on identifying, enlarging, and creating more of those moments and the behaviors, emotions and thoughts those moments contain (de Shazer, 1985, 1988). Also, person-centered-or client-centered-therapy as formulated by Carl Rogers (1951), postulates honoring the essential rightness of each person: Gradually, my experience has forced me to conclude that the individual has within himself the capacity and the tendency, latent if not evident, to move forward toward maturity. In a suitable psychological climate this tendency is released, and becomes actual rather than potential (Rogers, 1961, p. 35).
In the realm of substance abuse counseling, treatment models-such as the Johnson Institute intervention-used to emphasize confrontation. They'd come down hard on clients for their denial and resistance, then admonish them to take responsibility for themselves and the terrible effects their addictions were having on themselves and the people who love them (Liepman, 1993). I know for a fact that people managed to get clean and sober under this regime. But a lot of people didn't: they didn't engage, or they failed to stay with the treatment. Rates of relapse tended to be high, too (Loneck, et al., 1997; cited in Connors, et al., 2001). Current research points to the greater efficacy of another model; namely, motivational intervention (Miller, 1985) and its technique, motivational interviewing (Miller, 1991): Its reliance on supportive, nonconfrontational, and collaborative interventions is designed to minimize defensiveness and resistance to change and to increase self-efficacy (Connors, Donovan & Diclemente, p. 187).
Instead of impressing externally determined mores, standards, and imperatives on clients, motivational interviewing goes to clients and attempts to bring them forward from wherever they are; then, in the context of their individual history, needs, desires, hopes and wishes, seeks to draw them into willing participation in their substance abuse treatment. In technical terms, you're reaching for what is ego-syntonic in the client: for what feels uniquely true and real to them. I can't help but pause here and point this out, because for adolescents, finding their personal way of life without making any compromises to their families, society and culture is a matter of intense concern. Many of us adults never quite resolved that issue to our liking, so when someone actually speaks to that part of us that struggles with the question of personal authenticity, it gets our attention. Something feels right, good, interesting-and honorable-about the engagement.
Levine brings A Mind at a Time to life with case histories of kids with all manner of learning differences, or neurodevelopmental dysfunctions (p. 29), who were struggling in school, at home and/or in their social lives. These kids were demoralized, defeated, underachieving and very possibly en route to sorry futures. He then shows, through what could be described as a form of motivational interviewing, they learned how to mobilize their strengths, collaborate in the remediation of their weaknesses, and ultimately self-advocate for their future education. Take the case of the nine-year-old Clark, for example. Levine says:
Clark is starting to learn about his attentional difficulties. He is beginning to recognize that these traits are not his fault, but that he definitely needs to work on them to get them into better shape. He has been studying the attention controls and talking about techniques he might use to get more in control. For example, when his teacher gives instructions, Clark whispers them back to himself so he can be sure he is listening carefully enough. He also tries to go back over all his work to check for errors and plan his tasks ahead of time. He consciously asks himself, What's the best way to do this? or is this the best thing to do now? before undertaking this activity (pp. 54-55).
What my attention went to in that anecdote was the process that brought Clark from the state of being misunderstood, unappreciated and unhappy to a place where he could actively collaborate in his remediation and subsequent empowerment. Educators know full well the kind of patience, endurance, and knowledge required to pull off a transformation like that. It's not easy, even when the kid in question cooperates.
Similarly, substance abuse treatment, even with motivational interviewing, is not an easy road. If the substance abuse has progressed to a state of dependence or addiction, what addicts discover, even when they decide they want very much to quit, is that, in their drug of choice, they have engaged a worthy opponent. Drugs are like a bad relationship. You may decide you've had enough, but the drug says back to you, Going so soon? I don't think so! Coming off drugs and alcohol is a challenge even when you want to. Now, add this to the mix: You don't want to. And I say to that, Welcome to my world. Because that describes most of my adolescent clients.
Imagine the nine-year-old Clark six years later, unremediated, still struggling with hyperactivity and attentional difficulties, estranged from his family, teachers and peers, in a swamp of low self-esteem, and possessed of a solution that makes all his problems, conflicts and bad feelings seem to go away. In addition to that, it has provided him, for the first time in his life, with an apparently loving and affirming network of friends who ask only that he partake with them of this wonderful solution. In the life of an American teenager, that solution is often marijuana and alcohol. Although alcohol remains the first drug of choice among adolescents in general (Santrock, 2004, p. 199), most of the cases that are referred to me involve marijuana abuse. I use the word referred euphemistically. Actually, it would be more accurate to say that most of my clients are dragged kicking and screaming to treatment by their families. Or, they are required to come by their schools (Clean up or stay out!), or mandated by the courts (Clean up or go to jail and begin your young adult life with a felony on your record).
Now that I've set the mood, I'd like to freeze frame the image of a 15-year old Clark being dragged kicking and screaming to treatment, and answer the question that may be forming in your minds right now: Why in the world would anyone choose to work with kids like that?
Actually, when you think about it, haven't you as teachers in the classroom often been asked the same question by your friends and acquaintances when you tell them what you do for a living? How often do you hear comments like: I wouldn't mind imparting information to young people, but I couldn't stand having to discipline them. Add that you are a high school teacher and people either shake their heads or imply that you should be a candidate for a Purple Heart.
It's my experience that anyone who works with adolescents must be adept at two things: managing them and motivating them. By managing I mean understanding that an important piece of the developmental process for we humans is that the locus of control must move from without to within. It isn't enough that a teacher has the personal power to control a classroom of kids. The kids have to learn how to control themselves: know when to let their exuberant energy out and when to pull it in.
By motivating, I mean understanding that there are tangible payoffs to being able to manage one's own energy-payoffs that transcend the issue of compliance. Centuries ago, an American Indian boy hunting deer with his father had to learn how to bear his excitement and urge to rush in order to let the deer get within the range of their arrows. In our time, parallel examples might be staying calm enough to pass your driving test, or withstand the tension and intensity of playing in the big game in high school. I remember my first intermural swim meet in the 10th grade: I got so excited-and so noncognitive-that, on the first lap, I forgot to flipturn and swam right out of the pool. How about being able to get through stage fright-opening night terrors before the senior play, or public speaking in front of your class? Or, holding your focus long enough to complete a history exam?
An 18-year-old youth I did substance abuse counseling with had a history of weak attention control and impulsivity. I'll call him Mike. During his senior exams, all he could think about was bolting and getting high. Even after he stopped getting high, having to write a 500-word paper still made him want to bolt. In the spirit of valuing his strengths, I witnessed and affirmed his truly wonderful social skills and talent for verbal communication. He loved to take an idea and fly with it in the context of a conversation. I told him about the puer aeternus: Peter Pan and Icarus who imagine and fly high, too. And that's a good thing to be able to imagine and fly high. But, sometimes, it's important to be able to ground oneself. To plant one's feet and hold one's position. When you have a paper to write, you're got to be able to fold your wings and hunker down.
Mike really took to the metaphor. He'd say about some project that was due at school: I know I've got to fold my wings and go to the library and get to work on it. He could be said to have internalized the metaphor, and was using it to manage his own energy. And that's empowerment.
As an aside, one could do an entire talk about using metaphor to teach and inspire. The beauty of metaphors is that they are preverbal. A lot of research has been put forth in the last decade about the incredible learning that takes place in the first three years of our lives. As an avid student of developmental psychology, I am most struck by how that early learning can enhance or damage strong ego development. Metaphor powerfully leap frogs the constraints of language and goes to powerful learning experiences that occurred before we had developmentally achieved language. Metaphor can therefore help us access those feelings and conflicts that are beyond words (Cashdan, p. 182). Metaphor can be used in the service of catharsis and healing. It can also be used to remediate.
Levine describes the ideal teachers as front-line experts on mind development and learning in the age group(s) they work with. They should be knowledgeable about the highly specific neurodevelopmental functions required for success in these realms and the differences in learning that teachers are likely to encounter among any cohort of students (p. 308).
In the same spirit, I hold that a substance abuse counselor working with adolescents would, ideally, have a solid understanding of the developmental tasks adolescents are trying to master. By means of that understanding, the counselor would be able to assess what tasks are being mastered and which tasks are not.
Warren was a 17 1/2 year old boy, previously diagnosed as high-functioning Aspergers, who had begun smoking pot at the start of the 11th grade. Ten days prior to seeing me, he had tried to commit suicide by overdosing on over-the-counter cold medication at a mountain retreat with his high school class.
The essential features of Asperger's Disorder are severe and sustained impairment in social interaction and the development of restricted, repetitive patterns of behavior, interests, and activities. The disturbance must cause clinically significant impairment in social, occupational, or other important areas of functioning (American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, [DSM-IV], p. 75).
Adolescents with Asperger's often become experts in arcane subjects like dinosaurs or prehistoric sharks, about which they can talk endlessly, totally oblivious to the yawns and bored expressions of their families. I didn't say family and friends, because these kids frequently don't have friends outside their families. The suicide attempt and marijuana use may have been the event that caused Warren's parents to seek me out, but his lack of friends outside his immediate nuclear family was to become the subject of much of our work together. It was the developmental task at which he was not succeeding and it needed some serious and intense focus and support. It turned out to be the reason he tried to kill himself. It turned out to be the main reason why he smoked pot: As with our hypothetical Clark, smoking pot provided access to a network of friends who would accept him-prehistoric sharks and all-simply because he smoked pot, too.
I was originally drawn to the field of psychology because I am fascinated by the human developmental process. How do we become the human beings we become? If we get thrown off track early on, how do we find our way back to the person we were meant to be? Is there a person we were meant to be? Are such phenomena as fate and destiny real? Is there a true self versus a false self as some psychologists maintain (Winnicott, 1960; Rogers, 1961)? Or is there no self as most psychologists maintain, just a confluence of internalized images with a highly emotionally charged complex of images called an ego located at the center?
These are some of the questions that interested me when I chose to study and enter the field of counseling psychology. Several years later I had the opportunity to add a subspecialty; namely, substance abuse treatment for adolescents and their families.
Presently, the category I am identified with in insurance circles is Chronic and Difficult Cases. Consequently, the kids who are referred to me frequently come with a folder of other diagnoses under their arms, such as depression, anxiety, oppositional-defiant disorder-whatever. Like Mel Levine and a lot of other clinicians that work with kids, I find labels descriptively interesting but not dynamically useful. The Center for Collaborative Problem Solving at Harvard Medical School even goes so far as to call diagnoses such as ADHD and bipolar disorder dead-end, macro explanations. They prefer useful, micro explanations. For example, instead of ADHD they might say a kid has difficulty shifting cognitive set or impulsive, non-reflective thinking. For an emotional disorder they might note, poor categorizing and labeling of affective states, etc. (Ablon, 2003; Greene, 2001). Emphasis shifts from what you call symptoms to what you do about them. Labels can also keep us from looking deeply at the context in which the diagnosed conditions grew, and the environmental contexts and personal relationships that currently hold them in place.
It [the diagnosis] is not a search for a proper name by which one can refer to this affliction in this or other patients. It is diagnosis in the sense of understanding just how the patient is ill and how ill the patient is, how he became ill, and how his illness serves him (Menninger, pp. 6-7).
Kids who are referred to me are often on some kind of medication for the previously diagnosed disorder(s). Current research suggests, for conditions such as depression and anxiety, cognitive and interpersonal therapy in conjunction with medication can be optimally effective (Macaskill & Macaskill, 1996; Thase et al., 1997). On the question of psychotherapy versus medication, cognitive-behavioral therapy has been shown to treat depression equally well without the side effects of drugs (Antonuccio et al., 1995; Greenberg & Fisher, 1989). Other research suggests that for social phobias and bulimia nervosa, psychotherapy may be more effective than medication (Whittal et al., 1999); for people with obsessive-compulsive disorder, exposure with response prevention may be the most important component of treatment (Abramowitz, 1997).
So, when a kid already on psychotropic medications is referred to me, it's usually because he or she needs counseling. That is to say, he or she needs some kind of therapeutic cognitive/behavioral learning experience that is capable of hosting highly charged emotions. Also, the family matrix that is holding, mentoring, and attempting to provide for that child's maturational process may need some support and/or re-envisioning, as well.
As often as not, kids who are referred to me have stopped taking psychotropic medications. For one reason or another the drugs were not effective, or ceased to be effective: The side effects became as troubling as the conditions they sought to treat, or the kid was refusing to continue to take them. This presents a very interesting juncture, and would make for an interesting talk in itself. Suffice to say that I also perceive it as an invitation to rule out developmental, psychodynamic and family factors that may be contributing to this kid's present state of intrapersonal and/or interpersonal affairs.
In the case of any individual at the start of the process of emotional development there are three things: At one extreme there is heredity; at the other extreme there is the environment which supports or fails and traumatizes; and in the middle is the individual living and defending and growing (Winnicott, 1959-64, p. 137).
For many kids I meet, the hereditary factor has already been described in detail. As we know, many neurological dysfunctions are genetic: There's almost always a parent present who can describe how he or she struggled with the same learning challenges as their child. Heritability estimates of ADHD place it at about 70 percent (Erickson, p. 9). So, as the counselor on the case, I feel it is my duty and contribution to concentrate on the living, defending and growing kid who sits before me. If he or she has been brought to me because of substance abuse, I can usually add, the very unwilling kid who sits before me.
Substance abuse literature currently underscores the high correlation of psychiatric disorders and substance abuse. Velasquez, Cardonari, and DiClemente (1999) note that the results of the National Comorbidity Survey indicate that over half the Americans who have a lifetime alcohol abuse or dependence diagnosis also have a lifetime diagnosis of some psychiatric disorders (cited in Connors, Donovan, DiClemente, p. 181). The percentage goes up to 60% for people with a lifetime history of illicit drug abuse or dependence. This rate is similar to that presented by McDuff and Munese (1998), who also suggest that those with a substance abuse disorder, especially with drugs other an alcohol, are four to five time more likely to have a psychiatric disorder (cited in Connors, et al., p. 182).
So, what are we looking at here? When people are referred for substance abuse counseling, there's a high probability they're packing a psychiatric disorder, as well. How does this information correlate to substance abuse and LD?
WHEN THE OTHER DIAGNOSIS IS LD
One definition of a learning disability that is available to any parent with access to the Internet is:
[A] disorder in one or more of the basic psychological processes involved in understanding or in using spoken or written language, which may manifest itself in an imperfect ability to listen, think, speak, read, write, spell or to do mathematical calculations (the regulations for Public Law (P.L.) 1010-476, the Individuals with Disabilities Education Act (IDEA), formerly P.L. 94-142, the Education of the Handicapped Act (EHA); cited in KidSource OnLine).
The DSM-IV adds to this definition that demoralization, low self-esteem, and deficits in social skill may be associated with Learning Disorders (pp. 46-47). It's been observed that, in the long run, these secondary effects are the most damaging to young lives and the adults they eventually become.
Whether ADHD qualifies as an LD used to be a matter of debate. In 1991 the U.S. Department of Education issued a Policy Memorandum that recognized ADD as a disability under IDEA that can be diagnosed and treated under other classifications (Learning Disabilities, Emotional Disorders, or Health Impairments) (McNamara, pp. 162-163).
Much of the research that positively correlates learning disabilities with ASUD (Adolescent Substance Use Disorder) specifically correlates ADHD to substance abuse. A 2003 study calculates that nearly half of ADHD sufferers in adulthood have a comorbid drug use disorder (Johann et al., 2003; cited in Erickson, p. 9), and that ADHD and learning disabilities coexist in 19-26% of ADHD cases (p. 5). Other sources estimate that about 30% of LD kids will have ADD and 30% of ADD kids will have learning disability (Hallowell & Ratey, p. 213: In other parts of the text, Hallowell & Ratey speak of ADD as a learning disability. Here, they seem to be differentiating it from LD for statistical purposes). Furthermore, at least 50 percent of all kids with Conduct Disorder also have ADHD (Koplewicz, p. 206). Given all these correlations, it might, do well to look at some of the research that speaks to the subject of kids with ADHD and recreational drug use.
Alcohol researchers have found that individuals who have the overactive temperament, which includes impulsivity, hyperactivity, and some conduct problems, definitely are predisposed to substance abuse. Needless to say, this closely matches the temperaments of many ADD-ers (Hallowell & Ratey, p. 262).
It's also true that most ADD-ers who develop addiction started their behaviors early on-mostly during adolescence. If you have made it past your college years without dependence on a substance or on other addictive behaviors, it is likely that you will not develop an addiction (ibid., p. 263).
Rachel Gittleman-Klein, a pioneer in studying ADD's course through the life cycle, warns against an ADD child using marijuana even once. Its effects are so compelling for the ADD brain that it seems to become immediately psychologically addictive. It creates a calmness with a heightened sense of adventure-all within the brain. One of the true delights for ADD people is to play with their thoughts and their ideas and build intense and intricate fantasies. The irony is that marijuana makes ADD symptoms worse. It makes you more distractible, worsens your memory, increases the tendency to procrastinate, and decreases motivation (ibid., p. 267).
One study by psychiatrist Joseph Bierderman and his colleagues at Harvard University indicated that 52% of untreated ADD adults abuse drugs or alcohol. The drugs that they choose to abuse are alcohol and marijuana to settle the internal restlessness they feel, and cocaine and methamphetamines to feel more energetic and focused. Nicotine use is much more common in people with ADD, as is the intake of large amounts of caffeine People with ADD rarely abuse heroin, other opiates, painkillers, or tranquilizers, such as Valium. They are generally not stimulating enough to be of much benefit (Amen, p. 171).
In my clinical experience, people with Type 1 (Classic) ADD [with hyperactivity] and Type 2 (Inattentive) ADD tend to abuse stimulants, such as cocaine and methamphetamines; people with Type 3 (Overfocused) ADD tend to abuse alcohol; people with Type 4 (Temporal Lobe) and Type 5 (Limbic) ADD tend to be marijuana and stimulant abusers; and people with Type 6 ('Ring of Fire') ADD [excessive brain activity across the entire cerebra cortex] tend to abuse alcohol and marijuana (ibid., p. 172).
As we all know, the adolescent experience for LD kids involves more than just their learning differences. Numerous studies seeking to identify causes and correlations between specific conditions and adolescent drug use point to several factors. First off, may I say this: most of these studies distinguish between experimentation (trying something a time or two) and regular use (Santrock, 1987; Kaye, 1984). For kids with ADHD, however, experimentation with drugs can be disastrous and, therefore paradoxical, because experimentation is part of the adolescent experience. Disastrous does not mean hopeless, however. To a substance abuse counselor working with families, it means educating parents with ADHD children about not ignoring early signs of drug use. Factors that correlate to conditions conducive to regular marijuana use among all adolescents include: decreased interest in school and its related activities; being excessively peer oriented; having lots of older friends; lower levels of family intimacy; and the degree to which their parents drink and use drugs such as tranquilizers, amphetamines, and tobacco. It also means, helping parents act on what they see.
SUBSTANCE ABUSE TREATMENT
When I started interning as a substance abuse counselor and earning my stripes, as it were, the prevailing idea about the treatment of adolescents involved group therapy with their peers. Adolescent substance abuse treatment followed the model set for adults. We'd do an assessment to find out where kids were in terms of their attitude about their drug use, then put them in a group of kids with similar attitudes. For example, if they were of the opinion that getting caught using drugs was a raw deal, and their daily pot smoking habit was not a problem because they could quit any time they wanted and besides, it was nobody's business but theirs, they'd be called precontemplators and put in a group of other precontemplators. Precontemplation means exactly what it sounds like: prior to being able to contemplate how drugs and alcohol might be negatively impacting your life.
Most precontemplators are in treatment to placate some external demand. I found that dealing with a teenage precontemplator initially in a group of other like-minded teenagers was a bit like being a duck in a shooting gallery. I was a target for all their negative projections. I was the mechanistic legal establishment; I was the parent who failed to understand them; I was the teacher who thought they were stupid. For that reason, I opted to work with them individually for awhile. My agency supported me in this because the results were quickly apparent: individual counseling facilitated the creation of rapport. It's been estimated that 70% of all gains in therapy come from the quality of rapport that exists between therapist and client. Respect, careful and active listening, reflecting and summarizing, and highlighting discrepancies between goals and behaviors are all part of the motivational enhancement approach (Miller, 1985; Miller, Zweben, et. al., 1992; Rollnick et al., 1999; cited in Connors, et al., p. 105). Using this approach in individual counseling allowed me to give kids an experience of being uniquely valued and appreciated.
The kid's personal challenges can then be safely discussed. Family or school conflicts resulting from his drug or alcohol use are identified. (Since most of my clients are male, I'm going to use the male pronoun for a while.) What ideally happens during this process is the counselor is perceived by the youth as joining him in dealing with the negative realities he is encountering. This is effective for several reasons: The teenager does not perceive the counselor as part of the opposition. The counselor begins to be seen as an ally in dealing with the opposition-or, reality principle as I, Freud, and a lot of other people, like to call those forces of life that appear to run counter to our pleasure.
In using this strategy, the counselor actually piggybacks onto a developmental thrust with which the kid is dealing by virtue of being an adolescent. One of the tasks of adolescence is to learn how to balance these great life forces. Indeed, as a man named August Aichhorn, a psychoanalytically trained teacher and director at state institutions for delinquent boys in Austria circa 1910 observed: We can define the different stages of the child's development according to the degree in which the pleasure principle predominates over the reality principle (Aichhorn, p. 190).
The Stages of Change theory plays a big part in substance abuse treatment today. How many of you have ever tried to help somebody get out of a bad job situation or give up a toxic relationship when they weren't ready? They were still in the complain about it stage and you were going through the Want Ads or making appointments with moving van companies. At some point, you probably realized you were wasting a lot of energy. The tip-off was in how you were feeling. When you started to feel like Sisyphus-who is said to have been condemned to push a stone up a hill in hell every night, only to have it roll down to the bottom every morning-then, you were probably not speaking to the reality level of the person you were trying to help. You were not speaking to his or her stage of change.
When a precontemplator starts to say things such as, Maybe my daily pot habit has been causing problems with my family, or I've got to admit it has affected my memory, then he has become a Contemplator. He is beginning to weigh the pros and cons of his substance abuse. He is starting to express ambivalence about what he was formerly so defiant about. At this point, Accessing their aspirations and currently unrealized values can encourage a serious evaluation of 'where I am' versus 'where I want to be or hoped to be'(Connors, et al., p. 110). With a teenager who is compelled by his parents to be in treatment, it is here that huge pieces of resistance begin to fall away. Even the consequences his parents will impose should he fail to comply are seen in a different light: not as glaringly and hugely unfair, but as facts to be pragmatically dealt with. I'll talk more about this later. However, what I wish to underscore now is that the teenager is beginning to deal with the realities inherent in his substance abuse. He's actively and consciously processing causes and effects-and that's a big learning opportunity for him.
The stages of change that follow are: Preparation (identifying the strategies and skills necessary for making the changes you want to make); Action (actively changing-beginning one's sobriety or abstinence); Maintenance (maintaining one's sobriety, avoiding relapse, and dealing with relapse). Treatment strategies appropriate to each stage comprise a rich body of data (Conors, et al.; Schinke, et al., 2002). I'm not going to dwell on them here because I want to keep our fingers on the pulse of the learning opportunity just cited. This dealing with the reality principle; this coming to terms with the desire for pleasure and immediate gratification and the costs and consequences involved in seeking pleasure through broken promises, violations of the law, lying, stealing, or jeopardizing relationships and personal goals is-developmentally speaking-very interesting stuff. When you frame it right, you usually get the adolescent's attention.
A lot has been said about the power adolescent peers have to influence each other. We hear about peer pressure all the time. What we don't hear as often is, although a teenagers' peers influence their behavior and attitudes, it is from their families that they draw their deeper values and life-shaping beliefs.
COUNSELING THE FAMILY
When I began working as a substance abuse counselor, I already had some years under my belt counseling families as well as individuals. It didn't take me long to realize that when you're looking at teenagers under 18, you're looking at a composite. You're looking at individuals, to be sure. You're also looking at the families in which they reside until they are emotionally and legally ready to emancipate into their young adult lives. You're looking at their lives at school. Their experiences in the community: Do they have a probation officer? Are they in the foster care system? In other words, you're looking at a matrix within many overlapping matrices.
Matrix comes from the word mother. It means 1) The womb. 2) A place or enveloping element within which something originates, takes form or develops. Webster's New Collegiate Dictionary.
The agency at which I was interning turned out to be a real happy situation for me. They were open to trying what at that time were new ideas. I quickly saw that group work could be incredibly effective for some kids and not for others. Some needed one-on-one time before they were ready for the dynamics of a group. Another kid might do just fine in a group, but every night would go home to a family situation that did not optimally support his recovery. Or, what was even more common, went home to a family situation that could support his recovery if the family's forces were properly informed and mobilized.
What I knew for sure was that having a lot of precontemplator teenagers together in a group was like creating an opportunity for kids to keep infecting each other with the same bad cold. The peer dynamic was just too strong. Meeting with each kid individually bypassed all the inauthentic posturing, and greatly increased my chances of actually encountering the real kid. Earlier, I invoked D.W. Winnicott's term true self. Dr. Winnicott had been a pediatrician for 15 years, circa 1940, before training as a psychoanalyst. His contemplations about true-versus-false-self phenomena (1960) are beyond the scope of this paper. For my purposes here, a good working definition of true is: when we humans come from a true place in our beings, we feel most real and alive. As the counselor, you become aware you are in the presence of something tenderly human. Authentic conversation now becomes possible. The chances of kids in their truth actually moving toward the contemplation stage greatly increases. Once they are there, putting them in a group with other teenagers who are authentically preparing to stop using-or better yet, actively trying to stay clean-can now be effective. In such a context, the group dynamic is very powerful and works to everyone's advantage.
Empirical evidence now seems to support this observation: group therapies for adolescents with conduct problems might have detrimental effects on substance use due to negative peer influence (Dishion et a., 1999; cited by Stanger, 2003).
It wasn't long before I was doing a lot of individual and family counseling in the context of adolescent substance abuse counseling. As my experience and years in the field grew, I went into a private practice. I also contracted as an on-site counselor for Denver Academy, a private school in Denver that specializes in providing LD students grades 2-12 with a full-scale educational experience. I was interested in learning differences because I saw a lot of what I suspected were learning differences among my adolescent clientele. I welcomed the opportunity to work with teachers who were LD specialists. In doing so, I quickly realized I had landed-therapeutically speaking-in a very interesting position. I found myself straddling the four corners of an American child's life: In my private practice I worked with kids individually and through their families. In school, I could work with individuals, families and peer groups. Plus, I could enter the classrooms: I could get a teacher's unique perspective on who kids were and the challenges they were facing. Now, not only could I collaborate with parents to help create conditions better suited to bring forth their child's abilities, I could also collaborate with the teachers within the school setting.
Most of my collaborations with the teachers at Denver Academy did not involve substance abuse issues. Students were most often referred to me when their personal and family challenges began to overwhelm the student-teacher paradigm. For example, using all her powers of rapport and mentoring, the teacher could not seem to motivate the student. The teacher may have observed signs of depression, anxiety, and family stresses that needed deeper inspection than the teacher felt comfortable or capable making. There is another meaning to the word 'therapeutic' and this has to do with putting oneself in a position in which one can be communicated with from a deep level (Winnicott, 1990, p. 96).
As Mel Levine points out, when you're working with LD kids, eventually the intervention has to accurately focus on exactly what neurodevelopmental dysfunction(s) needs remediating. In a case study involving a boy named Max, Levine suspected he might have a neurodevelopmental problem with factual long-term memory. Levine says:
If a memory deficit turned out to be the case, then we would demystify Max about his specific breakdown and help him develop a personal bag of tricks to enhance his remembering It's only in recent years that we have been able to go well beyond the labels and identify specific obstructions to success. To do so requires open-mindedness and the close collaboration of teachers, parents, clinicians, and the child (Levine, p. 252).
As I struggled through the richness of this material, I wondered in what quarter I would find the junction where I could tightly tie the pedagogic remediation of LD to substance abuse treatment. I believe it is here in this close collaboration.
To focus even more closely, I'd like to invoke Jansky in her capacity as Assistant Clinical Professor of Pediatric Psychology (in Psychiatry) at Columbia Universtiy and Education Director of the de Hirsch-Robinson Reading Clinic at Columbia-Presbyterian Medical Center. She states:
The treatment of learning disabilities is primarily pedagogic. There is little solid evidence that therapies that rely primarily on medication, vitamins, diet control, eye muscle training, or motor patterning retraining are effective
It is extremely important for the reading specialist to work closely with teachers, other professionals, and with the parents. Parental support is essential to the success of intervention (Jansky, pp 306-07).
Without parental support, your chances of remediating an LD kid's weaknesses plummet. Says Levine: Parents should partner with schools. Neither can educate a child without the collaboration of the other. Such joint efforts may be especially hard to implement within modern dual-career or single-parent families, but nevertheless, the need is there (p. 303). Recent adolescent substance abuse treatment research points to the same need: The importance of poor parental monitoring as a predictor of continued adolescent substance use has led us to focus on parenting interventions that directly target monitoring of teens (Stanger, p. 62).
So, when your treatment population is LD teenagers who are abusing alcohol and drugs, a primary front of engagement involves the parents and the controls they can exert if their forces are effectively mobilized.
FOCUS ON PARENTING
In all the literature I read about LD, two needs are consistently cited:
1. The need for positive reinforcement to bolster sagging self-esteem, to revitalize hope in the adolescent and create a spirit of optimism. Only an optimistic mind is an open mind capable of learning. This could be named the Intrapersonal front.
2. The need for structure. LD kids are not alone in needing structure. All kids do. Winnicott describes it as a holding environment, likening it to the first structure that holds us-our mother's arms-when we are infants and totally dependent on maternal care.
There is no such thing as a baby. I was alarmed to hear myself utter these words and tried to justify myself by pointing out that if you show me a baby you certainly show me also someone caring for the baby, or at least a pram with someone's eyes and ears glued to it. One sees a nursing couple (Winnicott, 1952, p.99).
As humans mature out of the total dependence of infancy through changing ratios of dependence/independence toward emancipation as young adults, the holding environment has to adjust accordingly. Many of my interventions as a substance abuse counselor begin with trying to mobilize and fortify this environment. I like to describe it as a container that breathes with the adolescent: expanding when he or she fulfills his or her obligations and expresses through positive personal and social outlets; and contracting as a consequence of unacceptable or destructive choices. Ideally, the primary container is the family and is maintained by the family.
I am always struck by the degree to which being a human being (and counseling human beings) is such a balancing act. Integrating unconditional positive regard (Rogers, 1951), with reality processing, with the need to fortify the structure inherent in their family environments, in my experience, must be done simultaneously. For that reason, my first meeting is always with the teenager and his or her family. What I seek to model in that first meeting is that the container (now including me), can bear and survive powerful feelings and intense communication. In the process of doing this, I seek to listen and actively witness and reflect all the strengths and positive attributes of the substance abusing teenager. Usually, after hearing about the presenting problem, I will shift gears and ask the kid about his interests, hobbies and favorite subjects in school. I am looking for his strengths. I want to witness them in the presence of his parents. If he is well spoken or good at describing things, I will compliment him. Simultaneously, I will be observing how the family interacts.
Only after I see the kid settle in and get interested in our counseling relationship do I bring the conversation back to substance abuse. You could say it's a matter of proper sequencing. If most LD kids are already beating themselves up for their perceived deficits, then you as the counselor had better pull them to the solid ground of their strengths before you start trying to remediate their weaknesses. I'm certainly not alone in observing this. Many researchers have made strong inroads in how educators and parents view kids with learning differences and disorders. Truly, these kids often possess special talents that can go unadmired and underdeveloped (Geschwind, 1982; cited in Kestenbaum). Furthermore, learning disabilities are not necessarily synonymous with underachievement. The unique talents these kids possess imply the possibility of a myriad of special programs wherein they might be developed (Jansky, p. 296).
Mel Levine's work has already brought us a long way down this point of view. So much so that even the words Learning Disability and Learning Disorder have fallen into controversy. Many specialists are inclined not to use them at all, preferring to speak in terms of Learning Differences or neurodevelopmental dysfunction as Levine does. The implication being that each of us has our own unique way of unfolding as a human being. Given this premise, educators are therefore most effective when they can go to where the student is and bring him or her forward from there, instead of insisting that the student meet the teacher on a starting line determined by some objective, generalized, normative measuring standard. However, as a clinician, I have to differentiate between a learning style, a neurological anomaly that can be remediated, and pervasive developmental delay or a brain irregularity due to, for example, an earlier head injury. A Million-Dollar Question, particularly with chronic cases is, Do you see your son or daughter emancipating into an independent adult life, or always requiring parental support, and eventually the support of social services?
The first question implies all my counseling interventions. The second may invite many of these interventions, but it also implies that the kid's environment will always have to be at least partially managed for him even into adulthood. Philosophically, you could look at it this way. We humans are born prematurely. We are not born set like insects or some reptiles that receive no parenting. Nature doesn't complete us: other humans do (Jung, 1991). Relational connections must be made during our developmental years if we are to become optimally human. These connections are begun by others-usually our parents. Ultimately, they must be completed by ourselves; a task we wrest, in stages, from our parents during adolescence. Since self-advocacy and collaboration are critical components of remediation, at some point it's meaningful to differentiate kids who will be able to assume this task from kids who won't. The subject of psychiatry is [or should be] disturbance in interpersonal relationships, whereas the subject of neurology is pathological lesions of the central nervous system (Gans, p. 530). I often see families, and some clinicians, fail to differentiate between the interventions that are appropriate to each dynamic.
FOCUS ON CHOICES
LD remediation is primarily pedagogic; however it requires a strong parental support. Adolescent substance abuse counseling utilizes all the motivational elements of adult treatment; however, it too requires strong parental support because parental support during adolescence is developmentally appropriate. Some parents will argue with me on this point. They maintain that 15 or 16 year olds are ready start dealing with the real world, making major life decisions about such things as sexual behavior, alcohol and marijuana, and how they manage their time, including even curfew.
Research on how the brain develops tells us that during the years 14 to 18 our brains undergo a major pruning of neural pathways similar to what happens when we're two years old. The brain seems to be preparing us for the adult phase of our lives. It prunes away neural pathways that we're not actively using. So, when kids stop applying themselves academically, or playing a musical instrument, for example, they can experience a diminishment of those skills during this period because the neural pathways supporting them get pruned. Also, the frontal lobes in our brains appear to be the last part to mature. The frontal lobes are the seat of our executive functions: the goal setting, planning, critically evaluating functions. Many bright and talented teenagers can baffle us by some of the perplexing choices they'll make. What parents do so effectively at this time is support the exercise of these functions; namely, by joining the kids' executive function and helping kids focus on the truly relevant choices (Cline & Fay, 1993). Freedom, for a teenager, could therefore be defined as freedom to choose within a limited range of focus. It's the parents who help determine the range and choices. It's the teenager who gets to make the choice.
In my experience, kids expect their parents to do this. Kids may bluster and protest, but they expect two things: Parents to provide a range of just choices tailored to who they uniquely are; and parents to bear and survive their anger if a deliciously self-destructive choice is left off the list. In family counseling, a good deal of the work is determining what those just choices are, then allowing everyone to experience that the family container is resilient and strong enough to withstand the tempest this process might set off.
Learning is both cognitive and experiential. In the definition of experiential, I include the emotional and kinesthetic. For example, 8 ÷ 4 = 2 is a cognitive achievement. Here's an example of an experiential achievement: A student completes a detailed project and experiences what it's like to persevere, pull a lot of disparate elements together, and enjoy the feeling of accomplishment when the finished project turns out well. What seemed overwhelming at first really was doable after all. What students may learn about the history of Colorado is one thing. What they learn by experiencing actually bearing through and completing a ten-page paper about the rise and fall of silver mining is the other byproduct of great value. A lot of what teachers teach is not just cognitive data. It's how to show up to class on time; plot a schedule through a day, week and month; manage frustration until all the elements of a project come together when they are supposed to. It's how to bear the suspense and intensity of taking a big exam. How to temporarily fail, reapply yourself and eventually succeed. Kids who drop out of school early because they think they know enough often miss this very type of learning. I suspect it's just this type of emotional learning that they have the most difficulty bearing. Again, the remediation turns out to be a collaboration between school and parents. As Levine says: Schools should teach kids how to learn, and parents should teach them how to work by establishing work rules and a work ethic at home (p.61).
Similarly, drug treatment may ostensibly begin with education-giving the kids the facts, developing their understanding of what drugs are and how they affect the body. However, the other, perhaps more important component of drug treatment, is helping kids learn to bear the intensity of human emotions, how to work through complex emotional situations without bolting or turning to the self-soothing that drugs, alcohol and overeating can appear to provide. When you move from education to substance abuse treatment, the experiential component comes heavily into play.
THE FAMILY CONTAINER
To do this, you need to create a container that will hold the process of counseling.
You need a space that has some sanctity: a room that can be made to feel private. You need rapport. In the best adolescent treatment scenario the family is mobilized and circles its wagons around the substance abusing teen: not to keep the rest of the world out, but to create a supportive enclosure within. A lot of treatment consists of helping them do this. A meta-analysis and literature review conducted in 1997 (Stanton and Shadish) found that family therapy is superior to other modalities in treating ASUD (Adolescent Substance Abuse Disorder) and can enhance the effectiveness of other forms of treatment as well. Family therapy was specifically differentiated from family psychoeducation and support groups. Among the family therapies that have strong theoretical bases, structural-strategic family therapy (SSFT) was found to be effective in reducing drug use among adolescents. (cited in Weinberg et al., p. 258).
My experience as a clinician working with families certainly concurs with this finding. Structural family therapy emerged in the 1970s and came into prominence not only because of the effectiveness of the approach, but also because of the stunning virtuosity of its primary exponent, Salvador Minuchin (Nichols & Schwartz, p. 209). Leading figures in the development of Strategic and Systemic family therapies are Gregory Bateson, Jay Haley and Cloe Madanes.
The legendary hypnotherapist, Milton Erickson, was a seminal influence in the development of strategic family theory. Erickson focused on a client's symptoms and problems. His primary goal was to create changes in behavior. He also maintained that deep down the client knew what to do. As a hypnotherapist he saw the unconscious as a source of wisdom and creativity that, if unfettered by conscious inhibition, could solve problems and heal symptoms (Nichols and Schwartz, p 411).
Clearly, in this paper we're not going to be able to discuss a detailed application of structural-strategic family therapy to ASUD. What I would like to cite here is the concept of malfunctioning family hierarchies. Haley (1976) suggests that 'an individual is more disturbed in direct proportion to the number of malfunctioning hierarchies in which he is embedded (Haley, p. 117; cited in Nichols and Schwartz, p. 414). SSFT conceptualizes a family in terms of interrelated systems and the appropriateness of their boundaries. For example, the husband and wife form the parental system; the children form the sibling system; the grandparents another system. One of my first areas of focus is the parental system. In a family diagram, this system would sit above the other systems. For this reason, I like to refer to the husband and wife as the King and Queen. I've never seen a couple fail to light up when they hear themselves so described. The metaphorical implications are immediate. What also jumps forward are ways in which they could become a more united force in the family. Sometimes, father or mother roles have been usurped by one of the children. It's been my experience that being a child growing up is so compelling and all consuming, that kids do not want to become parents or a partner to a parent. When they do, it is usually because they have been sucked up into that system by a breakdown in the parents' relationship. Eventually, the power kids in these roles gain seems to offset the discomfort they initially feel. I say seems because such role inflations can be very detrimental to a kid's developmental process. Parent-child coalitions against another parent can also block treatment results if they are not addressed.
Not only is it important to fortify the family container in which the adolescent abides, often it's important to mobilize and fortify secondary and tertiary containers as well. Examples of systems approaches that move into wider spheres of influence are multidimensional family therapy (Liddle & Diamond, 1991) and multisystemic family therapy (Pickrel & Henggeler, 1996). Each approach attempts to intervene in, or at least take account of a broader network of social influences, including teachers, neighbors, police and peers (Weinberg, et al, p. 258; cited in Weinberg, p 258). In my own work, having access to some of these other containers-especially in my capacity as a school counselor-I'm convinced, has enhanced my effectiveness in many cases. Sometimes kids' weaknesses aren't problematic at home. It's in the school environment where they are exacerbated. A good example is a socially challenged kid who has a hard time making friends. In such a case, strategizing with his or her teachers on campus, and mobilizing supportive strategies at home, can be wonderfully effective.
WHAT ABOUT PEERS?
An on-going controversy concerns rating the relative importance of influences on adolescents. What affects a teenager more: family, peers, self-esteem, or failure to develop an internal locus of control? This controversy is uniquely meaningful to any examination of LD and adolescent substance use or abuse. A school-based study published in 1987 concluded that although susceptibility to peer pressure, self-esteem, and health locus of control are correlates of adolescent substance abuse, self-esteem and health locus of control constructs are less central to adolescent substance use and misuse than is susceptibility to peer pressure (Dielman, et al., 1987, p 220).
A later, 1996 review conducted by Weinberg, et al., states that peer influence seems to be less important than originally thought. To explain why it has consistently be rated as so important they note: Bauman and Ennett (1994) suggest that previously reported correlations between individual and peer drug use may primarily be due to adolescent drug users selecting drug-using friends and projecting their own drug use into their reports regarding peers (pp. 255-256). So, teenagers who use drugs assume every kid uses because they can't see beyond their own circle of drug-using friends. It's also been speculated that kids under report their use to surveys for fear of possible detection. So, perhaps the truth lays somewhere in between.
However the influences stack up, few people would deny the effects on anyone's behavior of the company one keeps. In the Stages of Change model, treatment plans contracted during the Maintenance/Relapse Prevention stage usually include changing your lifestyle. Every traditional 12-Step program eventually stresses loosing the old gang and eschewing the old playgrounds.
Bob Meehan talks about this at length in Beyond the Yellow Brick Road, which details an intensive adolescent substance abuse treatment model. A critical piece of Meehan's theory and practice is that peers rehabilitate peers. One of the biggest stumbling blocks in adolescent recovery, he observes, involves giving up the old gang of friends you used to get high with. In the initial stages of recovery, it's pretty hard to keep to your program when you're sitting in a basement full of friends getting drunk, high, or both. For adults, the vacuum created by the sacrifice of old friends is usually filled by family. Pulling back their family's embrace can tremendously life enhancing. When I say families, I do not mean their mothers or fathers, although for some adults who have burned all their social bridges, and other adults who never emotionally emancipated into being able to create lives of their own through marriage or some such partnerships, that may be their only option. For many adults in recovery, giving up the party crowd can mean reinvesting in a supportive marriage and revitalizing relationships with their children. This is developmentally appropriate and feels right and good.
For adolescents, however, pulling back into the family of origin does not feel so right, because a major task of adolescents is to fall in love with their peers. What they're doing, essentially, is building emotional bridges outside their families of origin. These bridges will eventually carry them out of the nest into their young adult lives where they will begin emancipated lives and ultimately create families of their own. So, to ask kids to give up their peer group can feel, to them, like you're demanding that they regress to an earlier, more family-dependent stage of development. Not only are you fighting with them now, you're fighting the powerful, natural thrust of their maturational process. Crossroads Drug Abuse Program, founded by Meehan, has made a specialty out of providing an alternative group of sober peers for kids who go through their program. This peer group consists of teens and young adult counselors who have become clean and sober, but are still believable as abnormally normal young people.
In my capacity as a school counselor, I remember vividly a conversation I had with another school counselor. She was telling me about the mother of a sixth-grade girl with LD. Her mother said said, I wish just once another kid would call my daughter at home. It's never happened. In all her elementary years, my daughter has never had a single, special friend. My colleague looked at me and said, We've got a lot of lonely kids here.
Fast forward three or four years and that girl-let's call her Meghan-may have finally found some friends. Even if they are heavy partiers and to keep them Meghan must go into full rebellion against her family, counselors should think long and hard about offering her the possibility of something else before asking her to give up the few meaningful social connections she has ever been able to make. What we did was hopefully circumvent that paradox. An intervention that followed my conversation with the school counselor involved coaching Meghan's teacher to play matchmaker. He had a good sense of who might be a potential friend to Meghan. So he created a special project that required teams of two. Then he assigned partners, matching Meghan up with someone she might have things in common with. A requirement of the project was to call each other at home and collaborate during off-school hours. The project was academically viable, but it was also a setup in which a friendship might take root. I've recommended this intervention several times, and in a couple cases it worked. A kid who never had a friend made a friend. Mel Levine coined the wonderful phrase, One mind at a time. Alcoholics Anonymous says, One day at a time. Maybe we could add, One friend at a time. It may seem a small thing in the magnitude of this huge and mysterious universe to help one LD kid achieve the developmental milestone of making a friend. But that's how this work works, isn't it? Small, incremental victories. Baby steps to more personal power. Making a difference in one life at a time.
WHAT IS SUBSTANCE ABUSE COUNSELING?
Teachers and administrators are frequently called upon to make referrals to substance abuse counseling for students who have crossed the line between experimentation and regular use and abuse. A usual response to getting caught, especially when you are sitting in the Dean's office with your parents is to say, I can quit if I want to, and Yes, I want to, and I will quit. Why? Because I want to stay in school.
At this phase of process, school officials will usually recommend substance abuse counseling, which the student in question will just as often decline by insisting, I can quit on my own. I don't need counseling. To verify that the student can and does quit, he or she is often required to submit weekly random urinalyses through an outside agency.
When a kid says I can and will quit on my own, it is said sometimes with the best intentions. Sometimes it's not. Even when it is, the chance of kids staying clean usually depends on their history of use. Successful scenarios often entail something like this: A student has just started smoking pot, or did so maybe one-time monthly at parties for several months before getting caught. Maybe the student had even taken to smoking on a weekly basis for three months. Let's say it's a girl. She has a strong personal investment in school, be it sports, academics, social life or the arts, and truly does not want to be restricted from these activities. And her parents are firm in their expectations that she quit. Such kids tell me their strategy is to stay a home for a couple weeks, avoid their friends, and suffer through the irritability response involved in giving up a drug. With the support of weekly urinalyses, these kids often can get clean without counseling. If they don't, they understand that substance abuse counseling will become part of the treatment regimen. This strategy can lower resistance to counseling if it should become necessary.
With kids who've smoked three-times weekly to daily, or who have little investment in the culture of their school, what they usually discover is, though they may wish to quit in order to stay in school and get their parents off their backs, pot does not want to quit them. They discover what many adults who try to quit a drug discover: they have engaged a worthy opponent. Often what follows is a violation of the contract the youth made with the school requiring regular clean urinalyses. In many private schools, the next step is to then give the student and family a choice: Get weekly counseling and therefore the support you need to stay clean, or clean out your locker because you're going home. The school counselor would not participate in that imperative. Counselors are not part of the discipline structure of a school. Counselors are part of the support structure should the student and family elect to meet the challenge of the imperative.
Even so, sometimes counselors can find themselves drawn up into disciplinary conflicts. When this happens, it doesn't feel good. Usually it happens at the hands of a uncooperative, or even belligerent, parent. The parent sees the counselor as the adversary. Often the parent feels threatened because you seem to be calling into question their parenting skills or procedures. No matter how empathetically or collaboratively you try to frame the problem, they go on the attack and make it quite clear that everyone, including the counselor, are to back off.
For example, I'm recalling an incident involving a 15-year-old girl we'll call Marlene. She was telling her friends in class before the bell rang about her big party weekend in which she got drunk with a bunch of boys. and how exciting it was to chase after parties on the weekend. Her friends were wide-eyed with interest. Unfortunately, from Marlene's point of view, so was her teacher, who happened to be standing within earshot. The teacher asked her assistant to start the class, while she took Marlene out of the classroom for a little talk. Marlene reacted to any discussion or questioning about her party habits by flying into a rage. The teacher got very concerned. What had she tapped into? How serious was all this? She then asked Marlene to sit in the division office while she called the division head, Marlene's mother, and me.
When children are still in the toddler stage, one of the hardest parts of being a parent is the eternal vigilance that is required to keep kids safe while supporting their developmentally critical explorations of the world. One of their first big lessons involves the meaning of hot! We hope a kid can learn this one as painlessly as possible. Learning is almost always accompanied by the word, No! For a child's survival, Hot and No must be learned. A whole lot of parenting discussion time could center on the word No. Its use as well as overuse. And, as the child develops from toddler to kid to adolescent, how the restrictions inherent in the word No change. How the importance of choice expands.
Actually, some child specialists speculate that all the parenting paradoxes inherent in parenting teens first make their appearance during the toddler years, around two years old. Some advise not overusing the word No, and saving your No's for truly important issues. If you polarize with a toddler and set up a paradigm of battling, you've actually started hardwiring the relationship for truly humongous battling when the kid hits adolescence (Ross, 2001).
We hear a lot about the importance of offering teenagers choices instead of mandates (Cline & Fay, 1993). Theoretically, these should only be choices parents can live with. Applying this idea to toddlers, an alternative to saying No all the time is to distract. If you don't want your child playing with the cat box you distract her away by offering something else to capture her attention. The key word here is offering. Again, you're offering a choice between the cat box and something you deem more acceptable, such as a toy or game. This is active parenting. It assumes you know what your child likes and could be interested in. What works for a toddler can also work for a teenager. Again, a critical component is know your kid and what he or she truly values. We'll talk more about that later.
The point I would like to focus on is the concept of vigilance. The pediatrician who became a psychoanalyst specializing in working with children once observed,
Fortunately, eternal vigilance is not eternal, though it feels so. It only lasts for a limited time for each child. Too soon the infant is a toddler, the toddler is going to school, and vigilance is then something shared with the teachers. However, No remains an important word in the parents' vocabulary, and prohibiting remains a part of what mothers and fathers find themselves doing right on and until each child in his or her own way breaks out of the parental control and establishes a personal way of life and living. (Winnicott, 2002, p.118).
Dr. Winnicott made no distinction between traditional learners and kids with LD. When I say traditional learners, I'm referring to kids who learn effectively from reading, listening to a teacher lecture, taking notes, memorizing, evaluating what they have learned, and outputting that information upon demand. One of the definitions of learning difference does not include low intelligence. Mental retardation is a whole other category. Kids with learning differences can be average to brilliant. They can also test within the average range of intelligence and be quite superior in specific areas such as computers, sports, music, etc. These areas could be described as their bliss. A lot of good research supports teaching such children through the opening of their bliss, and then generalizing this bliss to other subjects that all of us should be competent in for the purpose of surviving well in the 21st century. How this is done comprises the brilliance of many special education programs
Marlene was not a traditional learner. One the WAIS/WISC her verbal and performance IQ's were between 90 and 99. As a child she had been diagnosed with mild ADHD, impaired oral function, dyslexia, and evidence of nonverbal weaknesses that pointed to difficulties understanding experiences using nonverbal forms of reasoning. Her strengths were many, however. Even with her dyslexia, she rather enjoyed reading. And her reading comprehension was pretty good. She was quite good at processing orally transmitted information. She was also good natured, very social, and a strong relater.
Marlene was in a Special Education program. Her teacher valued her many fine qualities. Marlene hadn't been caught with alcohol on campus. She had simply been relating off-campus adventures. Both her teacher and I were quick to grasp how paradoxical this situation was. Marlene was acutely sensitive to her image as a happening teenage girl. She came from a family of high achievers. All her brothers and sisters were stars in some way-academically, socially or athletically. In partying, Marlene had found a way to ostensibly leap frog over her cognitive deficiencies and maximize her social talents. She sometimes expressed anxiety about the future when she realized many of her career goals did not match her skill sets. However, with drinking and socializing, she may have found a competitive common ground in which she could feel accomplished, or just normal. The school was not interested in punishing her. But it was willing to exercise due vigilance and explore the matter with her parents. Did her family know the extent of her partying? How much was she actually drinking? Was there a family history of substance abuse? Was she genetically hardwired for alcohol abuse? How could we all work together?
In middle school and high school, most programs dedicated to drug and alcohol education are structured in the educational model. Their purpose is two-fold: 1) to impart information and, 2) to make it clear to students what the school rules are, so they understand the personal and social consequences of their behavior. For example, bringing drugs on campus can result in expulsion. Education includes classes in general health and drugs and alcohol. Formats include round-table discussions, guest speakers series, experiential retreats, and role playing and other activities designed to develop peer refusal skills. Two assumptions motivate these programs: 1) the school will educate; 2) it will exercise due vigilance.
It's been my experience that most parents expect the school to be vigilant about drug use on campus. Other issues arise when the student is suspected of using drugs off campus. Some parents still welcome vigilance on this front. The ones who do not, in my experience, can fall into two categories: Those that have a personal philosophy about a child's developmental process that says, when it comes to drugs and alcohol, at 15 or 16 kids are ready to find out for themselves how hot is hot. In the world of hard knocks, kids have to figure out what's too much and become a stronger person because of it. The other set of parents are, for whatever reason, just not vigilant about supervising their teenage children and can resent any suggestion from a teacher or counselor that maybe the child needs a bit (or a lot) more tending.
Years of working with adolescents has taught me that one of the most effective fronts on which to manage an adolescent's experimentation, use or abuse of drugs and alcohol is the parents. It comes down to realizing that most 16 and 17 year olds, no matter how independent they may profess to feel, know they are not ready to emancipate into full independence. They know they are in many ways still very dependent on the family matrix-holding environment, container, nest. Whatever you call it, you're essentially talking about some sort of protective/supportive structure. Such a structure would be physically, emotionally and cognitively supportive.
Earlier I stated that I am a big proponent of letting kids experience the natural consequences of their actions. We humans love our pleasures, but it's the reality principle that quickens our intellectual development and, with each experience of successful mastery of reality, fortifies our self-efficacy and sense of self. A 15-year-old who has been captured by drugs (the pleasure principle), who takes the family car and drives a bunch of friends to Vail for a party weekend at the condo of one of those friends, learns very little about how reality actually works when his parents wring their hands and say, There's nothing we can do about it. He refuses to come home. Conventional wisdom suggests taking a hard line, maybe even bringing the police in on the matter. You have a kid who is beyond control of his parents, has essentially run away, is doing drugs, and driving without a driver's license. By taking an indulgent, placating line, parents can actually enable their kids to keep using drugs.
However: Whenever I give lectures, parents will ask me questions about their kid that I can't answer specifically because I don't know the family and I don't know their kid. Treatment is in the details. That's why motivational interviewing works when it works: it listens for the personal details and engages from those. Similarly, consequences and reality processing are in the details. If the correlation between LD, ADHD, Conduct Disorder and substance abuse is as high as we suspect, the implications to SA treatment are many. One of the tenants of substance-abuse treatment is letting kids experience the consequences of their actions. Even so, working with LD kids has taught me that experiencing consequences is a learning experience only to the degree that the consequences can be cognitively, emotionally and somatically assimilated. Therefore, it's critical that the counselor and parents of LD kids in substance-abuse treatment tease out what kids can actually master at any given point in their recovery process. I've guided some kids through very bumpy courses toward sobriety. Many times conventional substance-abuse treatment wisdom would have lowered the boom on them, withdrawn them from college, compelled them to move out of the family home, get jobs and emancipate. Many times I was as eager as their former teachers to pull the plug on them. But I was also aware that some of these kids weren't processing the whole picture, or didn't yet have the skills to enact effective action. Eventually, they did, but a lot of playing toward their strengths, and second chances, were required to fortify their recovery. Others might have accused me of being manipulated. I don't believe I was, but I did walk a fine line between trying to hold an ethical presence and motivating kids from their internal locus of control while simultaneously trying to fortify their internal locus of control.
This is not an easy process. You need all the help you can get. The most difficult kids to help are those whose parents cannot be mobilized. Often the scenario manifests in the form of divorced parents. One is trying to be present and actively involved in the lives of her children. The other is not around too much and when he is, he wants to be their friend. Some, let's say fathers, who fit this description will even offer their house as the party house. Sometimes they don't overtly offer it, but leave the house so unsupervised that it becomes the party house anyway. This can create a huge leak in the family container. It can also create a huge leak in the community container. Other parents who do supervise their children can't control what goes on in another parent's house. They don't always know there are no adults present at many of those parties.
In Marlene's case, it was the mother who did not want to curtail her daughter's partying. In another paper, I discuss the difference between experimentation and substance use and abuse. I'm not talking about spying on teenagers and crushing their developmental process. I'm talking about responding to a possible emerging problem with alcohol. Once I became aware that Marlene had had her stomach pumped that summer due to overdosing on alcohol, I suspected the situation was not as benign as the mother insisted. She was so defensive about being labeled a bad parent that no discussion or sharing of information with her was possible. What do you do in such a case? Well, truthfully, your options shrink, and the chances of success with that adolescent get pretty slim. Either she'll come to you through the courts (another matrix), or she'll come to you on her own, as an adult who has bottomed out.
In such cases, we often see the limitations of the earlier treatment model that purported to educate, even scare kids into realizing that drugs and alcohol abuse are bad. The inference is that they will then monitor themselves. I like to refer to this strategy as an adultomorphism(Yalom, 1980) because it assumes the adolescents process the reality principle in the same way adults do. One of the insights of current neurological research is that our frontal lobes are the last area in the brain to mature, maturing as late as 21 or even 30, as some researchers maintain.
Marlene's mother is operating on similar, adultomorphic, assumptions. I've told Marlene to respect alcohol. To space out her drinks over the course of the evening. To not ride with someone who is drinking. And I trust her to make good choices. If she doesn't, she'll learn from experience, which is the only way anyone ever learns anything anyway.
One of my first jobs as their substance abuse counselor would be to open a dialogue with Marlene's mother about the adolescent developmental process. In this particular case, I probably would not be invited to work with the family without external motivation. In a typical scenario, Marlene is ticketed for underage drinking, or being in possession of alcohol while riding in a car with a drunk driver, and court ordered to treatment. Now, mother and daughter could be said to be processing the reality principle together.
I would try to meet with mother and father and Marlene in the first session. Even though the King and Queen are divorced, they are mother and father to the girl-still critical roles in an adolescent's life. In that first session, I would essentially be simultaneously engaging two subsystems of this family: Marlene as daughter and sister; and the parental subsystem (Mom and Dad, ex-husband and wife). Multidimensional Family Therapy (MDFT) has conducted a lot of research focusing on the challenge of educating and mobilizing the parents while engaging the adolescent substance user (Liddle, 1991, 1992). It can be a tricky process, but a necessary one. For example, you want to call forth the structuring and holding power of the parents, but you have to be mindful of the adolescent's developmental process. Adolescence is a time for renegotiating the power differential between teenager and parent. Even if the teenager has garnered more power to herself than is developmentally appropriate, she still has a claim to developmentally appropriate power. If the therapist ignores this, the teenager almost certainly won't engage. Even worse, you can quickly drive a kid into a state of hopelessness. Regaining meaningful and appropriate control over their lives is as important to teenagers as it is to adults (especially parents who feel they've lost control of their children).
Drug-using teenagers do not feel personal agency or experience much control over their own lives, and relatedly, experience a profound sense of meaninglessness ... Therapists who ignore or are intimated by adolescents can do much to fuel the teenager's extant hopelessness Working with the adolescent alone for significant periods of the therapy is one way to substantively develop these content themes (Liddle, 1993, p. 391).
I would add to that: counselors who avoid engaging the parental system can fuel the hopelessness of the entire family as well. When a counselor enters the parental system, I am assuming that all the protocols of client-centered therapy are in operation. The counselor is respectful, empathetic, and compassionate, but he or she is willing to explore critical questions. For example, what sort of relationship does Marlene's mother have to alcohol? If a problem exists, is she willing to begin addressing that? These are clearly questions a teacher meeting with a family in a school setting cannot comfortably ask. One reason, the classroom is not a proper container. Also, Marlene's mother has not given the teacher permission to ask her personal questions. In teacher conferences, the focus is supposed to be on Marlene. In my role as a school counselor, before every initial engagement with a family, when I think we need to do some deep viewing, I always ask permission before I start asking such questions. It also helps to explain why such questions might be relevant. Most parents I find respond positively. After all, you're offering help with something they care about very much; namely, their kids.
Marlene's mother remained defensive and defiant. The only intervention the school could administer was to require that Marlene keep talk of her underage and therefore illegal drinking exploits off the campus. An early treatment opportunity was lost. Without the mother's collaboration, the school's vigilance seemed arbitrary, authoritarian-even mean-spirited. The reality principle could not be naturally, and benevolently, engaged. There was no impetus for Marlene to enter into other ways of dealing with her challenges other than the one that seemed to be working so well; namely, alcohol.
CONTROL AND THE ORDERING FUNCTION
Let's now leave the family group and return to the student with LD as an individual. If it's true that drug-using adolescents don't experience much control over their lives, it could also be said that a lot of LD kids don't either-whether they use drugs, or not. We humans do not like to be out of control. Experience is hurtful, bearable or pleasurable to the degree that control and out-of-controlness are in a ratio that is uniquely comfortable to each of us. Too much control and we get bored. Extreme out-of-controlness can be terrifying. Proper ratio is matter of personal taste, conditional to our temperaments, the degree to which we like to take risks, severe early traumas we may have experienced, how our limbic systems trigger, how our amygdalas (part of the brain that processes fear and anger) are wired. In other words, conditional to a lot of things.
While drug use appears to be more a function of social and peer factors. SUD [Substance Use Disorder] appears more related to biological and psychological processes (Glantz and Pickens, 1992; cited inWeinberg, et al, p. 254.)
High-risk children often demonstrate several characteristics that probably have a biological substrate Several of these features are components of executive cognitive dysfunction or disorders of behavioral self-regulation: difficulties with planning, attention, abstract reasoning, foresight, judgment, self-monitoring, and motor control. These in turn appear related to aggression in children, a frequently identified feature of children at risk for ASUD (Giancola et al., 1996; cited in Weinberg, et al., p. 255).
Michael Franz Basch in Doing Psychotherapy hosts a very deft discussion on the feeling of being out of control and how it correlates to our ability to problem solve, an ability he argues that is synonymous with the ordering function. When the brain cannot perform its ordering function, the particular subjective state that it generates is called anxiety. The experience of anxiety is usually described as an nonspecific dream, the fear that something terrible is going to happen, heightened by the fact that 'something' is not identifiable (p. 172).
Anxiety, Basch observes, is only one way of describing disorganization. A person can respond behaviorally by being unable to concentrate, feeling edgy, not being able to sleep, losing one's temper easily, etc. Conversely, not feeling helpless implies a successful ordering function. One way to look at this function is in terms of pattern matching. A sudden shadow in the bushes startles you. You feel anxious, then fearful. Suddenly you match the shape to that of your dog. Anxiousness vanishes. To match patterns, you have to receive information from outside yourself and match it with information (feelings, impressions) within yourself, often from your memory banks. The ability to match patterns from past to present never stops developing. Guided by parents, teachers, and other mentors in one's early years, in adulthood one assumes responsibility for one's continuing maturation within the framework provided by society for its fulfillment (p. 176).
You remember Mike: the kid who responded so well to the metaphor that invited him to fold his wings. Mike's family had followed a similar course as Marlene's for a while. In this brief case history, I wish to illustrate how family therapy, LD remediation (inclusive of focus on the ordering function), and individual counseling can work together in the course of substance abuse treatment for an LD kid.
AN LD CASE STUDY
I first met Mike when he was 16 and in the fall quarter of his junior year. He had been implicated in a pot-smoking incident at school and the vice-principal ordered him to take weekly urinalyses if he wished to remain in school. At that time, the family chose to focus on how the pot smoking was discovered rather than what was discovered, circled legal wagons around their son and essentially forced the whole matter to be dropped. Mike had been diagnosed years prior with a learning disability and continued to work with an Educational Consultant who told his parents that pot smoking wasn't the root of his problem, and therefore, advised against substance abuse counseling. Mike possessed above average intelligence, but was challenged by sequential and organizational deficits. In the 4th grade, he had been diagnosed with ADHD and put on Ritalin. His response to the medication was unfavorable and since then he had remained unmedicated.
When Mike was in the spring quarter of his senior year, his family contacted me in my capacity as a substance abuse counselor. In the summer during his junior and senior year Mike had lost his driver's license for driving while in possession of alcohol. He had also been ticketed for possession of marijuana. He had even spent two days in juvenile detention because, in his words, I had been smoking so much pot I couldn't quit even for my probation officer.
As his story unfolded, his family and I learned that he had started smoking pot in his sophomore year when he was 15. It wasn't long before he was smoking pot every day, several times a day. He says he soon lost his drive to do well in school. Furthermore, now that he was only weeks away from turning 18, when the courts could treat him as an adult, he still couldn't stop smoking. He was failing most of his classes and expulsion from school was a virtual certainty.
In substance abuse treatment protocol, one does not usually refer a client to residential treatment until outpatient treatment has been tried and failed. In Mike's case, at this 11th hour, the consequences were too dire to risk. I recommended in-patient treatment at a local facility for adolescents. The court agreed to defer all charges providing he showed up at his probation officer's office with clean UA's in two months.
Mike entered the residential treatment facility on a Tuesday at 10:00 a.m., and walked out of the facility at 3:00 p.m. the same day. He didn't feel comfortable being around some of the other kids who said they had used heroin or shot up methampetamine. The décor was not to his liking. There was too much structure. He missed his privacy and freedom. Whatever his reasons, he refused to go back. Note: New situations, especially situations filled with events and people he could not control, aroused a lot of fear in Mike which he covered with defiance and bravado. He was willing to do out-patient treatment with me while living in a familiar space; namely, his family home. It was not ideal, but it was an opening, so we took it.
Two weeks later, Mike gave his first clean urinalysis-just two days before his 18th birthday. Three months later, the court reinstated his driver's license due to continuing clean UA's and an aggressive attorney. Mike and his family were jubilant. A week later, he was driving again. I must confess that I was apprehensive about the court's leniency, and chagrined that I had lost such a strong matrix so early in his recovery. A week later, he resumed smoking pot.
Just so I don't lose anybody out there in the audience who is privately thinking, What's the big deal, so he smoked a little pot? We're not talking here about a kid who smoked a little pot. We're talking about a kid who smoked several times a day and, when he was smoking, cared for nothing but getting high. He fulfilled the criteria of dependence. This relapse period lasted for four months.
After he got his driver's license back, a big motivational and structural piece was gone, plus there were now too many choices for his skill level to deal with. I began to feel like a person trying to rescue a cat from a burning building. He resisted all positive interventions, such as attending Marijuana Anonymous 12-step meetings for adolescents. He evaded all family control. He cancelled sessions. I began to question whether counseling could be effective with this kid. Due to truancies and not doing his school work, he was once again in danger of being kicked out of school, failing, or both. His parents began to see vividly the cycle of how Mike mobilized them to rescue him (his father had started writing school papers for him in the guise of helping him pass his classes). A critical distinction for them to learn was the difference between helping and enabling.
Mike was verbally abusive to his parents when he was at home. His anger and language could be withering when his urge to pleasure was thwarted in any way. However, beneath this behavior was a powerful quality of hopelessness. He said he couldn't bear his low moods, his lack of faith in his ability to get control of his life and do the things he needed to be successful.
Of course, the intimation of underlying depression had to be ruled out. His mood swings, he reported, did not predate his drug use. So, there was a good possibility that his depression was drug induced. Marijuana abuse can exhaust the adrenal glands, clog the brain with THC, affect serotonin and dopamine delivery systems, and undermine the development of age-appropriate coping skills. A big part of learning for kids comes in the context of what the key adults in their lives model. Mike was turning his parents' home into a hotel where the guest gets to rage at the staff but the staff isn't supposed to react. The task that fell to his parents was to model how healthy adults take care of themselves. Mike was now 18. If he was looking for something that could stand up to his pot use, he was now going to find it in his parents. Instead of waiting for the court to engage him, they would now honorably engage him. A meeting was called and expectations were clearly stated. If his pot smoking had not stopped as he claimed, to be verified by his next UA, he would enter a residential program where he could also continue his education, or move out of his parents' home and begin his independent life. Mike realized that his parents just might pull the plug on him. He said he was ready to restart counseling in earnest.
On my part, as his counselor, I set boundaries, too. One more missed appointment or missed or positive UA and he went to back to residential treatment. 1st week's strategy: Not to hang out with friends who smoke pot. This is a true Achilles heel for adolescents. Although eschewing the old gang is a truism for recovering adults, for adolescents it seems to go crossways with their developmental process. Mike and I explored the degree to which each of us selects the social realities we live in; how much control we can actually have in that selection process. Mike opted to at least avoid those friends whose main interest in life was hanging out and smoking pot.
Since quitting again, Mike stated his dips into depression have decreased. The depression seemed to be a response to his lack of control over marijuana. Also, one of his strengths was reading. He cited books that engaged his imagination. Reading and talking about them made him feel like a successful learner and fired the hope that he could actually go to college. One of his strengths lay in the social arena. He had many friends, but he had tried to live full time in the party mode-eating only cake, as it were. A counseling component involved acknowledging his talent for living in a party environment (not everyone can), but then inviting him to explore the world outside the party. He liked music. He played an instrument. A task for the following week: he would record some of his own music.
Mike stated he had never struggled with an obstacle and reached a goal. As a kid growing up at home he never made a bed, cooked a meal, or cleaned a bathroom. He was presently struggling with what could best be described as dips into infantile rage. He was still merged with his parents and would become furious when he could not command their resources to procure immediate gratifications. More counseling tasks: to learn how to bear the tensions of communicating effectively with his parents, confront the wounds he had inflicted on their relationship and learn how to make amends.
Mike realized he had decided, early in high school, that people like me better when I'm false. Other kids liked his flippant, irreverent attitude. No one valued that he had a deep, philosophical turn of mind, so he said he didn't cultivate it. A big part of our work together became the cultivation of what he truly valued in himself as opposed to what others seemed to value.
Months later: Mike stated that after remaining clean for 2 _ months he'd hoped he'd never experience dips in his moods again, that would always feel as good as he did when he first quit pot. Had he been self-medicating with marijuana during critical developmental years when he could have learned age-appropriate coping skills for life's disappointments, delays and stresses? Or, did the apathy that seemed to grip him so powerfully require a renewed evaluation of supportive medication? On the other hand, the ability to be depressed can be a developmental achievement, and an indication of emotional growth (Winnicott, 1990, p. 73; Winnicott, 1954-5). Mike said he felt that, due to his substance abuse, he had lost everything his parents ever tried to give him. Was he beginning to grieve what he had wasted by being stoned and hostile to his family for the last three years? We resumed meeting two-times weekly in order to fortify a holding environment in which he could appropriately grieve. Mike revealed he feared he could not live an independent life due to his learning difficulties. His apathy lifted as we continued to strategically engage his learning challenges.
Although, Mike was able to maintain his abstinence from marijuana, his school no longer wanted him on campus. He opted to get his diploma through a local community college. His long-term challenges in sequencing and organizing still thwarted him. However, for the first time, he had actually begun collaborating in their remediation. A year prior, he could not sit through an exam because all he could think about was leaving and getting high. Now, though he wasn't getting high, he could still barely bring himself to keep a schedule, sit through a class, organize study time, and work through a paper. Part of maintaining hope for a future in which he could be self-sufficient most certainly had to involve coaching him through these learning challenges. One requirement of his treatment plan was to access the college's Learning Disability Resource Center. Mike refused to do this: one reason was he did not like showing vulnerability to strangers. His mother was the only academic coach he would accept at this time. That was the option that was open, so we went with it. As soon as he started to show improvement, and it looked like he might actually pass the classes required for his high-school diploma, both Mike and his mother exercised their penchant for leaping into future plans. Mike very quickly got overwhelmed, and stopped attending class. I therefore framed the sequencing task at hand in terms of taking baby steps. Invoking a conventional 12-step strategy One day at a time, I reminded Mike that it was his job to remain in present time. It was inappropriate to start worrying about what four-year college he was going to attend when he still had a hill to climb right in front of him. Let's get over that hill first. Mike was visibly relieved when he really got the idea of one day at a time. His mother agreed to help him sequence through the following weeks. Mike was to start keeping a day timer (a big challenge for him was to remember to look at it daily), create a schedule, complete community service as required by the court, and do chores around his parent's house. Thus began our focus on sequencing and concentrating on the next step-step by step.
Specifically, we discussed creating a work space in his bedroom. On school nights he was be in bed by 11:00 or midnight. Get up at 8:30; do a 30 minute exercise routine. Even thinking about not being free to hang out with friends until dawn and sleep all day elicited an oppositional reaction from Mike. We bore through the oppositional feelings in session. This gave Mike the experience of successfully bearing/containing his emotional energy without storming off or becoming verbally vicious. He also loved to escape schedules and concrete homework assignments by taking imaginative flights into music or books he was enjoying. We discussed the metaphor of a young man with wings-like Peter Pan. We looked at the positive side of puer energy, the verticality of spirit (Hillman, p. 102). Then we discussed when it's important to fold one's wings and attend to details. Mike's nervous system revolted at this; however, folding one's wings to achieve goals that are truly meaningful to oneself evokes positive feelings, as well. These feeling we nurtured.
Folding his wings started to feel bearable, even interesting. The process of sitting down and writing a paper involves collecting your resources, formulating your ideas, constructing an outline for the essay. It's like folding your wings and hunkering through a tunnel. However, as the essay's structure starts to grow and the ideas contained within that structure quicken, something happens. You discover that a huge open space has opened within the structure where you can actually imaginatively unfurl your wings and even fly. That's when writing becomes pleasurable. Mike was finally to experience the pleasure of writing an effective paper and getting positive feedback from his teacher
It was the beginning of many small steps, bumpy flights and a few crashes. But at this writing, Mike is in college and he is still clean-with a lot of structural support from his family and counselor. The sine qua non for him and all kids with LD, I believe, is their willingness to become collaborators in their own remediation, self-advocates for what they need to succeed, and celebrants of their own strengths, talents and passions.
DEVELOPING A FUTURE ORIENTATION
Mike had experienced the completion of a sequence of action in which he had brought to bear his attention and skills upon a challenge and succeeded. In the words of Albert Bandura, who pioneered theories of social learning, he had begun to develop efficacy expectancy (Bandura, 1977): He could move through a challenge and achieve the results he wanted. He was now at a point where he was able to start thinking about having a future.
Until Mike had actually experienced success, it did not seem possible for him to even entertain the idea of having a future career, much less succeeding at it. Developmentally, Mike was behind the curve on this. Developing a sense of the future begins in childhood and reaches a kind of culmination at 15-16 (Nurmi, 1991; cited in Marko and Savickas), which roughly corresponds to the 10th grade for most kids. Marijuana abuse, at this time, can really wreak havoc on this process. It's beyond the scope of this paper to discuss in detail how THC has an affinity for the hippocampus, a subcortical structure in the brain that allows new memories to be stored. If human consciousness can be reduced to attention and short-term memory (Hallowell & Ratey, p. 216), then kids with ADHD are twice at risk. Both ADHD and marijuana abuse can create an ahistorical self-a fragmented sense of self that is devoid of cognitive and emotional continuity.
Mike's dive into marijuana abuse correlated with a fear of being able to create an independent life for himself. Getting clean at 18 made it possible for us to address these trepidations. Like a lot of kids with substance abuse histories, Mike's future orientation operated mainly as a source of anxiety. When he got clean, he had to come to terms with the organizational and sequencing dysfunctions that challenged him throughout his secondary school career, and which could hinder his success in college. As it turned out, he was capable of mastering them to the degree that he became good enough at organizing time, agendas and projects to attend a traditional liberal arts, four-year college, which is what he wanted.
Daniel Levinson, in his seminal book, The Seasons of a Man's Life, describes this process of orienting to the future as the birth of the life's Dream. This process moves to center stage between the ages of 17-22.
In its primordial form, the Dream is a vague sense of self-in-adult-world. It has the quality of a vision, an imagined possibility that generates excitement and vitality
Whatever the nature of his dream, a young man has the developmental task of giving it greater definition and finding ways to live it out (p. 91).
The Dream can serve as an incredible ordering device. Where there was chaos, now there's a path. A path requires, and helps strengthen, the ability to focus. For the path to emerge from the chaos, another dynamic must become conscious: awareness of true desire.
A couple of years ago, six 11th and 12th grade boys were referred to me for substance abuse education. All of them had been diagnosed with ADHD. Two were severely dyslexic, and various other learning differences were present among them. This was a school referral, and I was to meet with the boys as a group on campus. They were strongly suspected of being players in a peer drug culture. As the facts unrolled later that year and the next, they were all heavy marijuana users. One confessed, after undergoing residential treatment, that he had also been into cocaine, ketamine (a tranquilizer used on animals by veterinarians), and opiates.
These guys were not thrilled to be in this group, to say the least. The first minutes of our first meeting were like being submerged underwater in an unpressurized diving tank. For openers, I asked each of them to introduce himself. You'd think I was dentist asking each of them to pull out one of his own teeth. Next, I asked why they had all been referred and gathered together to meet with me? From the looks on their faces, I surmised I was, at that point, supposed to realize that I surely must be the most ridiculous creature on the planet.
Because people think we do drugs, one of them guffawed.
Do you? I replied.
Then, they all guffawed. Clearly, this was not a group of penitents ready to change their ways. These guys belonged to a subculture with values and priorities foreign to mine. If there was a meta-communication I was being invited to understand in that moment, I surmised it was this: You don't know anything about us because you don't value what we value. And you don't have a clue what we care about. So, I decided to focus in on that. I asked them what I believe is a Million Dollar Question.
How do you think adult addicts who have gotten hideously and helplessly hooked on drugs quit?
The boys begrudged me a couple of replies. Because they have to? They'll go to jail if they don't?
Your answers are all about people who are being forced to quit by other people. There are lots of stories about people who quit drugs for six months while they're in jail, only to take it up again the moment they get out. I'm asking about people who actually decided they want to quit. As you all may know, or will someday discover, when you get really hooked on a drug, quitting is not so easy. You may be ready to quit, but like a bad relationship, the drug is not ready to quit you. One day you say, I quit! The next day, the drug says, 'I don't think so!'
I repeated the question. What is the only way adult drug addicts who want to quit finally manage to do it?
A boy shot off a terse reply: Will power.
That certainly helps. But without this one thing, will power becomes like a bungee cord. You can pull it only so far before it snaps you back.
The boys looked at me expectantly, and wearily. I gave them the Million Dollar Answer. They find or rediscover something else in life they love more than drugs. If they don't, even if they manage to quit for a while, they don't have a chance of staying clean.
The guys looked rather nonplussed.
So, I'd like to ask each of you some very personal questions, if I may. What do you love? What do you value most in the world? What do you value most in yourself? Is there anything you love more than drugs?
I didn't get a straight answer out of any of those guys that morning. But I did get their attention. Gone were the winks, smirks and private laughs. I felt, for the first time, that their public masks lowered. I saw them actually looking at me with interest. Freud maintained that dreams are the royal road to the unconscious. I've always felt that interest forms an equally direct road to where each of us individually resides within our private cores.
I wondered later if I didn't get a straight answer out of those boys that morning because they didn't know. A year after, one of them came to visit me. He had been in residential treatment for six months and drug free for one year. He was on a personal mission to talk to his peers about drugs and make amends for having sold drugs to them in the past. He told me about all the ways drugs had affected his life. One of the things he said was, drugs kept me from love. He was out of love with his parents, his teachers, and friends in a way he did not understand until he got clean. He was also out of love with his life's Dream, of which he was just starting to become aware.
How important is the Dream? Two big thinkers on the subject of human development-Sigmund Freud and Carl Jung-are remembered more for their disagreements than agreements. They agreed about this, however. Jung said that an unfulfilled major life's goal is a major cause of emotional disorders in adults. Freud said that one of the most damaging results of inhibited development is failing to find one's mission in life (Carotenuto, p. 187). Winnicott observed that immorality for the infant is to comply at the expense of a personal way of life (1963c, p. 102) The ancient Greeks defined sin as failing to become all you can be. Identifying and being true to a personal way of life comes into intense focus as a priority for adolescents (Winnicott, 1963b). A lot of adults take detours and stumble or fall on the way toward their life's Dreams. Many of us know how painful that can be. But for a kid never even to awaken to the possibilities of a Dream is a developmental disaster.
THE PARENT CONNECTION
Much of my work with adolescents in general, and kids with LD in particular, involves creating an affirming relationship (hence, environment) in which adolescents as emerging young adults can experience and bring forth who they are discovering themselves to be. To do this, kids require the assistance of adults capable and willing to dispassionately witness and affirm their process. Some of the most oppositional behavior I encounter in adolescents derives from parents (and teachers) failing to appreciate a child's unique way of manifesting in the world, and even rejecting what that kid feels to be real, true and interesting. I'm not talking about hair, or clothes, or tastes in music. I'm talking about deep urges to life that signal the emergence of a personal way of being, and the Dream.
For example: I was brought in on the case of Luke, an 18-year-old young man in his senior year. Luke's entire school career was complicated by multiple learning disabilities, and mood disorders inclusive of rages that were truly scary to his mother. For these reasons, he was heavily medicated and seemed a little wooden when he spoke. Luke's father was a high-achieving professional. I sat in on a college selection meeting with his parents and the school's college advisor. Luke had been required by his parents to take three years of college preparatory courses. Their dream for him was that he attend a four-year liberal arts college. Luke could be described as socially and academically awkward. However, when he talked about sports' car mechanics and maintenance, he came alive. His teachers and parents said his even reticence about reading lifted when he read car magazines and mechanical manuals. Socially, he discovered his grace with peers when he helped them with their cars or just shared his knowledge. A big part of my subsequent counseling work involved introducing the real Luke to his parents. It was a struggle for them to release the dream they had superimposed over his Dream. I must admit, as a clinician, I was chagrined that none of the mental health people who had worked with Luke had seen any correlation between his rages and the frustration and rejection he experienced daily in an academic program that taught only to his weaknesses for the preceding three years. Even his special education teachers seemed to have played to his parents' wishes and failed to advocate for this kid.
Kids with LD frequently have an LD parent. If these parents did not have anyone advocate for them when they were adolescents, it can be painful for them to revisit the subjects of true desire and finding a personal way of life. All kinds of feelings get aroused: a sense of deep loss, resentment, even jealousy. Sometimes, it takes a bit of courage for a counselor to enter such a discussion with parents, who may not only be strong personalities, but are also paying your fee. But courage is what we ask of LD kids every day. Sometimes, we've got to ask it of ourselves, too. By the way, Luke ended up attending a state college's school of mechanics. I had only known him a short while, but he asked me to speak for him at his high school graduation.
I am learning that the question, What do you love more than drugs? covers a lot of territory. Coming to a place in our psychological maturation where we can answer that question on a profound and life-determining level is a major developmental achievement. For example, what immediately constellates around any answer is the reality principle. We can all find ourselves loving things that are mutually exclusive. The love of a drug will eventually override our love of family (spouse, parents, children). We become like the proverbial boy with his hand stuck in the cookie jar: To get his hand out, he has to release one of the cookies. In Greek and Roman mythology, the question evokes the god Saturn, who is the god of time and limitations. Yet it is his blessings that are ultimately considered to be the most wonderful. Adolescence is when you first meet the paradoxes of love in all their complexity and depth.
More reality: Every Dream poses challenges. It asks, Do you have the courage and skills to undertake this Dream? Do you have the forbearance to undertake the ordeal of honing necessary skills? Are you willing to delay gratification for bigger future rewards?
What do you love? is a worthwhile question for any adolescent, whether they abuse substances or not. However, what it means to LD kids is I something I'm just beginning to appreciate. As many questions as answers arise. For example: Theories in early childhood development suggest that the cognitive achievements entailed in object permanence as described by Piaget (Miller, 1993), and the ability to hold an emotionally soothing, self-nurturing image of say, the primary maternal presence (Mahler, Pine, and Berman, 1975), are two quite different achievements (Cashdan, 1988).
Question: Is there a correlation between difficulties in picturing-forming, holding and retrieving sensory impressions-and the difficulty some children have separating from their parents in order to enter preschool, or even kindergarten? Similarly, when they reach middle adolescence at 15-16, to what degree do imaging challenges affect the emergence of the Dream? Levinson (1979) describes the Dream as a transitional object. In doing so, he invokes Winnicott's concept of the teddy bear, or blankie, that young children use to transition to a greater degree of independence from their mothers, thereby enabling themselves to venture farther afield in their explorations of the world (Winnicott, 1951).
How can we as counselors and educators support the process that adolescents with imaging problems need to go through in order to even imagine transitioning to their young adult lives? Remember Mike? A big part of his maintenance program after he had achieved abstinence from marijuana involved just such imaginings. I've come to consider this work an integral part of substance abuse counseling. The implications for vocational guidance as an adjunct to substance abuse counseling are fascinating.
RECOMMENDATIONS FOR SUBSTANCE ABUSE COUNSELING
Having access to special education teachers in my capacity as a school counselor certainly made it easier for me to design and execute interventions that rolled LD remediation into counseling in general, and substance abuse counseling in particular. In my private practice, I don't always have such a fast track to a kid's teachers. What I do then is educate the parents about what options and support are available in the schools their children attend. I don't necessarily know all the programs, but I can get the parent asking questions and seeking some action.
If the correlation between ADHD, Conduct Disorder and adolescent substance abuse is as high as we think, any substance abuse counselor can assume that a solid percentage of his or her adolescent clients will have learning differences. Years ago, I would always assess a kid's school career-were they failing or dropping out? Often I would ask kids to read for me: not just to see what I was dealing with, but to ascertain whether they had the basic reading skills to survive as independent adults. If they didn't, I knew it was futile to try to get them clean from drugs without simultaneously equipping them to survive and, hopefully, eventually flourish in their worlds. Clearly, I have only opened the discussion about the correlations implicit in learning differences and adolescent substance abuse. I look forward to seeing the discussion continue.
© Franklin Cameron, February, 2004. All Rights Reserved.
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