ALCOHOLISM TREATMENT: GENERAL CONSIDERATIONS IN WORKING WITH ADOLESCENTS

In working with an adolescent, it is wise to avoid obvious authority symbols, such as white coats, framed diplomas dripping off the walls, and a remote clinical attitude. Adolescents are probably already having some degree of difficulty with authority figures anyway, and they don’t need you added to that list. Being somewhat informal in dress and setting can remove one barrier. On the other hand, spiked hair, playing tapes, sitting on a floor cushion, and sucking on a “roach” when they arrive won’t go down very well either. They want you to know about those things, but not be into them; unless, of course, you really are (even then, leave the roach at home). An attempt to fake out the adolescent will fail. They are a hard group to fool, and they place a high premium on honesty. Respect this and honestly be yourself. This means asking for a translation of their vocabulary if you are not familiar with the lingo.Empathy rather than sympathy is the goal. This is true of all therapeutic relationships. Sympathy is feeling like the other person. Empathy is knowing how the person feels, understanding it, but not feeling like he does at the moment. For instance, it is simply not helpful to be depressed along with the person.In general, three types of therapy are done with adolescents. One involves manipulation of the environment. This can include arranging for the father to spend more time with his child, getting the kid who hates Shakespeare into a different school program, or organizing a temporary placement for the child whose parents are nonsupportive at the time. These can be very valuable interventions.Standard insight therapy—psychological, psychiatrically oriented traditional therapy—is not often used. Not many adolescents are ready for, or even could benefit from, this kind of therapy. The ones who can benefit from it tend to be “bright,” advantaged young people, who seem more capable and older than their peers or their chronological age would suggest.The most commonly productive therapy is what could be termed a relational approach. This requires time for you to become well acquainted and for the adolescent to feel comfortable with you. The counselor is supportive of the person without doing it for him. The counselor is a neutral person, available to the adolescent in a very different way than are parents or peers.The issue of confidentiality always comes up. It can be a mistake to guarantee that “nothing you say will ever leave this room.” The counselor does have the responsibility for others as well as the adolescent client. Given blanket protection, what happens when the kid announces he plans to rob the local deli, or another says she plans to drive the family car off the road at the first opportunity? A different approach was suggested by Dr. Hugh MacNamee. His practice was to tell whomever he saw that though most of what they said would be held in confidence, if they told him anything that scared him about what they might do, that would be harmful to themselves or others, he was going to blow the whistle. He made it clear he would not do so without telling them; nonetheless, he would do it. In his experience, adolescents accept this, maybe even with relief. It may help to know that someone else is going to exert some control, especially if they are none too sure about their own inner controls at the moment.In a similar vein, Dr. MacNamee would suggest keeping the adolescent posted on any contacts you have with others about him. If a parent calls, start off the next session by informing the adolescent, “Hey, your Dad called me, and he wanted….” If a letter needs to be written to a school, probation officer, or someone else, share what you are writing with the adolescent. The chances are fairly good his fantasy about what you might say is worse than anything you would actually say, no matter what the problem. Because trust is such an issue with adolescents, it is important that you be willing to say to them what you would say about them behind their backs.Although the aforementioned is a good general approach to the issue of confidentiality, you may need to be aware of other complicating factors. In particular, we refer to the legal issues of a child’s right to care versus parental rights to be informed. There may be circumstances in which an adolescent has a legal right to be seen and treated without parental knowledge or consent. In any case, the ground rules you are following must be clear to the adolescent client.*150\331\2*

USING ST JOHN’S WORT IN SEASONAL AFFECTIVE DISORDER (SAD): HOW LONG SHOULD YOU CONTINUE TO TREAT YOUR WINTER DEPRESSION?

In general, those who recover spontaneously from their winter depressions during the summer months are able to stop their antidepressant treatments – be they light or medications – when long sunny days arrive. The same principle should apply to St John’s Wort and I would recommend that those who normally feel fine in the summer discontinue the herbal anti-depressant at that time. On the other hand, there are those who feel somewhat down all year round, only more so in the winter. These people are likely to benefit from St John’s Wort all year round.

For a further information about the effects of the seasons on mood and behaviour, and strategies to deal with the difficulties caused by the short dark days of winter or other forms of light deprivation, I refer the interested reader to my book Winter Blues (Guilford Publications, 1993), which deals with these topics in greater detail.

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COMING OFF TRANQUILLIZERS: VISUALIZATION

Continue the relaxation session by taking time to get as comfortable as possible on the floor using blankets, cushions or coats. You may not feel cold when you lie down but as you relax your temperature could go down. (People who feel unhappy on the floor can be supported in a chair.) Lie down, shoulders relaxed, palms up. If you have back pain you may be more comfortable with your knees slightly bent and your feet on the floor.

Start with five minutes abdominal breathing, and try to be aware of your breathing during the session. Arrange for someone to play a relaxation tape. Choose one that has a passage of soothing music at the end. Close your eyes and imagine you are with the group or with someone who has made you feel secure in the past. Let the tape ‘wash over you’ without struggling to concentrate.

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WITHDRAWAL SYMPTOMS: CHEST SYMPTOMS AND PALPITATIONS AND EYE PROBLEMS

Chest Symptoms and Palpitations

Always see your doctor if you have chest pain have experienced tightness, numbness or pain in the chest or down the left arm. This could be another rebound effect. After you have been reassured by your doctor, accept the temporary discomfort, it will pass. Abdominal breathing often helps.

It is not surprising that people become convinced that there is something wrong with their hearts when they experience palpitations or missed beats. If you were running for a bus and your heart rate increased, it would not worry you. Because you are cutting down on drugs that have slowed the heart rate, you can expect a similar effect.

Eye Problems

Sore eyes and visual disturbances are common. Users often change their spectacles several times during withdrawal. Check with your oculist to make sure, but you will probably find that the blurred vision and sore eyes will clear up as withdrawal progresses. Pads of cotton wool soaked with witch-hazel on closed eyes may be soothing. Tinted lenses are helpful if you are sensitive to light.

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WITHDRAWAL SYMPTOMS: HYPERVENTILATION (OVER-BREATHING)

Clients find it very hard to believe that so many symptoms can be due simply to not breathing properly. Rapid, shallow breathing is very common in withdrawal. It may be due to spasm (tension) in respiratory muscles, or it may be that the central mechanism in the brain is temporarily disturbed. This does not mean that you will stop breathing, but it does mean you will have to practise abdominal breathing.

When someone is anxious, over-breathing is usually present (again part of the ‘fright and flight’ response), but in withdrawal it seems different. Users in hospital for acute withdrawal have been observed to over-breathe even whilst asleep.

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HOW DO I COME OFF MY PILLS? ACUTE WITHDRAWAL IN HOSPITAL

The speed at which you can withdraw may depend on what is happening in your life. If you have a stressful job, particularly where driving or operating machinery is involved, or have young children or a sick person depending on you, it may have to be taken slowly.

Acute Withdrawal in Hospital

If sick leave is possible, your doctor may be able to arrange hospital admission. This is usually advisable after a long drug history, or where the side-effects are causing chronic ill health. A four to six week stay is usual with at least two weeks without the drugs before leaving hospital. For some, there will still be a recovery period after discharge.

Since this is essentially a medical problem, a pharmacological or drug dependence unit is preferable. Some people refuse a bed in a psychiatric hospital. Others are eager to come off their drugs quickly and will go anywhere. Resist well-meaning therapists who attempt psychological probing in early withdrawal. You may not have deep psychological problems. Even if you have, it is not the time for the ‘Why do you hate your father?’ approach. It should be a time for rest and reassurance. Deep conflicts will arise spontaneously if they need to.

Try not to develop a ‘pill phobia’. Accepting other drugs temporarily to keep you comfortable could help your recovery.

It is exciting to see the physical changes that appear as people come off their tranquillizers—eyes lose the dull glazed look, skin colour and texture improve, and hair comes back to life.

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