This innovative book focuses on helping high-risk adolescents and their families rapidly resolve long-standing difficulties. Matthew D. Selekman spells out a range of solution-focused strategies and other techniques, illustrating their implementation with vivid case examples. His approach augments individual and family sessions with collaborative meetings that enlist the strengths of the adolescent's social network and key helping professionals from larger systems. User-friendly features include checklists, sample questions to aid in relationship building and goal setting, and reproducible forms that can be downloaded and printed in a convenient 8 1/2" x 11" size. Blending family therapy science with therapeutic artistry, the book significantly refines and updates the approach originally presented in Selekman's Pathways to Change.
|Publisher:||Guilford Publications, Inc.|
|Product dimensions:||6.00(w) x 9.00(h) x 0.81(d)|
About the Author
Matthew D. Selekman, MSW, LCSW, is a family therapist and addictions counselor in private practice and Director of Partners for Collaborative Solutions, an international family therapy training and consulting firm in Skokie, Illinois. He is an Approved Supervisor with the American Association for Marriage and Family Therapy. Mr. Selekman served as the invited Henry Maier Practitioner-in-Residence at the School of Social Work of the University of Washington and is a three-time recipient of the Walter S. Rosenberry Award from Children’s Hospital Colorado for his significant contributions to the fields of psychiatry and behavioral sciences. The author of numerous professional articles and seven books, including Working with High-Risk Adolescents and Collaborative Brief Therapy with Children, Mr. Selekman consults worldwide to schools and treatment programs serving adolescents and their families. Since 1985, he has given workshops extensively throughout the United States, Canada, Mexico, South America, Europe, Southeast Asia, South Africa, Australia, and New Zealand. His website is www.partners4change.net.
Read an Excerpt
Navigating through Complex High-Risk Adolescent Mazes
We are continually faced with great opportunities which are brilliantly disguised as unsolvable problems.
— Margaret Mead
Across the country, economic hardship and state and federal funding cuts for services to high-risk youth and families have forced social service and child protection agencies, mental health clinics, addictions programs, residential treatment programs, and even specialized hospital-based programs to reduce their staff sizes, or even to close down. As a result, clinicians still working in such settings are being inundated with many challenging and complex adolescent cases. These kids arrive at their programs with extensive treatment histories and past traumas, and come from multiproblem families, which for even the most seasoned family therapist can be very difficult to work with. Furthermore, because of administrative productivity requirements, health insurance limitations, and time constraints, clinicians working in the trenches are expected to see more of these difficult cases for much shorter durations of treatment.
To help combat these clinical challenges, those fortunate surviving agencies, clinics, and specialized treatment programs that have well-endowed training budgets are purchasing expensive empirically supported family therapy treatment packages. These include staff family therapy training, supervision, case consultation with stuck cases, and a program evaluation component. Unfortunately, the vast majority of these agencies, clinics, and treatment programs can't afford them. Even if they could, they lack the staff to implement them and the capacity to provide 24/7 home-based treatment and crisis management.
These empirically supported family models have produced solid therapy outcome data that indicate they work well with high-risk treatment populations such as adolescents who are violent, delinquent, disruptive in school, substance-abusing, eating distressed, self-injuring, severely depressed, and suicidal (Alexander, Waldron, Robbins, & Neeb, 2013; Diamond et al., 2006; Diamond, Diamond, & Levy, 2014; Diamond & Stern, 2003; Henggeler & Schaeffer, 2010; Henggeler, Schoenwald, Borduin, Rowland, & Cunningham, 2009; Henggeler & Sheidow, 2011; Le Grange, 2011; Liddle, 2010; Liddle & Diamond, 1991; MST Services, 2014; Robin & Le Grange, 2010; Robbins, Horigian, Szapocznik, & Ucha, 2010; Rowe, 2012; Schwartz, Muir, & Brown, 2012; Smith & Chamberlain, 2010; Szapocznik, Hervis, & Schwartz, 2003; Szapocznik, Waldron & Brody, 2010). Yet they are not panaceas, and the leading proponents of these models seldom write about or present in-depth data on why some families prematurely drop out or experience treatment failures. Most of these models are heavily problem focused, therapist or/team expert driven. From my perspective, they are not client directed or collaborative enough, and do not incorporate enough important psychotherapy outcome research findings on the common factors. Studies in psychotherapy research suggest that 40% of what counts for treatment success is client extratherapeutic factors, a subset of the "common factors" described in the literature, such as utilizing client strengths to the maximum degree, resources, resiliency protective factors, past successes, theories of change, and stages of readiness for change to empower clients to resolve their difficulties (Duncan, Miller, Wampold, & Hubble, 2010; Norcross, 2011; Selekman & Beyebach, 2013; Sprenkle, Davis, & Lebow, 2009). In view of the client extratherapeutic common factor research findings, clinical evidence-based practitioners recognize the dangers in adopting the "one-size-fits-all" treatment philosophy. They view the clients as the experts on their lives and recognize the importance of establishing collaborative partnerships with them so clients have the lead voices with goal setting and all clinical decision making. In addition, clinical evidence-based practitioners recognize that it is best to view these challenging cases through multiple theoretical lenses. These practitioners know they need to include themselves as part of the observations they are making in the clinical encounter; to ask bold and well-thought-out questions from a position of not-knowing and curiosity; and never to lose sight of how the complex interactions among the families they treat involve larger systems professionals, key resource people from their social networks, and the community at large. These other people hold tremendous potential for the co-generation of multiple high-quality solutions.
All family therapy models need to be flexible, and more integrative to better meet the contemporary needs of today's high-risk adolescents and their families. The empirically supported family therapy models will have even better outcome results by adopting a stronger client strengths-based, outcome-informed emphasis, and by integrating some of the ideas from newer therapeutic approaches that are showing clinical promise. In this spirit, this highly practical book presents a collaborative strengths-based family therapy (CSBFT) model that combines the best elements of the major empirically supported family therapy approaches with clinical practice wisdom regarding what works with high-risk adolescents presenting with both externalizing and internalizing disorders. What is unique about the CSBFT approach is that it individualizes the treatment for high-risk adolescents and their families. Under this model, therapists carefully tailor what they do therapeutically with the clients' preferences, theories of change, expectations, goals, and input regarding therapeutic intervention design and selection, throughout the clinical decision-making process.
In this chapter, I first discuss four key dimensions of adolescent risky behaviors including how they are maintained individually, by peers, families, concerned professionals, and members from their social networks. Next, I provide a comparative critical analysis of the strengths and weaknesses of the major empirically supported family therapy approaches and recommendations for ways to further improve treatment outcome results. Two clinically promising family therapy approaches for self-injuring and suicidal adolescents are also discussed. I follow this with a discussion on the importance of evidence-based clinical wisdom and the benefits of combining therapeutic art with family therapy science. I then offer a brief overview of the CSBFT approach, followed by a discussion on individualizing what we do therapeutically to the unique needs and characteristics of high-risk adolescents and their families. Finally, I present 16 CSBFT practice guidelines for working with more challenging high-risk adolescents and their families.
Let's start with a perspective on four important dimensions of adolescent high-risk behaviors: (1) adolescent risky behaviors as resources for coping; (2) key findings from recent neuroscience research on the adolescent brain; (3) the need for positive risk taking and collaborative risk management with high-risk adolescents; and (4) how "high-risk" adolescent problem-determined systems are created and maintained.
ADOLESCENT RISKY BEHAVIORS AS GIFTS AND RESOURCES FOR COPING
Having worked for decades with adolescents who were deemed "high risk" by mental health, healthcare, and school professionals, I have observed that there is a logical dimension to their provocative, intimidating, troubling self-destructive and destructive behaviors. For many adolescents, their high-risk behaviors have served as gifts, resources, and attempted solutions to help them to cope with individual, family, and social stressors in their lives. It is no surprise that they gravitate toward particular behaviors that work for them. You probably see these kinds of things in your practices routinely:
Using anger and aggression to gain power and control over others when one feels disempowered and devalued in one's family, among one's peers, and in life in general.
Cutting oneself to get quick relief from emotional distress, to soothe oneself, or for numbing out bad thoughts and feelings.
Engaging in extreme daredevil behaviors as a way to escape from feeling emotionally dead inside.
Using cocaine, methamphetamine, and other stimulants to elevate one's moods.
That's not to say these behaviors are benign or to be encouraged. The longer adolescents engage in high-risk behaviors, the more uses they find for them and the more fearless they become (Selekman, 2009; Selekman & Beyebach, 2013). Often, these youth will associate with peers who engage in similar behaviors, share the same struggles in their lives, and with whom they feel a strong sense of connection (Hardy & Laszloffy, 2006; Taffel, & Blau, 2001). It is important to note that, developmentally, adolescents must figure out a way to fit in with their peers; failure to do so is equivalent to social death (Selekman, 2009)!
Bear in mind as well that adolescents who turn to high-risk behaviors may do so with distress they feel in the wake of a traumatic experience. According to van der Kolk and his colleagues (van der Kolk, 2014; van der Kolk, MacFarlane, & Weisaeth, 2007), we need to respect the clients' use of self-injury, eating-distressed behaviors, and substance abuse as coping strategies or defensive shields to ward off flashbacks, painful feelings and memories, and suicidal thoughts. Premature removal of these coping strategies can contribute to a youth's being so emotionally vulnerable that he or she becomes suicidal and needs to be hospitalized.
THE ADOLESCENT BRAIN AND HIGH-RISK BEHAVIORS
The past decade's neuroscience research on adolescent brain development helps explain why adolescents are risk- and sensation-seeking beings (Siegel, 2014; Steinberg, 2014). The findings from this research help us to understand why adolescents continue to engage in risky behaviors even when they repeatedly lead to quite severe consequences. This research also helps adolescents and their parents or legal guardians understand what is driving these behaviors. Knowing this important information can help prevent unproductive parental and professional social control responses like yelling, lecturing, dishing out severe and lengthy consequences, being medicated, psychiatrically hospitalized, or sent to residential treatment as a response to their risky behaviors. Research indicates that the frontal lobe areas of adolescents' prefrontal cortexes are not fully developed until ages 23 — 24. The prefrontal cortex area of the brain has to do with impulse control, planning, and judgment. So it makes sense that adolescents with their still-developing prefrontal cortexes would be impulsive, make poor choices, and repeatedly choose ultimately unhelpful means for managing stress and life difficulties they are faced with (Siegel, 2014; Steinberg, 2014).
The adolescent's hypothalamus and amygdale are also immature. These components of the brain have to do with mood regulation and management and serve as our brains' alarm systems (houses our fight-or-flight response) in response to emotional and external threats. This is why even small disappointments or frustrations can evoke intense and extreme emotional reactions in adolescents. In addition, some high-risk adolescents' amygdalae are so hypersensitive that when they are exposed to emotional distress they cope by lashing out at others or engaging in self-destructive behaviors for quick emotional escape. Adolescents' primitive survivalist brains drive them to pursue shortcuts to pleasure by engaging in risky behaviors for quick relief from emotional and physical distress. They are more likely to repeat high-risk behaviors that are attached to positive emotional memories and experiences that are stored in their brains' limbic system region. Finally, adolescents are more likely to engage in more extreme risky behaviors when observed and sanctioned by their peers (Schoen, 2013; Siegel, 2014; Steinberg, 2014).
The good news is that due to our brains' plasticity (our ability to create new neuronal pathways in our brains), we can develop a repertoire of positive behaviors and habits, such as mindfulness meditation, yoga, dancing, exercising, making art, or writing poetry (Selekman & Beyebach, 2013). These positive habits can become the go-to activities for coping with emotional and physical distress the more consistently they are practiced. Neuroscientists Schwartz and Gladding (2011) teach clients to counter their brains' self-defeating and/or self-destructive behaviors by telling themselves, "I AM NOT MY BRAIN!" Instead, clients are encouraged to pursue a wide range of healthy coping strategies and meaningful activities that they come up with and have been exposed to by their therapists, such as mindfulness meditation.
POSITIVE RISK-TAKING OPPORTUNITIES AND COLLABORATIVE RISK MANAGEMENT
Since we know that adolescents, by nature, are risk and thrill seekers, why not provide them with ample opportunities to be challenged by positive risk-taking activities and tasks? Positive school and community activities can take the form of psychological, physical, and social challenges, such as: rock climbing; fund-raising strategies for community or social causes that they are interested in; offering a wide range of service work opportunities; forming new clubs or groups to counter student difficulties like bullying and eating disorders; inviting a gang member to co-facilitate a violence prevention group; or serving on a student advisory council to help school administrative staff make the school experience more inviting, intellectually stimulating, and opportunity rich.
Adolescents who have been deemed "high risk" often possess many strengths and talents that can be accentuated and utilized to empower them and to help turn around their lives and the lives of others. When empowered, they can become positive leaders and peer counselors in their schools and communities. They enjoy and find meaning and purpose in life when helping the less fortunate and doing prevention and outreach work with both their peers and younger children (Selekman, 2009; Selekman & Beyebach, 2013).
Another way we can aid adolescents engaging in risky behaviors is to encourage them to take the lead in making good choices, through looking at their options and reflecting (Steiner, 2014; Welch, 2009). We can ask the following types of questions:
"With your crew (friends), how much and how often do you have to party (drink/do drugs) with them in order to be accepted by them?"
"Do you think it is possible to cut back a little if you chose to and still be accepted by your friends?"
If the answer is "Yes" ask, "How will you decide to cut back and how specifically will you pull that off successfully?"
If the answer is "No" ask, "What will you choose to do, especially if your heavy partying is continuing to cost you big time in most areas of your life?"
"HIGH-RISK" ADOLESCENT AND PROBLEM-DETERMINIED SYSTEMS
There are two major ways adolescents can be labeled as "high risk" and they and their families can become ensnared in problem-determined systems. The first pathway is by being red-flagged for engaging in risky or intimidating behaviors, like cutting, substance abuse, eating-distressed habits (bulimia, binge eating, obesity, self-starvation), aggressive behavior, and delinquent behaviors, such as bullying or gang involvement. The second pathway is by just coming out of or having a history of incarceration, psychiatric hospitalizations, and residential treatment. This latter group is often placed in specialized support groups at school or in therapeutic day school settings with the belief that they will have grave difficulty surviving emotionally, behaviorally, and academically in regular public or private school settings and need a lot of individual attention. There also may be a strong push from the juvenile court system, the school, or their psychiatrists for them to receive intensive multimodal outpatient treatment, which often includes being on psychiatric medications.
According to Anderson (1997) and Anderson, Goolishian, and Winderman (1986), once a "problem" is identified or defined, a system of helping professionals and, in some cases, concerned members from the adolescent's social network coalesce around trying to solve the problem or control identified "high-risk" behaviors. For example, if a female adolescent student is identified as a "self-injurer" at school, often there is a wide range of pressing questions, beliefs, and emotional reactions (fear and anxiety to take immediate action to protect the student from herself) that are triggered in the minds of the school professionals involved, such as: "Is she suicidal?"; "Has she been sexually or physically abused?"; "Does she have 'borderline personality disorder'?" Due to school liability issues, there may be a strong administrative push with her parents for her to be psychiatrically evaluated or worse, hospitalized. This may lead to her being placed on antidepressant medication and either referred to a specialized adolescent outpatient program for self-injurers or a short stint in a psychiatric hospital, with the thinking that she might be at high risk for a suicide attempt. Once she gets involved in the specialized intensive outpatient program or gets out of the hospital, she will be tightly monitored and seen quite regularly at school by her school social worker or counselor and may be placed in a special group for students just coming out of hospital and residential treatment programs. Within the context of the problem-determined system, a negative self-fulfilling prophecy and an oppressive dominant story can inadvertently get set in motion. This can lead to the adolescent's questioning her own abilities to cope and to her return to self-injuring and possibly concurrent self-destructive habits. Even if the adolescent refrains from cutting herself, appears happier, and is avoiding associating with former toxic peers, these positive sparkling moments often go unnoticed because they do not fit with the dominant story of her having "poor coping skills," or that "self-injurers are sneaky and I bet she is still doing this behind the scenes," and so on. If caught at school cutting again, the parents will be notified their daughter may need to be placed in a therapeutic day school setting and they need to closely monitor her at home, which means loss of her privileges and freedom. These interactions can go on endlessly between the professionals, parents, concerned members of their social networks, and the identified "high-risk" adolescents. Often, the adolescent and the parents lose their decision-making voices in the problem-determined system. Interactions with the professionals in power positions can enforce response and action as long as they are concerned. Problem-determined systems and their concomitant oppressive dominant stories and problem life-support systems are not just limited to school systems. They can get set in motion by the complex interactions between multiple larger systems professionals, the family, concerned members from the family's social network, and the lightning-fast spread of concern and rumors among adolescents' peers' communications via social media.(Continues…)
Excerpted from "Working with High-Risk Adolescents"
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Table of Contents
Foreword, Harlene Anderson 1. Navigating through Complex High-Risk Adolescent Mazes 2. Family Engagement: Tailor the Relationships of Choice 3. Building Strong Partnerships with Pessimistic Helping Professionals and Members from Families’ Social Networks 4. Collaborative Treatment Team Planning and Goal Setting 5. Co-Developing and Selecting Interventions to Suit Clients’ Strengths, Theories of Change, and Goals 6. Family–Social Network Relapse Prevention Tools and Strategies 7. “The Atomic Bomb Kid”: Working with a Violent Adolescent 8. From “Numbing Out Bad Thoughts and Feelings” to “Welcoming Death”: Working with a High-Risk Suicidal Adolescent 9. Therapeutic Mistakes and Treatment Failures: Wisdom Gained and Valuable Lessons Learned 10. Therapeutic Artistry: Finding Your Creative Edge References Index
Clinical child/adolescent psychologists, family therapists, counselors, social workers, and psychiatrists. May serve as a supplemental text in graduate-level courses.