Book Review

TREATING THE UNMANAGEABLE ADOLESCENT

We live in a time when the number of crimes involving adolescents and young adults is skyrocketing. When youngsters show destructive behaviour or come in conflicts with the society or law, it is much easier to put blame on them than reform them. General public, including mental health professionals, often hold contemptuous attitude and extend prejudiced comments towards them. They take little effort to understand what such youngsters are going through. With lots of recent heated discussions about this in the backdrop, it would be relevant to have a look at how one can manage and rehabilitate a juvenile delinquent.

Though there is a lot of discussion on behaviour management, there aren’t many books which do an in-depth examination of the practical issues faced by mental health professionals dealing with adolescents suffering from disruptive behaviour disorders(DBD). The book being reviewed here, “Treating the Unmanageable Adolescent - A guide to oppositional defiant and conduct disorders”, is authored by Neil. I. Bernstein and was published by Jason Aronson in 1996. It will serve as a descriptive yet simple handbook for the therapists, especially beginners, who deal with adolescents. With elaborate case examples and role plays, this book makes the simplest presentation about handling DBD. Though the content may be familiar to experts, fresher’s will find it easy to understand the information and apply it in therapeutic settings.

Neil. I. Bernstein is a practicing clinical psychologist based in Washington DC, USA. He has   more than 25 years of experience in guiding troubled teenagers and their families, and his expertise is widely acknowledged. He serves on the advisory board of ‘Partnership for a Drug Free America’, and is a familiar face in child mental health related TV shows and public awareness programs in the US. He has many books on adolescent mental health to his credit. He acknowledges that the catalyst behind this book is the feedback given by his adolescent clients and their families. He has special interest in oppositional and conduct disorders, and discloses that he is still struggling to understand what fuels such destructive behaviour patterns while trying to develop better ways to alter them.

The book has fifteen chapters, and most include elaborate case descriptions that exemplify the issues they cover. In the introductory note Bernstein reminisces his encounters with a childhood playmate Ralf, who was from a broken family and had DBD. He describes how he befriended and invited that boy home and ended up getting his baseball cards looted.

The first chapter explains the developmental considerations, DSM specifications and prevalence of DBD. The author elaborates on its characteristics, family patterns associated with it and the specific issues raised by inner city youth who grow up in adverse circumstances and also provides some useful formulations with case examples.

The subsequent two chapters explain how to develop therapeutic alliance with the reluctant youngsters and their parents, and focus on the origins, manifestations, and remedies of the resistance they exhibit. The fourth chapter enumerates ways to confront, challenge defenses and set limits. Also listed are some anticipated confrontations and ways to handle them.

In the fifth chapter, the author argues that, if done judiciously, therapist disclosure is a potentially powerful agent of change. He observes that if the therapists are open and informal, the adolescent will find them more trustworthy. The disclosure can serve as a model for mature adult behaviour to the youngsters, which will be facilitating them to share their own fallibilities. He also discusses how to deal with various client reactions inside and outside the office, how important is it to keep personal boundaries to insulate one from intrusions, and how the therapist can deal with the emotions evoked by these adolescents.

In the author’s opinion, treatment termination is to be considered once the client has sufficiently progressed. Forgotten assignments and comments about busy schedules may be considered as signs of breaking away. Sometimes the youngsters themselves may express the wish to terminate therapy. Some youth, on the other hand, may find it difficult to terminate as it is their first ever relationship based on mutual trust and respect. The emerging ability of the youngster to assert themselves in a non-destructive manner would be the yardstick for progress in therapy. This can be assessed by giving them test situations and asking how they would handle those.

As the anger and impulsivity will intensify conflicts with the society, any treatment of DBD should include training on self-control. Author points out that, CBT, the most dominant approach to self-control, become more effective when the need for change is emphasized. Youth with DBD usually focus on their self-righteous perceptions and lack awareness of other’s feelings. They need to learn to deal with and express anger appropriately, as it can help to resolve conflicts. The author elaborates constructive use of anger, methods to change negative attributions, anger management training, thought stopping, and games to improve impulsivity in an interesting manner. A neat description is also provided of how self-control gained from the therapy can be extended to real life settings by encouraging the youth to remain prepared for provocations, and by getting them provoked by their close acquaintances and asking them to report and discuss these incidents in therapy sessions. When others, including therapist, appreciate their improved way of handling provocations, that becomes a reinforcer for them.

The author presents “thought stopping method” as a technique that can be used to divert attention from provocative stimuli. First, basic relaxation techniques are introduced by explaining how professional athletes and artists relax immediately before their performances by taking deep breath and exhaling. Next, training is given on progressive relaxation. As an extension of this, counting backwards, focusing on the numbers or envisaging visual imagery of enjoyable moments in life are also encouraged.

The book describes two simple but useful techniques, “fogging” and “freezing”. Fogging is used to downplay the significance of others’ provocative comments.¹The trick here is to handle such comments without retorting. For example, if someone says “You’re stupid”, the response could be “You’re right, I’m one”. Use of humor too is recommended, provided it won’t escalate the conflict. Freezing is a technique to improve self-control by delaying the immediate reaction to provocation. Here, the youngsters are asked to imagine that they are actors in a conflict sequence of a movie and that the director suddenly shouts “cut”. By this, they are taught to stop whatever they are doing irrespective of its significance.

The book suggests that youngsters can be helped to overcome their resistance in therapy groups and consequently in real life situations by therapist modelling. For this purpose, the clients are also asked to watch and criticize videotapes of both awkward adolescents and smooth operators. Encouraging them to sharpen their existing skills is more effective than pressing them to acknowledge their shortcomings. The chapter stresses the therapists’ role in social skills training by narrating its essential ingredients like modelling, liberal use of praise, noting and expanding micro gains, encouraging and rewarding self-disclosure, and ensuring secure feelings of the clients.  

The book also expands on skill sequencing techniques, the art of conversation, assertiveness skills, and social problem solving with role play illustrations. Problem solving technique is well explained here. The procedure is simplified by breaking it down to small steps. Clients are encouraged to share their encounters with annoying situations. They are then asked to think about the problem from the perspectives of both the parties involved, and to focus on how it started. They are also asked to identify the accompanying emotions and the desired outcome. By asking to consider the alternatives in a non-judgmental way and to find out the likely consequence of each possibility, they are facilitated to identify the most beneficial alternative to the discussed problem.

Despite the bravado and indifference they show, youth with DBD are usually unhappy with their lives and avoid close relationships. They often lack a realistic view of self and it is a therapeutic task to help them develop it. The chapter on building self-esteem deliberates on its assessment and determinants and a recipe to develop self-esteem.

The ninth chapter presents techniques to develop empathy, morality and vulnerability. Methods to develop socio-moral reasoning are elaborated with themes like theft and domestic violence. To conceptualize its development, Kohlberg’s stages of socio-moral reasoning are used.² Stage one represents laws of jungle: the least mature and most superficial moral view, where there is no consideration for mutual needs and people comply with powerful and physically superior authority for fear of harm. Stage two is more pragmatic, and focuses on satisfaction of needs and avoidance of negative consequences. Here the return of a favor is the intention behind doing something for another person. Most youth with DBD function at this level, and they do not violate rights of those who do them favors. Those in stage three, which is more mature, can establish relationships with others and see things from their perspective. They feel guilty after a wrong behaviour which reduces the chances of its repetition. Whoever reaches stage four understand and respect conventional standards and will be able to socialize well and respect others’ rights.

Chapter ten, ‘Guidelines for managing behaviour problems’, is about the hurdles parents face while living with those youngsters. In the next chapter, the author underlines that the difficulties these youngsters face in school are multi-determined. He highlights a number of factors, ranging from scholastic difficulties to peer influence and parental expectations, as reasons for their discontent. Suggested interventions to increase their interest to continue in school include accommodation in small sized classes, matching students with competent teachers, using hands-on learning approach, individualizing instructions, giving meaningful assignments, encouraging extracurricular activities and positive peer culture including peer mentors. Impact of school at home and the aspects of therapist involvement with the school are also described in detail.

One full chapter is dedicated to family interventions using parent management training, functional family therapy and multisystemic therapy as the frame-works. Challenges of group therapy in DBD youngsters are enlisted in the next chapter. As the peer group has most influence on adolescents, an understanding of how, why and what the antisocial youth will do in groups and how it can influence the outcome of group treatment are elaborated well with literature back up.

In the penultimate chapter titled “Putting it all together”, Bernstein summarizes the entire information with the help of a case example, and demonstrates how the application of techniques given in the book can be employed in less-than-ideal circumstances. Details of individual sessions, interactions with the family, interventions at the school level and group interventions are given, followed by a case summary. This chapter is indeed a unique feature of this book and helps the readers to recollect and refresh whatever they have assimilated.

The last chapter on ‘hard core youth’ shares what the author has learned from his treatment failures. He comments that unsuccessful treatment is multidimensional. The chapter highlights the personal and family characteristics and environmental factors that usually contribute to treatment failure. The chapter also illustrates real life situations which can trigger an improvement or lead to a so called ‘spontaneous cure’ of DBD.

Taken in all, the book is rich in essentials of treatment approaches with ample literature support. Its dual focus on measures to understand the clients and steps to alter their core symptoms makes it attractive and handy. This book illustrates how to effectively help young people presenting with a wide array of DBD symptoms. As it being very descriptive, some readers may find it dragging too. While most other available books on this topic restrict themselves to individual techniques or methods and fail to integrate the available interventions for the remediation process, this book fulfils therapists’ need for clinically useful information by integrating a variety of interventions targeting on specific issues. Though a novice may find it very informative, experts in this field may not spot much new information as it being a single edition book without updates. Those who try to apply the techniques mentioned in the book in Indian clinical settings may face many practical difficulties as the book focuses largely on group sessions, that too with trained therapist assistants. Many school interventions the book mentions may also not be feasible in our settings, considering the socio-cultural differences.

REFERENCES

1. Feindler EL, Ecton RB. Adolescent anger control: cognitive behavioural techniques. New York: Pergamon; 1986.

2. Kohlberg L. The psychology of moral development: Essays on moral development. vol 2. San Francisco: Harper and Row; 1984.