Tag Archives: teenager

DXM: A drug in plain sight

By Emily Weaver, Sharon J. Davis and David Saarnio November 10, 2020

We are writing this article to raise awareness among parents and counselors about a legal and easily accessible drug that is widely used by adolescents to get high: dextromethorphan (DXM). DXM is an ingredient found in certain medications meant to help us get better, so teens frequently abuse this drug without being aware of the potential consequences and dangers. Given the personal insights and experiences we have with the damaging effects of DXM, we are sharing this story in hopes of reaching a larger population and creating more efficient prevention strategies related to teen drug use.

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When co-author Sharon Davis’ son was 17, he began abusing over-the-counter (OTC) cough medicine. He had been using marijuana and K2 (synthetic marijuana) for a few years, but it was Coricidin — a cold medicine marketed as being for people with high blood pressure — that really damaged him.

Sharon’s son became a different person. He had always been a moody kid, but his moodiness turned to anger, mania and psychosis. Over a four-month period, his father and mother took him to the emergency room four times. It wasn’t until he attempted suicide that they really got him the help he needed and found out the full extent of his addiction.

He had been introduced to Coricidin through some friends. Soon he was using 30 pills at a time. Coricidin use led to cocaine use. Cocaine use led to methamphetamine use. Two years later, he is working on recovery, but his mind and mental health will never be the same.

According to the Partnership for Drug-Free Kids, 50% of American teenagers have misused a drug, and drug overdose is the fourth-leading cause of death among teens. Parents, counselors and other adults are well aware of the problem of teen drug use, and the nation’s opioid epidemic has brought the topic of medication misuse to the forefront of public attention. That attention is long overdue. However, that focus also misleads us because other critical concerns are being overlooked.

For example, our society is largely neglecting to talk about the large-scale problem of adolescent misuse of OTC medicine and its potential as a gateway to other drugs. In fact, OTC cough and cold medicine is one of the most popular drugs that youth use to get high. According to the Monitoring the Future survey funded by the National Institute on Drug Abuse, more teens got high from OTC medicine in 2019 than from prescription opioids.

Why OTC?

OTC cough medication is easy for teens to get. In some places, teens can purchase these medications from their local convenience stores. Furthermore, most stores have these medications out on the shelf where they are easy to steal. Teens can also get them from peers and even from parents. Because they don’t necessarily perceive these types of medications as “dangerous,” many parents will store them in an unlocked medicine cabinet, unknowingly allowing their teens easy access to them.

The psychoactive drug in OTC cough and cold medicine is DXM, which falls into a class of drugs known as dissociative hallucinogens. Other drugs in this category include PCP, ketamine and nitrous oxide. The Food and Drug Administration (FDA) approved DXM as a cough suppressant in 1958. It remains legal to buy and use in the U.S. DXM is a safe drug when used as directed, but when used in 10 times or more the recommended dose, it acts as a powerful dissociative, distorting reality. Currently, 85%-90% of OTC cough medications contain this effective antitussive (cough inhibitor). DXM is a synthetic opioid drug, but it activates different opioid receptors in the brain than prescription opioids do.

Teens typically misuse DXM to feel the euphoric, dreamlike experiences and hallucinations it causes. When individuals use DXM to get high, they experience various levels of inebriation, known as plateaus.

There are four plateaus associated with DXM. The first plateau involves mild intoxication and stimulant-like effects. The second plateau features increased intoxication and mild hallucinations. At the third plateau, the user enters a state of altered consciousness with impaired senses and psychosis. The fourth plateau involves a sense of derealization (in which the world appears unreal) and depersonalization (e.g., detachment from the self).

Users describe the higher plateaus as akin to being in other realms or alternate universes. Commonly, users feel an out-of-body sensation, like being transported to another dimension. They lose their sense of self and time. It is common for users to post videos or blogs about their experiences, including what they felt like and what they saw while high. The slang term robo-tripping is how many teens refer to being high on DXM. Slang terms for the drug itself include triple-C’s, robo, skittles, red hots and dex.

Why is DXM problematic?

DXM is a dangerous drug when used outside of therapeutic doses, yet little has been done to curb its misuse among teens. For decades, we have known about the consequences of misusing this drug, including seizures, hyperthermia, tachycardia, psychosis, mania and even death.

The opioid epidemic in this country is a national crisis. It is worthy of public attention and government funding to address. At the same time, DXM misuse among teens is also startling, and yet it is rarely highlighted. This drug is more popular than opioids among young people, and it is legal, inexpensive and easy to get.

It is imperative that prevention efforts and policies address this problem. For example, laws similar to those passed in 2005 that required pharmacies to move the popular methamphetamine-making drug pseudoephedrine behind the counter could make DXM less readily available. Some states already require purchasers of OTC cough and cold medications containing DXM to present an ID proving they are 18 or older. We believe this should become mandatory nationwide and that sellers of these drugs should be held accountable.

Furthermore, mass awareness campaigns targeting parents, teachers, law enforcement and counselors need to remind adults of the dangers of these drugs, whereas prevention programs for children and teens should increase their focus on the dangers of OTC medications. National campaigns and policy changes are called for, but these alone will not likely be enough to cause real change. True prevention efforts require work on multiple levels — from the policymakers in Washington to counselors and parents in local communities. Each of us has a part to play, and each can make a difference.

Where do teens hear about DXM?

In today’s era of prolific internet and social media use, teens have more access to the world than ever before. In past decades, peer pressure to use drugs was a huge concern. It was thought that susceptible teens would be influenced by their peers in the neighborhood and at school. This peer pressure occurred face to face.

Today’s teens still confront in-person peer pressure, but they now also face this pressure virtually. Peer influence can come not just from the local teens at school but from millions of teens across the world online. Many teens access the internet and find out about drugs of abuse, including how to get high on OTC cough and cold medications.

A quick search of popular sites such as YouTube can lead teens to videos that either warn of the dangers of DXM or encourage users to experience the high from it. Unfortunately, many websites include dosing recommendations and “tripping” suggestions for having a better experience of getting high.

For example, Reddit, one of the most popular social media sites around the world, has an estimated 430 million active users. Reddit consists of threads that allow its users to post about certain subjects and topics. These threads are like cybercommunities made up of members who hold similar interests. One of these threads, called “r/DXM,” has more than 31,500 users. This thread allows people a place to describe their DXM highs and the side effects. It also provides advice on how to minimize certain side effects such as nausea.

Other websites and cybercommunities such as Dextroverse.org and the Vaults of Erowid provide teens outlets to post about their DXM highs and get advice from other users on how to use the drug. The site DexCalc.com allows users to enter their weights and get a recommended dose for the “plateau” of high they want to achieve. Although many of these websites claim that their purpose is “harm reduction,” teens typically use these sites for suggestions and advice on the “safest” using pleasures. All of these websites are accessible to teens, and all of them are free to use.

Prevention efforts

Fifteen years ago, the FDA issued warning labels on OTC cough and cold medications aimed at making parents aware of the dangers of medicine abuse by teens. The Stop Medicine Abuse campaign launched nationwide in 2004, but clearly that campaign was not successful. More needs to be done to dissuade youth from abusing OTC drugs.

As counselors, we need to step to the front lines of true preventive efforts. This means that we need to know more about DXM (and other OTC medications), the reasons teens are using it, the ways teens are getting it and the most effective methods to prevent its misuse.

Getting parents involved is a good first step. Parents must know what to look for and how to talk to their teens about OTC drugs. Counselors need to get the message out to parents to be realistic and truthful when educating teens about DXM. Scare tactics do not work for many teens; in fact, they may make teens more curious about experiencing the outcomes for themselves. A better approach for prevention may be for parents, family members and other adults to increase the quality of their connection to and communication with youth.

Research shows that establishing consistent messages against drug misuse and having clear boundaries early on can be among the best prevention efforts for teen drug use. Simple steps, such as hiding medications and taking inventory, can also be effective. Most parents want to trust their teens, but having medications that contain DXM where teens can access them is not wise, and many parents are not aware of the dangers of DXM medications. OTC cough and cold medicine should be as securely stored as opioid prescriptions.

In addition, parents need to know what sites their teens are accessing online. A parallel line of defense involves checking browser histories and having clear rules about what teens can access online. Drug use is a leading cause of death among teens (resulting in more than 5,000 deaths per year according to figures from the National Institute on Drug Abuse). Parents wouldn’t want their teens searching for firearms or lethal poisons online, and no parent should want their teen searching for how to get high from DXM. Parents may not be comfortable with this advice. After all, it may feel like snooping, and teens are likely to resist as well. Even so, what teens access online can be one of the biggest telltale signs of drug use.

Establishing rules for computer/internet usage (e.g., allowing a teen to use the internet for two hours a day after completing homework), installing a firewall and setting locks or passwords for downloads can all be safety measures that contribute to prevention or, when needed, intervention. The earlier that parents establish household internet rules, the better. Proactive planning and putting rules in place before children reach their teen years may prove much easier than trying to establish new rules once teens are in late adolescence.

Talking to teens about drug use is often uncomfortable for parents. Many parents do not know where to begin. Some parents are worried that talking about drugs will increase their children’s curiosity about using. Other parents simply find the topic embarrassing or awkward. As counselors, we need to help parents develop communication skills with their children and teens, but especially starting in middle childhood. Counselors can provide parents with resources for where to find information about drugs of abuse, and we can intervene if a teen has already started using. It is almost a certainty that teens talk to other teens about getting high on OTC cough and cold medication. As counselors, we need to encourage parents to talk to their children about choosing not to get high on it.

If Sharon Davis, as both a counselor and parent, had recognized the signs of DXM abuse in her son, he might have gotten help sooner. The message we want parents and counselors to hear is that DXM is one of the most popular drugs for teens, and despite it being legal and easy to get, it is not safe when misused. Sharon was unable to prevent all the damage done to her son, but we hope that her story will help parents of children and teens across the country to protect their own sons and daughters.

 

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Emily Weaver is a graduate student in the clinical mental health counseling program at Arkansas State University. She plans to graduate in the spring, become a licensed professional counselor and pursue a career in addictions counseling. Contact her at emily.weaver@smail.astate.edu.

Sharon J. Davis is a professor at Arkansas State University and a certified rehabilitation counselor. Contact her at sharondavis@astate.edu.

David Saarnio is a professor of psychology at Arkansas State University with a specialty in developmental psychology.

 

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

For such a time as this: Plan of action for young adults, adolescents and parents

By Esther Scott June 22, 2020

[Editor’s note: This is the third of four articles in a series on action plans for different areas of life during the COVID-19 pandemic.]

To young adults, the risk of contracting the coronavirus or suffering a negative outcome may feel remote. Research studies show that when young people talk about risk reduction, they tend to be referring to reducing social or reputational risks. As a young adult, you may be in the same boat. While the individual risks of COVID-19 may seem low for young people, it is worth stating that becoming infectious could worsen the health and financial security of your community and make it much harder for you to find work, especially if you are just graduating.

Remembering that your youth and health give you “superhero” powers will help you take a more active role in this crisis to protect yourself and those you love. As the line from the Spider-Man comics and movies reminds us, “With great power comes great responsibility.” You have the power of good health, and it is your responsibility to help solve the problem by protecting yourself and others.

Here is a plan of action for young adults, adolescents and their parents.

 

1) Obtain reliable information.

A deep understanding of how people view risk is crucial to stopping the spread of disease. Gathering a similar understanding of COVID-19 can help young people to participate willingly instead of resenting authority. It is important that you see breaking physical distancing guidelines as being risky not only for yourself and those you love, but risky for your entire community.

The same is true when it comes to understanding your economic risks. Analysts believe that young workers and new grads may be hit harder because they tend to work in the food, retail and hospitality industries — places that are experiencing harsher impacts as consumers stay home more. Obtaining reliable information will help you navigate the expected upcoming changes.

2) Control peer pressure. Prioritize safety over reputation.

One obvious reason for the prioritization of social reputation over health risk is peer pressure and the need to fit in socially. In the wake of COVID-19, there were numerous stories in the media highlighting young people who continued to gather despite social distancing guidelines. There were also reports of young adults violating shelter-in-place and social distancing orders to meet lovers and potential hookups because they felt pressured by friends to do so.

One way to evade social pressure is to plan your response ahead of time. Hosting remote meetings and parties could be one such response. With the rise of social media, distant hangouts are trending.

 

Plan of action for students and adolescents

In this difficult situation, it is best to look at the positive side: We have unbelievably valuable time to spend at home. This unprecedented situation that we are experiencing affects everyone. Adolescents too can learn to manage what they can control so that they emerge from this stronger. We can use this crisis to help them grow as resilient, autonomous human beings. Here is plan of action that can help students and adolescents make the most of this situation.

1) Keep a structured routine — a time for everything.

It is particularly important to keep a predictable routine. Develop a schedule that includes activities such as family sports, reading books, and collaborating with the rest of the family. It is important that students, especially teenagers, spend time in productive physical activities. Go out and throw the ball, shoot some baskets, go for a walk around the block or simply do some jumping jacks.

2) Continue education by reading and writing.

Two other important activities for students and adolescents during this crisis are reading books and writing thoughts. This time at home is the perfect opportunity to dedicate yourself to reading books and stories that have been on the shelf for a while. If possible, we recommend reading together as a family, including reflecting on the content of the story or answering questions that come up after reading it.

Writing thoughts or a diary with the events of the day or a gratitude journal about things you enjoy will continue to help you put these circumstances in perspective. If you graduated from high school or college this year, consider staying in school to pursue the next level of education. It could help you land a higher-paying job in the future.

3) Get involved.

Participating in household chores and taking responsibility for “their things” (their room, their clothes, etc.) is especially motivating for older children and adolescents. Allowing them to collaborate in the kitchen by researching new recipes or cooking (especially when personal assistants such as Google Assistant and Alexa are available for recipes) can also help develop growth and autonomy.

There are various ways that students and adolescents can take their place in this moment in history and make this time more enjoyable. They can write letters to the older adults in their families or communities and show appreciation for health personnel by sending prayers to them and those who are sick. It is good for young people to develop a sense of belonging in their communities and to know that their actions make a difference.

 

Plan of action for parents

Sticking to a routine is essential to keep your sanity (just as it is for your children). Maintaining a schedule can be helpful in creating a bit of normalcy in this unexpected situation and in reducing your anxiety level because your brain will feel in control.

Be a team. Keep it balanced. If you have a partner, try alternating who is looking after the kids or making meals. But most importantly, communicate your needs to your team. Remember that flexibility is key in times of crisis. Be kind to yourself; you are doing the best you can.

Although we have yet to see the full extent of the economic slowdown induced by COVID-19, analysts currently expect that we will recover once the virus is under control. So, hold on.

 

 

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Esther Scott, LPC

Esther Scott is a licensed professional counselor in Arlington, Texas. She is a solution-focused therapist. Her specialties include grief, depression, teaching coping skills and couples counseling. Contact her through her website at positiveactionsinternational.com.

 

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

School vaping cultures: Acknowledging the impact of COVID-19

By Zachary Short and Nicole Baliszewski June 4, 2020

This past January, global tobacco conglomerate Altria saw a major drop in its stock value on the New York Stock Exchange, depreciating at a value of almost 40% versus its record-breaking highs in 2017. What caused this sudden dip in one of the biggest-rebounding industries of the 21st century? It would be fair to suggest that the COVID-19 pandemic has caused some major complications for both the traditional and electronic cigarette corporations located across the United States.

As a respiratory-based infectious disease, COVID-19 poses an unparalleled threat to the health and safety of individuals across the age spectrum with significant histories of vaping or smoking. In fact, a recent study in the New England Journal of Medicine found that Chinese patients with a history of smoking were twice as likely to suffer from severe infections associated with diseases such as COVID-19 in comparison with those without any smoking history.

Having always opposed the youth vaping/smoking culture, counselors and community advocates across the nation are currently working to answer a significant question: What actions can we be taking to protect our communities from the combined threat of COVID-19 and recent vaping trends?

The truth is, now is the prime time for considering how we can influence our communities to create better post-quarantine schools for our students.

The loss and revitalization of the smoking industry

Only five years ago, health specialists with the Truth Initiative anti-smoking campaign speculated that the tobacco industry and most of the nation’s smoking addictions would expire with the Generation Z demographic. But vaping, the process of inhaling prepackaged aerosols (also known as vapor), has led to the resurgence of nicotine products within school systems.

Through a combination of peer pressure and social media campaigns, students from all backgrounds have found themselves under the influence of Altria’s newest partner, Juul Labs, maker of the Juul electronic cigarette. Largely as the result of the popularization of this flavored electronic smoking device, the number of high school students who use nicotine products has increased from 3.6 million to 5.4 million in the span of only one year, according to the Centers for Disease Control and Prevention (CDC).

How significant it would be to know that schools were free of the harmful aftereffects of adolescent smoking, leaving school counselors and clinicians available to attend to the important mental health developments that are so essential in our school systems right now. Instead, we find ourselves dealing with another truly concerning issue: According to the Truth Initiative, 1 in every 4 high school students now uses e-cigarettes.

These concerning statistics represent a call for preventative action in middle schools across the nation. A number of schools and organizations have taken such counteractions to trends in vaping by launching interventions such as confiscation, disciplinary action, and even educational programming. But the culture of vaping continues to persist as a significant concern for parents and educators.

The most terrifying thing about the Juul product so far is that it appears to come off as being innocuous to many people. Most students and parents recognize it as the small USB-shaped device that produces fruit-flavored smoke. Very few seem to grasp the long-term consequences of vaping habits. That being said, those consequences might already be here.

The individuals at risk

Based on data collected by the CDC in early March, evidence suggests that COVID-19 poses a serious threat to all individuals ages 65 and older. Fortunately for students under the age of 18, the percentage of those infected and harmed has been relatively low by comparison.

While most parents find some comfort in hearing that the student demographic is the least impacted by the pandemic, the statistics can change drastically if students are part of the vaping culture that is rampant among youth. According to data provided by the CDC for China’s mainland population facing COVID-19, individuals with respiratory issues predominantly associated with even a small history of smoking or vaping have a 6.3% case fatality rate, in contrast to 2.3% overall. Recognizing how exposure to vaping increases a person’s health concerns, imagine the increased risks that our students could face should their still-developing physiques come in contact with both nicotine products and a respiratory infection.

“What they say is about 80% of people feel the flu, but they will be OK. Where we are getting into trouble is that it can lead to severe pulmonary distress,” says Anna Song, an associate professor of health psychology and leader of the Health Behaviors Research Lab at the University of California Merced. “Smoking is a risk factor for having this disease progress, be incredibly severe, and lead to mortality.”

As we know, COVID-19 has posed widespread challenges to the health and lifestyles of the global population. Societal and educational norms have begun to deteriorate, and everyday tasks and responsibilities now come with an unprecedented health risk to individuals and their families. Of great concern to us is that the unattended trends and cultures of our school systems could be having a negative impact on our students right now. To allow these trends to persist beyond this pandemic is to continue putting our students at risk unnecessarily.

A unique opportunity for change

What makes now such an ideal time to invest in removing the harmful vape cultures that continue to linger in our school systems? Students are largely being required to undertake remote learning during this time, and that may continue for many students even as a new school year begins. The changes and circumstances that come with students’ remote learning actually promote our greatest opportunity for the development of an anti-smoking culture.

Society is recognizing that our plans, policies and preparation were inadequate to succeed in the face of an unanticipated global pandemic. Thus, things are beginning to change. Legislation is developing to create preventative actions around practices deemed unhealthy by medical specialists, and educational policy is constantly being reformed to reflect the needs and issues present in our impromptu teaching conditions. If there was ever a time to acknowledge the statistics that point to the harm that nicotine products pose to our adolescents and to advocate for the safety of our children, it is now.

Large systemic changes are challenging and often are out of our hands, but educators and parents currently have the opportunity to make a notable difference in students’ environments. During this time of partial quarantine, most families are now all in one location — the home. Our students currently find themselves in a setting where they are under the watchful eyes of their families and where smoking purchases and practices are essentially impossible.

In addition to that, they are also in a potential learning atmosphere. Through the joint efforts of educators and parents, our youth can be exposed to real educational and intimate conversations regarding the dangerous practices of smoking. These conversations can mean the world to students who currently feel that their futures and health might be dictated by vaping culture.

COVID-19 has had a harsh and unpredictable influence on our way of life, but it also presents us with a rare opportunity to support our students through one of the greatest health issues of their generation. So, making use of the present, it is time that we as a supportive community of counselors consider what we should be doing to help facilitate and emphasize this process of growth for students’ mental and physical health.

Our responsibility to intervene

As of early April, individuals within Rowan University’s Department of Psychology have been conducting their own research to confront the vaping culture that remains prevalent during the COVID-19 pandemic. Their research takes an interesting approach to behavioral analysis with younger age groups, including the development of interesting activities such as mobile- and video game-based interventions that promote smoking abstinence.

Fortunately, this is just the tip of the iceberg when it comes to the collective efforts of universities to combat vaping trends in student populations. Even educational institutions outside of higher education are recognizing the statistically supported danger that vaping is putting our students in when facing the current health pandemic. As a community, it is our collaborative responsibility to provide education and to take the necessary precautions to protect our students’ health. We are just beginning to understand the proper steps to take when working from a remote distance.

Educating the community: Providing knowledge of the increased risks and hazards of smoking behaviors is the first step to reducing nicotine consumption within our school systems. Given the myriad resources available on the consequences of vaping from the CDC, the National Institute on Drug Abuse and even university websites such as Johns Hopkins Medicine, it is the obligation of school counselors and other school personnel to appropriately share this information with our local communities. It is important to remember that this information needs to be given not only to the students we support, but also to our educational partners and to the families who are acting as our immediate support systems in homes at this time.

Promoting real conversations: With the knowledge and statistics being supplied to our students’ homes, it is more important now than ever that school systems promote real conversations with students regarding the present vaping cultures. Whether it is school counselor-to-student or parent-to-student conversations, we need to understand what the student perspectives are when they see products such as Juul in the media while also witnessing terrifying statistics regarding the spread of a global virus.

With those who are currently smoking, it is vital that we understand their concerns and interests so that we can provide them the appropriate support they need. These conversations are the optimal opportunity to promote and communicate resiliency, empathy and community support to our students. And with those who have never touched a vaping device, communicating this information and the associated risks is the best possible preventative action at this time.

Advocating for policies: To reiterate, now is a turbulent time when leaders are reflecting on educational preparations and policy and how they might be applied for future incidents. In addition to redesigning our school’s remote learning policies, we need to be working as a professional community to advocate for anti-vaping policies within our schools. It is essential that school counselors reflect on school policies regarding smoking tolerance, as well as preventative actions to take, so that they can create real opportunities to support student health.

Fortunately, states and health institutions are rallying to create a number of anti-vaping models that can be implemented or referenced by school counselors looking to better their schools. One such model is the Make Smoking History campaign, conducted by the Massachusetts Department of Public Health, to reduce the percentage of vaping disciplinary actions taken in middle school settings. This is the time to ask for and support the voices of the education community to find out what should be done for the development of our educational systems — not just on a school-by-school basis, but from a legislative perspective.

Forming support groups: Finally, acknowledging that this is a difficult time for individuals who have a dependency on smoking tools to which they no longer have easy access, we need to prepare and create remote counseling groups to support them through potential issues such as withdrawal or rehabilitation. A number of counselors may struggle with the concept of remote group counseling, but these students still need emotional and mental health support to cope with their new distancing from vaping. Counselors should utilize the medical resources and personnel within their school districts to support students in their transition to healthier living. Ultimately, it is groups such as these that we should be planning to implement more frequently in our later return to school.

The truth is that in the midst of a global health crisis, most individuals view the issue of vaping in school systems as relatively small. But the fact is that vaping is a real health issue for our youth, and in combination with the threat of COVID-19, it puts our newest generation of students at exceptional risk for loss. In a moment in history when many counselors are at home and wondering what they should be doing to support their students, imagine what significant change could occur if we all directed a portion of our efforts to acknowledging and countering the present vaping culture.

 

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Related reading, from the Counseling Today archives: “Pushing through the vape cloud

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Zachary Short is a master’s counseling in educational settings student at Rowan University. He currently works as a clinical research intern in a high school setting, where his research in student behavioral outcomes is being supported through the Mental Health Grant Demonstration Program. Contact him through LinkedIn: linkedin.com/in/shortzachary/.

Nicole Baliszewski is a master’s counseling in educational settings student at Rowan University. She currently works as a clinical intern in a middle school setting, where she seeks to provide trauma and mental health support to the special education student population. Contact her through LinkedIn: linkedin.com/in/nbaliszewski/.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Engaging avoidant teens

By David Flack May 4, 2020

Ben** is a 16-year-old high school sophomore. He completed a mental health assessment about four months ago, following a referral from his school due to behavioral concerns, poor attendance and “possible issues with marijuana and other substances.” He previously attended school-based mental health counseling in seventh grade and has been meeting periodically with a school counselor for about a year.

(** Ben is a former client who gave permission to use his story. His name and some identifying details have been changed to protect confidentiality.)

At the time of assessment, Ben was diagnosed with major depressive disorder, moderate. He also completed screening questionnaires for trauma, anxiety and various other issues. All scores came back well below clinical levels. Despite the school’s concerns regarding substances, a formal drug assessment didn’t occur.

Todd and Julie, Ben’s parents, have been divorced since Ben was 3. Ben lived with his mother until about a year ago. Todd now has full custody but frequently travels for work. Both parents have been fairly disengaged in the counseling process. In fact, Doris, Ben’s fraternal grandmother, was the only family member to attend the assessment.

At the assessment, Doris appeared overly enmeshed with both Ben and Todd. She also reported that Julie “has bipolar but won’t take any meds” and “drinks too much, at least if you ask me.” Doris also stated that Ben “probably was abused” by Julie’s ex-boyfriend but refused to provide further details. “I don’t think I should have said anything.”

Following the assessment, Ben entered services reluctantly, meeting with his original counselor for almost two months. At that time, he was referred to me because the original counselor decided, “I can’t be effective with such a resistant kid.” The counselor said Ben’s attendance was poor and that he displayed an unwillingness to engage when present, did not complete treatment homework, and “showed up high at least a few times.”

During our first meeting, Ben reported, “All that other therapist did was keep saying how her office was a safe space to talk about feelings and crap like that. You know, the bullshit therapists always say. The bullshit I bet you’ll say too.”

Numerous studies show that an effective therapeutic alliance is essential for engagement, retention and positive treatment outcomes. However, many teenage clients simply aren’t interested in counseling, let alone creating connection or building rapport with some strange adult. This is especially true when it comes to avoidantly attached teens such as Ben.

Building effective therapeutic alliances with these youth can seem daunting to even the most seasoned counselor. In this article, we’ll explore practical, field-tested strategies for cultivating rapport with avoidantly attached teens. First, though, let’s briefly review some core attachment ideas.

We aren’t sea turtles

When a mother sea turtle is ready to lay eggs, she heads to a beach and digs a hole in the sand with her rear fins. She lays her eggs in this rudimentary nest, covers them, and quickly returns to the ocean. At this point, the mother sea turtle has completed all her parenting tasks and has nothing more to do with the eggs. Male sea turtles have nothing at all to do with their offspring.

When the eggs hatch, the newborn sea turtles awkwardly scamper to the ocean, using fins meant for swimming, not avoiding predators on land. If they survive this mad dash, they’re fully ready to live on their own. No caregiver ever provides nurturing, teaches them life skills or protects them in any other way.

Humans aren’t sea turtles. In our early years, we need caregivers just to survive. If these caregivers are attentive, protective and nurturing, human babies quickly learn that the world is a safe place, their needs will be met and people are glad they’re here. These children will be securely attached. However, if their primary caregiver isn’t dependable, then this healthy attachment process can be disrupted, resulting in an insecure attachment and possibly lifelong challenges with relationships, self-esteem and personality development.

There are three styles of insecure attachment: avoidant, anxious and disorganized. Avoidant attachment is the most common style of insecure attachment, with studies indicating that up to 1 in 4 Americans fall into this category. Undoubtedly, this percentage is higher in clinical settings.

Young children who develop an avoidant attachment style predictably have caregivers who are emotionally unavailable and ignore the child’s needs. These caregivers may reject the child when hurt or sick, typically encourage premature independence, and sometimes are overtly neglectful. As a result, the child learns, “I’m on my own.”

Attachment styles are continuums, so avoidantly attached teens don’t all act the same. That said, these youth often appear defiant, defensive or dismissive. They’re likely to present as highly independent, oppositional and unwilling to change. They’re also likely to be suspicious of any empathetic gesture.

A little more about empathy

Simply put, empathy is the ability to understand the feelings of another person. As counselors, we’re taught that empathy is an essential component of all effective therapeutic relationships. I certainly don’t disagree with this. However, it seems to me that empathetic gestures are far from one-size-fits-all.

With reluctant clients of all ages, many counselors demonstrate empathy by saying things such as, “Seeking support is a courageous step” or “My office is a safe space to explore your feelings.” It’s like turning the volume up on some secret empathy knob. With anxiously attached clients, this could be quite effective. For avoidantly attached teens though, this is often overwhelming. Life has taught these youth to be cautious of such statements. So, when they hear such statements, they retreat.

I’m certainly not suggesting that we turn our empathy off as counselors. However, in the early stages of building therapeutic alliances with avoidantly attached teens, we need to turn the volume down. With this in mind, don’t congratulate avoidantly attached teens for starting counseling, especially if doing so is simply their least bad choice, and don’t declare your office a safe space. They know better.

I believe this more nuanced perspective of empathy is an essential foundation for engaging in the attachment-informed strategies that follow.

Starting out right

With avoidantly attached teens, first impressions are essential for starting out right. Here are four tips to help ensure that first meetings are therapeutically productive:

Emphasize rapport building. First meetings often involve stacks of paperwork, required screening tools and initial treatment planning. I encourage you to put that stuff aside and spend time getting to know the teen sitting across from you. You’ll have to finish all those forms eventually, but if this new client never returns, tidy paperwork and a well-crafted diagnosis won’t matter much. Besides, you’ll get better answers from teens such as Ben once you’ve developed some rapport.

Get parents out of the room. Unlike Todd and Julie, parents or caregivers almost always attend first meetings. When they do, I meet with everyone to cover the basics, such as presenting concerns, my background, and confidentiality issues. I then ask parents what they think I should know. After I get their perspective, I have them leave. That way, most of the first meeting can be focused on learning what the teen wants from services and cultivating rapport.

Focus on what they’re willing to do. Therapists love to focus on internal motivators and lofty treatment goals, but this isn’t useful with avoidantly attached teens, who want one thing — to leave and never come back. You’ll get further by helping them identify external motivators, such as fulfilling probation requirements or keeping parents happy. Helping avoidantly attached teens move toward these concrete goals proves that you’ve actually listened to what they’ve said, makes you an ally, and keeps them coming back.

Don’t hard sell therapy. When confronted with resistant clients, it’s easy to overstate the advantages of engagement. After all, if we didn’t believe in therapy, we wouldn’t be therapists, right? However, our enthusiasm may be exactly what an avoidantly attached teen needs to justify a quick retreat. Instead, objectively present your treatment recommendations, then explore the pros and cons of engaging. In my experience, most avoidantly attached teens agree to services when they don’t feel coerced.

With the first meeting successfully concluded, our next task is to cultivate an effective therapeutic alliance. Edward Bordin (1979) wrote that the therapeutic alliance is composed of
1) a positive bond between the therapist and client, 2) a collaborative approach to the tasks of counseling and 3) mutual agreement regarding treatment goals. When we strive to fully integrate these elements and genuinely embrace a teen’s motivators, we stop being an adversary and become an ally. For avoidantly attached teens, we also become a much-needed secure base — maybe their only one.

Building a strong therapeutic alliance with avoidantly attached teens requires us to focus on being trustworthy and creating connectedness.

Trustworthiness

Avoidantly attached teens have learned to continuously question the honesty of others. As a result, it is essential for us to be absolutely impeccable in our trustworthiness as counselors. It isn’t enough simply to be trustworthy though; we must demonstrate it — and not just once or twice but during every single interaction.

Brené Brown (2015) likened trust to a jar of marbles. Every time that we demonstrate our trustworthiness, we put a metaphorical marble in the jar. As the jar fills, trust grows. When it comes to building therapeutic alliance with avoidantly attached teens, there are five especially important marbles:

Authenticity. In the context of therapeutic alliance, authenticity means being our true, genuine selves during interactions with clients. In other words, we set aside therapeutic personas and canned responses. Instead, we show up as who we really are. This should be our goal with all clients but especially so with avoidantly attached teens, who are often quite sensitive to insincere behaviors or actions — a skill they learned to help them navigate difficult relationships with the adults in their lives.

Consistency. Being consistent means acting in ways that are predictable and reliable, something avoidantly attached teens probably haven’t experienced much. When we are consistent in our interactions with these teens, we are not only demonstrating trustworthiness but also modeling a new way of being in relationships. A few ways to demonstrate consistency include always starting and ending sessions on time, scheduling appointments at the same time every week, and following through on any promises we make.

Nonjudgment. Avoidantly attached teens have often learned to notice seemingly minor cues, such as a slight change in facial expression. This is a useful skill to have in situations in which care is unpredictable. With that in mind, it is important for us to avoid comments, gestures or facial expressions that could be interpreted as judgmental. This seems obvious but can be harder than it sounds, especially when a client is frustrating, evasive or baiting us — you know, like teens do sometimes.

Usefulness. Another way to demonstrate trustworthiness is to provide something useful at every session. This doesn’t mean achieving a major clinical breakthrough every week. That wouldn’t be realistic. However, there should be a tangible takeaway of some sort each time that we meet with an avoidantly attached teen. Possibilities include a helpful skill, a solved problem, an opportunity to vent or a meaningful insight — as long as it adds value to the youth’s life.

Transparency. This means being completely open about the therapy process, including our intentions as a helper and what clients should expect from services. Truly transparent therapists spend time exploring the pros and cons of counseling, reasons for discussing certain topics, and the theoretical underpinnings of proposed treatment approaches. In other words, transparent therapists strive to eliminate the mystery from the process. Like a good magic trick, knowing how it works should make it more engaging.

Connectedness

According to Edward Hallowell (1993), connectedness is “a sense of belonging, or a sense of accompaniment. It is that feeling in your bones that you are not alone.” I often describe this deep connectedness as feeling felt. In order for any of us to truly feel felt, we must believe that we are understood, respected and welcomed. We must feel as though we’re interacting with another person who has purposefully chosen to join us in this exact place and moment.

Avoidantly attached teens haven’t had this lived experience of connectedness. When working with these teens, we should always strive to model connectedness in ways that honor their implicit suspicion of empathy, while simultaneously helping them move toward more secure attachment styles.

Allan Schore (2019) refers to these as “right brain to right brain” connections. We can intentionally create such connections by using approaches that focus on emotion, creativity and attunement. It seems to me that teen therapy typically focuses on problem-solving, decision-making, psychoeducation and similar left-brain approaches, ignoring the importance of helping clients become more comfortable using their whole brain.

Here are five simple yet effective strategies for intentionally fostering right-brain connections:

Validate and normalize. Viewed in the context of his lived experiences, Ben’s distrust, oppositional behavior and even substance use were functional. In other words, Ben found value in these behaviors. In fact, he once said, “I guess what I really want is to push people away, and I’m good at it. Really good!” We can validate intentions without endorsing problematic behaviors. With avoidantly attached teens, this is often an essential step to building therapeutic alliances.

Use first-person plural language. The words we use matter. Here’s one example: Instead of using the pronouns “you” and “your,” shift to “we” and “our.” This shift results in a subtle, yet tangible, change in our interactions with avoidantly attached teens. It also helps reinforce that we’re together in the process and that the teen’s experiences are understandable. I’m not sure that clients overtly notice this word usage, but I definitely believe there is value in making the shift.

Use more reflections, ask fewer questions. Most therapists ask way too many questions. To an avoidantly attached teen, questions can seem intrusive, annoying and disingenuous. It may seem counterintuitive, but fewer questions from you will actually result in more talking by the client. Instead of all those questions, use reflections. While you’re at it, avoid cautiously worded reflections. Instead, commit to what you’re saying, with statements of fact such as, “That was tough for you.” Such statements demonstrate connection, not interrogation.

Talk less, do more. From a developmental perspective, full-on talk therapy isn’t the best fit for teens, especially for avoidantly attached ones who don’t want to engage in the first place. I suggest incorporating some no-talk approaches for building rapport and addressing therapeutic goals. The card games Exploding Kittens and Fluxx are excellent choices for building rapport. They are teen-friendly, easy to learn and filled with opportunities for making metaphors. Favorite therapeutically focused activities include collages, creative journaling and walk/talk sessions.

Be fully present. Being present means having your focus, attention, thoughts and feelings all fixed on the here and now — in this case, the current session with the current client. From my perspective, this requires more than a basic attentiveness. It requires being fully engaged, human to human, with no judgment or agenda. This level of presence can feel risky at times, for counselors and for avoidantly attached teens. However, the connectedness it brings makes the risk well worth taking.

Relationships are reciprocal

Imagine your response if a client reported being in a relationship in which the other person refuses to share personal information and frequently makes statements such as “I’m curious why you want to know that,” even when the question is fairly innocuous. Perhaps you’d amend this client’s treatment plan to include working on healthy relationships or building appropriate boundaries. I sure would. Yet, this is what we do all the time as counselors, based perhaps on an assumption that self-disclosure is inherently bad.

It seems to me that we shouldn’t expect teens, especially ones who are avoidantly attached, to be open with us if we aren’t open with them. I’m certainly not suggesting that we share every detail of our lives with teen clients, but I do believe we should be willing to disclose relevant information, answer questions asked out of true curiosity, and be as honest with clients as we expect them to be with us. By doing so, we model effective interpersonal skills, demonstrate healthy ways to connect with others, and solidify the therapeutic alliance.

When teen clients ask questions of a personal nature, some therapists view this as a form of resistance, as a way to avoid the topic at hand or as behavior that interferes with treatment. I disagree, at least sometimes. Perhaps the teen is making an initial attempt to cultivate a relationship with us. Perhaps these questions are a sign that we’re becoming a secure base for the teen. Perhaps we’re witnessing a little nugget of change. Why would we shut that down?

When we deflect all questions of a personal nature, maybe we aren’t reinforcing appropriate therapeutic boundaries or challenging client avoidance. Maybe we’re rejecting a tentative attempt at connection. Maybe we’re demonstrating that we aren’t a secure base. Maybe we’re reinforcing the client’s avoidant attachment style.

For the first several weeks, sessions with Ben were slow going. He often showed up late, sometimes refused to talk and frequently stated he didn’t need or want help. One day, I taught him Fluxx. He commented that the game was about unpredictability. “I hate that,” he said.

The next session, Ben brought his own game, Unstable Unicorns. “It’s a complicated game,” he said, “but I’m a complicated person, and you seem to understand me.”

I let that register, picked up my cards, and lost three games in a row. At the end of the session, for the first time ever, Ben said, “See you next week.”

John Bowlby (1969) described attachment as a “lasting connectedness between human beings” and stated that the earliest bonds formed by children with their primary caregivers have significant, lifelong impacts. When meeting with avoidantly attached teens, it’s essential that we remember the ghosts in the room with us. It’s essential that we intentionally earn marbles. It’s essential that we slowly, but steadily, create connectedness. When we do, we invite teens such as Ben to move toward a more securely attached way of being.

 

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David Flack is a licensed mental health counselor and substance use disorders professional located in Seattle. For 20 years, he has met with teens and emerging adults to address depression, trauma, co-occurring disorders and more. In addition to his clinical work, he regularly provides continuing education programs regionally and nationally. Contact him at david@davidflack.com.

Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

@TechCounselor: Navigating social media with teens

By Adria Dunbar February 5, 2020

I recently did a presentation for a group of high school parents on social media use. Instead of focusing on their children, I began by asking parents about their own use of social media sites like Instagram and Facebook. As a counselor, I believe my reflections on this experience might be helpful to other practitioners when working with adolescent clients or their parents. To begin our discussion, I asked the following questions:

  • How many of you use social media?
  • How many of you have thought about changing your habits around your social media use?
  • What keeps you from making these changes?
  • How often do you feel pressured to post, like, or comment on someone else’s posts?
  • How many of you have had similar conversations with your children?

This was one of the most eye-opening discussions of social media use I have ever had with parents. I had assumed parents periodically reflect on their own use of social media and were having conversations with their children about navigating the digital world. Every parent in attendance said they participate in social media sites. They all had considered leaving or changing the ways in which they use social media, but maintained their connections for a wide range of reasons, such as staying in touch with family and friends; using the marketplace; monitoring children’s use; getting news; or learning about events in the community. In addition, almost all of the parents had even felt pressured to participate in an online social media platform in order to maintain relationships, support someone in their social circle or avoid awkward interactions. However, none of them had considered having conversations with their children about their social media use. Why is that?

Many adults and parents assume that tweens and teens know more about social media than we do. And this may be true. But, at the same time, adults can help children process their experiences in these environments. Younger people may know how to post stories, use filters, and increase followers more than their parents, teachers, coaches, or counselors; however, this does not make them experts in social media. Young people need help navigating the uncharted territory these online environments create. Most counselors and parents are aware of safety concerns involving online activity, but there are other big-picture aspects they should also consider asking about, such as:

  • Tell me more about the social media platforms and apps you use. How do they work? What do you like about them?
  • What are your interactions like? Are they positive, or do you sometimes get caught up in negativity or conflict?
  • What kinds of pressure do you feel equipped to handle on your own? What types of pressure leave you feeling unsure how to handle?
  • How do you filter who you allow into your social media and who you deny entrance?
  • What is your ideal number of followers or likes? What would reaching that number mean to you?
  • What will you do if someone you know from school or work sends a follow or friend request, but you question their intentions? How would you feel about blocking or unfriending someone?
  • How would you react if you saw something inappropriate or unkind on one of the more publicly accessible platforms such as Instagram, Tumblr, Twitter or Facebook? Would your reaction change if you knew that your response could resurface in the future or in a different app?

Keeping up with the ways in which technology is changing our relationships and world can be a lot of work, but we cannot allow ourselves to take our hands off the wheel. Although not all counselors choose to participate in social media sites, such as Facebook, Instagram, WhatsApp, or Snapchat, it is crucial to stay up to date on the ways these social media platforms impact clients’ lives and relationships. For those who work with child and adolescent clients, it is equally important to find reputable resources to share with clients’ caregivers. Websites like commonsense.org can be helpful as a starting point. Local libraries and schools often hold workshops or sessions focused on navigating digital spaces as well.

Just as we cannot expect parents to navigate the digital world without guidance, nor can we expect that adolescents will understand all the social nuances of the online social world without our help. By partnering with adolescents, and allowing ourselves to find vulnerability in our lack of expertise, we may be able to help them think through some big questions about who they are, what they represent and how they want to show up in the world—not just online but IRL (in real life).

 

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Related reading, from the Counseling Today archives: “#disconnected: Why counselors can no longer ignore social media

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Adria S. Dunbar is an assistant professor in the Department of Educational Leadership, Policy and Human Development at North Carolina State University in Raleigh. She has more than 15 years of experience with both efficient and inefficient technology in school settings, private practice and counselor education. Contact her at adria.dunbar@ncsu.edu.

@TechCounselor’s Instagram is @techcounselor.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.