Student with backpack

Part of the ongoing series “High School Confidential: In the Trenches with Substance-Using Teenagers”

Editor’s Note: This is the second in a series of blog posts by Dr. Peter Cohen. Read the first in the series here 


I retired at 64, as the medical director for my state’s drug and alcohol administration. After working 50 plus hours a week for over 30 years, I still wanted to work with troubled and troubling teenagers, but at a reduced pace. With a part-time opportunity at a therapeutic school, I came full circle.

I would help shape the school’s policy and practice in identifying and intervening with students with drug and alcohol problems…

Two hospital administrators from the hospital that first hired me back in 1981 had finally fulfilled their dream of creating this free-standing school. One had been my hospital’s medical director and my mentor, while the other had been the director for the inpatient school program. When I walked through the front door, their names were in view on the walls of the main entrance. Although they were no longer running the school, their legacy remained: a pioneering approach for helping kids achieve, kids that no other school or treatment program would touch.

The school requested my psychiatric consultation for difficult cases. In selected cases, I would also prescribe medication treatment to simplify school and mental health coordination. Finally, I would help shape the school’s policy and practice in identifying and intervening with students with drug and alcohol problems. That was a lot to do in only 15 hours per week, but what an opportunity.

It’s the people that make make or break a school—how they carry out their mission and their spirit of cooperation and collaboration—but the physical aspects of the building always give the first and lasting impression. And here was a modern two-story building in an up-and-coming Washington, DC suburb, surrounded by many nearby social, health and educational services. Outside, children and teens were kicking a ball around on the athletic field, while others were nearby playing full court basketball. Inside, the school was designed so that K through 8th grade students were on the first floor and the high schoolers were on the second. The building also had a full gym with spectator stands, multipurpose cafeterias, library, music room, art rooms, sunlit classrooms, and halls with inspiring quotes inscribed on the brightly painted walls.

The building was well-maintained, an essential element for morale. Displays about the art program, physical education and the team sports were inspiring. It was also evident that formal music instruction was not a high priority, as the school districts were not committed to provide adequate funding for this critical component of education.

The kids, referred from two school districts, were predominately black, which has very little meaning in itself. In fact, my being melanin-deficient, AKA “white,” has never been an issue from day one, even when a teen has been irritated or impatient with me, for example when I couldn’t decode their lingo and shorthand phrases. It would take me just as much time for the ear to catch the rhythm, language, and musicality of Shakespeare, and it was a privilege to be listening in. Moreover, on that first day, two engaging “full of themselves” students made it very clear that I must address them by their nicknames: “Sunny” and “Sha-nay-nay.” Both monikers were new to the staff, apparently created by the students on the spot.

Yes, the development of a positive cultural and racial identity is crucial, but here as everywhere, teenagers are teenagers, perpetually fluctuating between being astoundingly mature and hilariously goofy, and between being cute and provocative. Here, though, these teens carry stories about the burdens of school failure and learning challenges, poverty, chaotic family interaction, and severe trauma. Behaviorally, what is striking are the many students who can’t sit in class long for attentional and emotional reasons, find new ways to test and defy rules, and have very little confidence in their academic abilities. Many have responded unsuccessfully to a variety of psychiatric medications.

Training about how to identify and intervene with substance-using teens, including the use of motivational interviewing skills, are not now but should be essential components of staff development.

As far as the professional staff, I noticed that those on the front line ranged from having high school to college degrees, consistently wavered between being proactive or reactive, and in one day, could be creatively engaging, or frustrated and worn down. The same applied to teachers and therapists, who, despite job challenges, were remarkably blessed with extraordinary patience and dedicated to helping students progress. And the principal was the “coolest one in the room,” holding the school together, a model for positive, thoughtful, non-reactive, problem-solving behavior.

But I also noticed three major challenges, challenges that beset almost every program for which I have worked, observed or consulted:

First, in every case where drugs and alcohol are being used, healthy psychological, emotional and cognitive growth gets thrown off track and the safety of the program is placed at risk by unpredictable, disruptive, and occasionally violent behavior.

Second, training about how to identify and intervene with substance-using teens, including the use of motivational interviewing skills, are not now, but should be essential components of staff development.

Third, interventions are only as effective as the clarity and consistency of the administrative process of supervision. Formal training of effective interventions has its place in staff development, but these skills need to be reinforced with “at the moment” oversight when, for example, a student loses control, and always followed up with a debriefing. How to formalize these processes will be the subject of a future blog post.

But back to my first day at school. I was the newcomer, the new kid in town, and my first job was to get to know students and staff, to forge positive alliances, and to understand their goals, aspirations, and priorities.

QIWYWAs (Questions I Wish You Would Ask)

Sorry, only one question today.

Q: Don’t you get impatient wanting to make the obvious changes that are needed in a school?

A: Who doesn’t? But a school is a complicated system with multiple and competing priorities. As a physician with lots of credentials, I still don’t need or want ultimate power. And I shouldn’t. I don’t have the gifts to be an administrator; being accessible and helpful is enough. And I’m most interested in helping create sustainable, predictable, and effective policies and procedures for helping kids. These initiatives should be valued by staff and students as indispensable and designed to outlast changes in administration and leadership.


Peter Cohen headshotPeter R. Cohen is a board certified child and adolescent psychiatrist with additional certification in addiction medicine. For the past 34 years, he has worked in hospitals, residential programs, and outpatient clinics. Between 2004 and 2012, he served as the medical director at the county and state level, focusing on policy and quality assurance for behavioral health programs. Now semi-retired, Dr. Cohen works part-time at a therapeutic high school in suburban Maryland.

Want to submit a question to Dr. Cohen? It may be answered in future blog posts! Email Jessica Williams at jessica at ireta dot org. If you submit a question, you will remain anonymous on our blog.