Note from the Editor:
This post is part of a series by adolescent psychiatrist Peter Cohen called “High School Confidential: In the Trenches with Substance-Using Teens.” Please click here to read previous posts.

Remember R.J. from my last entry? The innately gifted, but inattentive, oppositional, school-failing, peer-fighting, shoplifting, sexually abused 16-year-old boy? And to add to the heavy burdens this young man carries, his marijuana use has been interfering significantly with nearly every aspect of his functioning and thwarting therapeutic progress.

Imagine it’s his first day at the therapeutic high school where I work as a psychiatrist. What could we do to make things go right?

RJ silhouette

Credit: Thomas Riggs

I propose this first: What if we refrain from labeling him before he walks into the school? Yes, his long list of problems will fill countless pages in his individualized educational plan. And true, this list might help predict how he will react to stress, to new situations like changing schools, to the taunts of peers and to the demands of the classroom. Or which peers he’ll gravitate toward if left to his own devices.

But research suggests that the manner in which an institution greets and interacts with its clients from the first interaction can either foster or ruin a positive alliance, which in turn will promote or doom R.J.’s chances for success.

How’s this for an opening conversation?

You: “Hey, R.J., welcome to the school. How’s it going?”

R.J.: “F.U. man, I don’t want to f…ing be here and don’t you f…ing look at me or talk to me.”

And if you’re the doctor and keep pressing R.J., he might also tell you to “Go f… yourself. I don’t want to take any of your damn pills.”

R.J.’s responses are rude and shocking, but predictable. No matter how dysfunctional, his defenses serve a purpose–to protect his integrity–though they do so at a great price. They are also what you typically hear from troubled and troubling teenagers with chronic substance use, ADHD, trauma, depression, and a history of failure. They come with the territory, the way headaches and heart disease accompany high blood pressure.

So why do we professionals and caretakers act so surprised when we hear these words? And who are we to attack his defenses head-on? He has just met us. And if anger, warnings, threats, and physical force don’t work, then how should we react? Here’s one way to look at it: Compare our outraged reaction to R.J. with our natural empathy and compassion with someone who has cancer.

No matter how dysfunctional, his defenses serve a purpose–to protect his integrity–though they do so at a great price.

Think of how generous and welcoming we would be with a patient with pancreatic cancer just admitted to the hospital ward. His first words can be angry and irritable, as he complains about his bone pain and says, “You don’t understand or give a damn.” Don’t we usually cut him a break?

We understand that his worsening disease has forced him to go to a special place for care. We imagine that he has sat in his bed before and overheard his being called nothing more than “the pancreatic cancer in Room 6.” And when he explodes with rage, we consider that family and other professionals might have responded poorly to his fury and ignored his emotional pain.

Do we really expect that this irritable cancer patient should speak with utmost courtesy? “Gee willikers, Doc, I’m so sorry for getting angry at you. It just so dad-gummed frustrating. So please, I’m going to say something I’ve never told anyone before. I don’t want this condition. It scares me. And all I want you to do is get rid of the pain.” Highly unlikely.

What are we more likely to hear? “You’re the millionth person asking me the same damn questions. Hello, but I don’t want to die. So unless you can do something for me, get lost and give me my pain meds.”

Now is the time to respond to his immediate needs, reduce his stress, and then ask about the first things he wants to do when he gets well or when his medical condition improves. In other words, we start with his motivation, recognizing that this damned cancer is getting in his way of living a better life.

Back to R.J. First start with this: What are his basic needs? And what can we say to recognize them?

“R.J., if you’re still hungry, how about some breakfast? And while you’re eating, how about we talk about what you like to do and what you want to accomplish here at the school? And if you like, I could tell you a little bit about me.”

He has a voracious appetite.

RJ breakfast

Credit: Andria

Once his stomach is full, when he’s more comfortable, move on to ask about his motivation. He responds with, “I want to get out of here, go back to my home school, get back to drawing, and playing basketball, and rapping, and hooking up with that girl I met online, and someday being a chef.”

You then arrive at an informal agreement that the school will do its best to help him fulfill his goals as long as he pulls his weight. You might even invite him to your lunchtime poetry and rap group. (On a side note, I offer this experience to kids with writing aspirations. With R.J., I might encourage him to write about his family, to express what’s still hanging over him, protecting him, or haunting him. Call it a genealogy rap.)

And now that breakfast is over, what next? Do you introduce him to his teachers, the staff, the coaches, etc.? Not yet. Think about matching him with one of the students on an upward trajectory, one who has similar interests, and is as positive as any teenager can be about what this school can offer. Let this peer walk R.J. from class to class and introduce him to the staff and other kids. I recommend this because I think there’s face validity to the notion that peers get peers into trouble, out of trouble and away from trouble. You can walk around with the duo, monitoring the interaction and answering questions. You can also observe the inevitable interaction between R.J. and his best friend, who’s been a student at the school for some time.

By focusing on his motivation, his goals, and his talents, you have created a framework for helping him when he gets into trouble. Of course trouble will happen.

Finally, before the last school bell, you check in with R.J. to hear how the day went and to set a goal for the next day. You also introduce him to core values of the school: teamwork, a work ethic, integrity, respect, and leadership. Otherwise known as TWIRL.

And if R.J. leaves the building without a scowl, you know you are heading in the right direction.

Remember: whether it is cancer or problems with emotions, behavior and drugs, all the accompanying obnoxious symptoms of these ailments stand in the way of fulfilling one’s goals. And goals are what makes R.J. a promising kid, what give him hope. In the spirit of Victor Frankl’s Man’s Search for Meaning, aspirations and hope are what make R.J. wake up in the morning to face another day.

That’s how I encourage your dealing with R.J.’s problems from day one. By focusing on his motivation, his goals, and his talents, you have created a framework for helping him when he gets into trouble. Of course trouble will happen. Like his showing up late for school, going AWOL, coming to school stoned, shoving a student or staff person, refusing to go or stay in class, or defacing the wall. You can discuss with him whether or not his behavior got in the way of his goals. You can help him because your first interactions were designed to foster trust, honesty, and dependability. And when he melts down, he might turn to you, a staff member, or a peer to calm down, listen, problem-solve, and move on.

Any questions?

Q: When are you going to discuss how to deal with his drug problems?

A: I will, but you can’t address substance use without taking a first crucial step. I call it “setting the stage.” In movies or theater, you create the right conditions so that the audience will want to care about the story and find it genuine and believable. You must choose the right action, words, costumes, sets, music, and actors. With R.J., you have set the stage for trust, empathy, and problem solving.

Then, when his truths–his painful truths–come roaring out, he is more ready to ask for your help. And, typical for most teenagers, he’ll be the one to decide how and when he confronts his difficulties. On his schedule, not yours.

Next Time: What about his drug use?


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. For almost twenty years, 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.