Engaging Teens in Treatment for Trauma
Parents and family members remain one of the strongest influencing factors in an adolescent's successful treatment. Researchers and specialists in treating teens with symptom of trauma offer advice to clinicians.
While it has long been known that establishing a working alliance with adolescents and their parents often presents challenges, few studies have specifically focused on engagement and retention of adolescents in trauma treatment. In general, a number of issues have been found to have an impact on the success or failure of engaging and retaining adolescents in psychiatric treatment.
These include logistical issues (referral source, geographic distance to treatment), socio-demographic factors (income, gender, and race/ethnicity), therapeutic components (relationships/alliances), factors related to the child (previous psychiatric treatment, hospitalizations, suicidality, co-morbid psychopathology, externalizing disorders) and those related to the parents.
The two dimensions having the most impact on engagement and retention appear to be parental and therapeutic alliance issues. These two factors are more consistently predictive of success or failure in engaging adolescents in treatment than are socio-demographic or child factors.
Since adolescents presenting for trauma treatment typically live with their families or are under the care of a guardian in some kind of a family-like setting, family members can have a strong influence on an adolescent's treatment. This is true even when the direct involvement of family members is minimal. Clinicians who can avoid alienating family members and find ways to maximize the potential support of caretakers will be much more likely to help the child succeed in treatment.
Adolescents in need of trauma-focused care are often embedded in chaotic family environments, characterized by a high level of stress, interpersonal conflict, and parental depression (often seen in families of traumatized children). All of these dynamics, particularly if not addressed, can lead to treatment attrition. The therapist needs to appreciate what can motivate parents in these situations, since the parents are more likely to seek treatment for their traumatized adolescents because of unwelcome acting-out behaviors rather than because of the severity of trauma-related symptoms.
We have found that the involvement of a support person increases the likelihood of treatment success. A supportive adult can encourage the adolescent's participation and help the teen acquire and maintain skills learned while in the program and use them after treatment ends. However, program facilitators need to be aware whether there is a history of sexual or physical abuse or other offense by the adult.
In cases of intergenerational trauma, you will need to use your clinical judgment in weighing whether or not participation by the adult would increase the likelihood of re-traumatization. It is extremely important to consult with the adolescent and discuss any proposed involvement by an adult. Confidentiality issues should be addressed and legal issues regarding confidentiality clarified. Input from the adolescent should be respected and alternatives to parental involvement discussed.
There are, nevertheless, several reasons why it can be helpful and important to collaborate with parents or other caretakers. First, by informing parents about the nature and goals of treatment, you can gain their support in helping their adolescent participate in the program and overcome the effects of trauma on his or her life. Parents and caregivers can provide support in a number of ways, including ensuring regular attendance at sessions, completing skills practice assignments, and re-assuring and praising the adolescent for having the courage to work on overcoming his or her traumatic experiences.
Second, by providing family members with basic information about PTSD, you can instill hope that effective treatment of PTSD is possible. Helping family members conceptualize post-traumatic symptoms as a disorder can decrease blame and conflict around those symptoms and help relatives understand their adolescent's sometimes perplexing behavior.
Finally, collaborating with family members can be crucial to successful treatment outcomes because of the intergenerational nature of many instances of trauma. That is, the family members of many adolescents with PTSD may have significant trauma in their own lives, and many also have PTSD. Since the avoidance of trauma-related stimuli is a cardinal feature of PTSD, relatives who have PTSD may have difficulty supporting their adolescent with this same disorder and may even inadvertently sabotage participation in treatment.
By collaborating with family members and educating them about the nature of PTSD, the therapist can provide them with critical information that may lead them to get help themselves for their own experiences. It may also encourage some parents or caregivers to use some of the program materials on their own to deal with their PTSD.
Collaborating with family members provides a pro-active approach to identifying possible obstacles to the adolescent learning and using the skills. It can provide support for the adolescent and uncover issues that may need to be monitored or addressed in the family in order to optimize treatment outcomes.
Excerpted and adapted from Coping with Stress: A CBT Program for Teens with Trauma by M. Kay Jankowski, Harriet J. Rosenberg, Stanley D. Rosenberg, and Kim T. Mueser, published by Hazelden, 2011.