Adolescent Family Counseling for Substance Use and Depression

Setting the Scene: Client and Clinical Context

Destination Hope is a multifaceted, multimodal treatment center that provides mental health services to a broad client base, with areas of specialization including family care and substance abuse intervention. It offers individual, family, and group therapy options. In addition to acute and residential care, Destination Hope also provides structured outpatient and long-term options for individuals and families to help prevent relapses and promote quality of life.

Jim is a 14-year-old Caucasian male whose sister died in a car accident four months prior. Losing a sibling is challenging enough for any individual; for someone going through puberty at the same time, the effects of emotional devastation and loss can be confusing and even traumatic. Therefore, Jim's behaviors, his shift in social scene, and his changing sense of identity during this period need to be viewed in context. Perspective can help Jim's parents understand that changing one's peer group and experimenting with different identities is a typical part of the transition from childhood to adulthood.

However, Jim's father is a recovering alcoholic. When beer bottles and evidence of substance use surfaced in Jim's life, his parents were understandably concerned. Likewise, Jim's personality changes — such as being more withdrawn and not participating in class — are possible warning signs of ineffective coping. Whether or not Jim's behaviors are due to suppressed emotions connected with the trauma of losing his sister, or whether those behaviors would have manifested regardless, is less important than the immediate clinical task. In fact, Jim's father has used silence and suppression of emotion as his primary means of dealing with stress and trauma, and Jim's behaviors may reflect this modeling. What matters most is helping Jim and his parents cultivate new coping strategies that lead to improved daily functioning and psychosocial wellbeing.

Jim's parents brought him to counseling after finding empty beer bottles and compressed air cans in their son's room. Mutuality between Jim and the counselor was established despite the fact that Jim denies his behaviors are problematic. Jim's mother is less concerned than his father about the substance use and is more broadly worried that her son may not have effectively processed the loss of his sister.

Client-Worker Transactions: Sessions One and Two

In accordance with American Psychological Association (2007) guidelines for record keeping in clinical practice, detailed accounts of client-counselor transactions were recorded. A high level of detail promotes accuracy and helps other case workers maintain continuity of care (American Psychological Association, 2007). The following transactions took place during the first and second sessions working with Jim and his family, and represent the application of core skills competencies throughout the interactions at Destination Hope.

Jim and his parents arrived for the session on time. Jim sat between his parents. Jim's mother initiated the discussion by stating that she and her husband loved their son and had been worried about him after finding empty beer bottles and compressed air cans in his bedroom. Jim's father remained silent, and so did Jim. Both Jim and his father looked down or around the room, appearing disengaged. However, when asked questions directly, they responded cogently and were clearly paying attention to the conversation.

The worker asked Jim directly, "What would you like to say in response to what your mother just told us?" This represents the use of an open-ended question. Jim rolled his eyes, his face assuming an expression of annoyance and impatience. He said, "I was just experimenting — it's no big deal. I'm not that into it; I just wanted to see what it was like, and I did."

Jim's mother then asked, "And did you like it?" Jim responded, "No. Maybe. I don't know. I really don't see the big deal." Jim's father spoke up for the first time: "It is a big deal, and you know it. That's why we're here." Jim remained silent and folded his arms across his chest.

The worker then said to Jim, "Jim, why do you think your parents brought you here today?" Again, this represents an open-ended question. Jim replied, "I guess they're worried about me." The worker then addressed both parents with an open-ended question: "Would you both agree with what Jim just said? What are your reasons for coming here today, as a family? What other issues, besides your concern for Jim's behavior, would you like to discuss? Perhaps we can all talk about our goals in therapy." Shulman (2011) underscores the importance of these types of establishing questions during intake and rapport-building sessions with clients.

Jim's mother reiterated her love and concern for her son, describing him as "vulnerable." She noted: "He has been hanging around a different group of friends, which is fine, but he seems a lot less interested in school and other activities lately, and we want to make sure that he remains healthy and happy. He still has good grades, but his teachers have been informing us about early warning signs in class. When he was suspended for the first time for skipping school, that was when we really knew something was up. Everyone gets in trouble now and again, but if we don't pay attention to it now, it could become worse."

In response, the worker used mirroring and other communication techniques to establish empathy with the client, saying, "I see that you have been allowing your son to grow and mature into a young man, but that you want his increased freedom to be tempered by a sense of awareness, intelligence, and personal responsibility." Upon reflection, the worker acknowledged potentially reading too much into this statement — a small degree of transference may have been at play. If given the opportunity to respond differently, a more measured approach would have been simply to acknowledge the mother's concern before turning to the father for his input. Gender dynamics may have influenced the differential responses to the mother and the more reticent father during the intake session. New skills developed during this initial session included all of the beginning-phase and first-group dynamics Shulman (2011) outlines.

Application of CBT Techniques with Jim and His Family

Modulation of expression and communication style is a key skill exhibited throughout the second session. Cognitive-behavioral therapy (CBT) techniques were deliberately applied, adapting to the unique dynamics of this family. Zhang, Filbin, Morrison, et al. (2019) found that when working with diverse clients, "counselors do indeed change their conversational behavior to become more diverse across interactions, developing an individual voice that distinguishes them from other counselors" (p. 1). This individualized voice helps differentiate CBT techniques employed specifically for this client, acknowledging differences in age, gender, socioeconomic background, religion, ethnicity, and linguistic heritage within an atmosphere of trust. For example, the worker asked the father, "How did your father and mother deal with conflict, crisis, or the difficult feelings surrounding loss or death?" This open-ended question established rapport with the father and also demonstrated core skills such as reaching for feelings and putting feelings into words (Shulman, 2011).

Reading the clients involved observations of body language and frequent direct checks with clients to confirm or revise initial impressions. Unnecessary biases and assumptions were avoided by asking clients directly about factors such as gender roles and parenting styles. When the father derisively referred to Jim's new social group as "Goth," the worker asked the father what "Goth" meant to him and why that subculture concerned him. The father responded that the "Goth" kids seemed antisocial. Jim quickly interjected — one of the first times he spoke without being addressed directly — defending his friends and claiming that they "understand me, unlike some people." When the worker asked, "What do you mean by that?" Jim explained that his old friends only cared about material things or sports, whereas he cared about "deeper" things. The worker then asked his parents how they could support Jim in cultivating new hobbies and interests productively, and used empathy skills to note that Jim appeared to be in a phase of "wearing different hats," trying on new identities, and that refraining from judgment might help promote a more harmonious home environment.

Adolescents engaging in self-harm behavior, including substance use, respond well to various types of cognitive-behavioral interventions in clinical trials (Taylor, Oldershaw, Richards, et al., 2011). Likewise, Oud, de Winter, Vermeulen-Smit, et al. (2019) found CBT "effective for youth with a (subclinical) depression" (p. 33). When caregivers were involved in the therapeutic process — as in Jim's case — CBT proved especially effective (Oud et al., 2019). Particular CBT interventions of note for clients like Jim include behavioral activation and cognitive restructuring. Hogue, Bobek, MacLean, et al. (2020) extend the range of CBT interventions for adolescents with externalizing behaviors to include: "(a) functional analysis of behavior problems, (b) prosocial activity sampling, (c) cognitive monitoring and restructuring, (d) emotion regulation training, (e) problem-solving training, and (f) communication training" (p. 1). The plan for future sessions is to incorporate as many of these CBT interventions as possible, noting in formal records which methods Jim or his parents prefer and are most likely to employ as long-term solutions.