Adolescent Family Counseling for Substance Use and Depression
I. Setting the Scene

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

2. Jim is a fourteen year-old Caucasian male, whose sister died in a car accident four months prior. Losing a sister is challenging enough for any individual; for one 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 differential identity during this time do 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 Likewise, Jim’s personality changes—such as being more withdrawn and not participating in class—are possible warning signs of ineffective coping.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 irrelevant in this case. In fact, Jim’s father has used silence and suppression of emotion as the means by which he deals with stress and trauma. Jim’s behaviors could be a result of modeling his father. What matters most is helping Jim and his parents cultivate new coping strategies that lead to improved daily functioning and psycho-social wellbeing.

3. Jim’s parents brought him to counseling after they found empty beer bottles and empty compressed air cans in their son’s room. Mutuality between the teenage client, Jim, and the counselor was established in spite of the fact that Jim denies that his behaviors are problematic. Likewise, Jim’s mother is less concerned than his father about the substance use and more generally worried that her son may not have effectively dealt with the loss of his sister four years ago.

II. Client-Worker Transactions

In accordance with American Psychological Association (2007) guidelines for record keeping in clinical practice, detailed accounts of client-counselor transactions were recorded. Level of detail promotes accuracy, and also 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 the client and his family, and represent the application of core skills competencies throughout the interactions with Jim and his parents at Destination Hope.

Jim and his parents (mother and father) arrived for the session on time. Jim sat between his parents. Jim’s mother initiated the discussion by stating first that she and her husband loved their son, and that they 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 they were asked questions directly, they responded cogently and were obviously paying attention and following the conversations.

Worker asked Jim directly, “What would you like to say in response to what your mother just told us?” This question represents the use of open-ended questions. To this, Jim rolled his eyes, his face assuming a demeanor 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 said, “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 to say, “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.

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.” Worker asks open-ended question to both parents, “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. Let’s start with you, Jo-Anne (referring to Jim’s mother).” Shulman (2011) underscores the importance...…family engagement. The language counselors use in therapeutic sessions is of critical importance, setting the tone for therapy and also promoting empathy and understanding to mitigate differences in culture or worldview (Rodriguez, Walters, Houck, et al., 2017).

III. Description of Learning

Interpersonal stressors are inevitable in life; family therapy and CBT can reveal diverse coping strategies for managing stressors and perhaps even benefitting from them. Family-based therapy and CBT together comprise the most effective psychosocial interventions for adolescents at risk for substance abuse (Fadus, Squeglia, Valadez, et al., 2019). Working with the client in these sessions, and critically reflecting on the clinical practice environment and process, promoted the development of core counseling competencies.

I learned a lot about myself during these sessions, and also about the process and purpose of CBT. Godley & Passetti (2019) note that family-based, motivational, CBT-oriented approaches like the ones used here including the Adolescent Community Reinforcement Approach have the “strongest empirical verification” for preventing relapse and ensuring long-term positive clinical outcomes (p. 1). Evidence-based practice norms require mental health workers to employ the latest empirically validated techniques, from specific CBT methods to methods of self-assessment.

The sessions with Jim and his family brought to light the difficulties in maintaining the delicate balance between empathy and overreaching. For example, I may believe that I am “connecting” or “feeling” the client, but my sense of understanding may be based on false impressions or assumptions. It may be impossible to ever know for sure whether we are on the exact same page as a client. Their willingness to self-disclose, especially in a group setting, may be constrained by a number of factors. In the future, I would prefer to see Jim in an individual counseling session, as well as each of his parents in a one-on-one basis, in order to deepen the rapport.

Processes used in family-based CBT do need to be grounded in empirical knowledge about what actually yields tangible, measurable, long-term results. Monitoring Jim’s behavior, keeping track of his performance in school, remaining in touch with teachers, and encouraging his parents to be less anxious and more supportive may be the most important ways of preventing Jim from going down the road his father fears the most. For Jim, the use of CBT will help him develop emotional intelligence and counteract the poor emotional self-management skills his father has represented…