xxAACP Newsletter, Volume 11, Number 3, Summer 1997
President's Column: Treating Adolescents:
A Model for Community Psychiatry
In my private practice, working with teenagers and their families, I stretch all available resources to bring to my patients the best of community psychiatry; active involvement of families, group as well as individual treatment, invitations to my patients to involve their peers in their therapy with me, and mobilizing family resources for respite, or, occasionally, informal out of home placement. I must know what is happening with their schools and the meaning of school problems to my patients. I may have to deal with burned out teachers and fearful school administrators. I must have a feel for the social phenomena of adolescents; gangs, skateboarding controversies, kids carrying weapons, drugs, sex and rock concerts. If I am to be relevant to the kids I work with I must be there for them over time as a reliable ally who can help them mediate their relationship with the world.
I also must be able to let them go when they are through with me and trust the community resources with which I have collaborated will get them back to me if needed. In short, the emotional health of an adolescent is greatly influenced by community forces. Teens are often on the cutting edge of social change. Adolescent mental health workers must be there as well with some understanding of these community issues.
In my work in agencies, including my years at the mental health center, the issues have been the same. Clients needed close relationships with alternative caring adults who can help them gain perspective on their evolving relationships with family and peers. In a population of kids facing poverty, discrimination and frequent disruptions, community issues are critical factors for them and their families. Continuity of treatment relationships is also a crucial piece, perhaps more so than for most adults. An adolescent mental health worker needs to have a style which embraces rage at social ineqyities, yet models for developmental issues. They must appreciate the oppositional styles of many teenagers and find kids with unusual affections fun and funny. It is the role of all adults who deal with teens to give to them the love and appreciation they are due for being kids. At the same time one needs to have an ease in setting limits, defining the boundaries of what the community will tolerate and help the kids integrate their emerging selves into the larger social order.
What do kids ordinarily encounter from the mental health system and all the other systems of care? They often see us try to categorize them in ways that most often make little sense to them or us try to categorize them in ways that most often make little sense to them or their families. Kids emerge in systems of care because they fit the categories for that system's funding sources. On referral to many mental health systems kids encounter evaluators with forms and symptom check lists eager to categorize then in a nosological system which often fails to embrace the complex problems they present. Many mental health programs and most other systems of care have evolved apart from our psychiatric nosological systems, but are most often equally fuzzy conceptually. Mental health programs may be crisis based or focus only on case managing non-existent therapeutic resources. Social service systems which exist for the protection and welfare of teenagers often serve to disrupt and dishonor their sense of family and community. The juvenile justice system at times seems blind to the emotional and developmental status of teenagers. Each system evolves case plans for kids without any recognition of another system's role with a kid or with any sense of the kid's needs for continuity of care.
The move to family and community centered systems of care, often with blended funding schemes, inspired by the CASSP initiative and Robert Wood Johnson grants have done a great deal to correct some of the systems issues involved in children's services. Both the American Academy of Child and Adolescent Psychiatry's Task Force on Community Systems of Care and the AACP's Child and Adolescent Committee have embraced the values and concepts articulated in these programs and we have stressed issues related to the community in the care of teenagers. The AACP and the AACAP have recently formed a working alliance which is now charged with creating a draft of the Level of Care and Utilization System (LOCUS) for kids. It is our task to bring a functional sense of these concepts of care for teenagers into this discussion. How can we develop a tool which offers a simple guild to placement decisions yet is mindful of a child or adolescent's needs developmentally, their status with their family and community, and the alternative systems which offer care. The AACP is now fully engaged with the issues of developing community and culturally relevant systems of care for kids and supporting a creative psychiatric involvement in such systems. In these efforts we pledge ourselves to honor the need for continuity in relationships for teenagers with Serious Emotional Disturbances. I will assure that we will do right be the embattled mental health counselors, the youth workers in other systems and the psychiatrists who, working together on excellent treatment teams, offer their indescribable stew of unique, creative, quirky, funny, passionate and loving styles and techniques which actually help kids to get better.
Charles Huffine, MD
President
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