Earning Buy-In from Treatment-Resistant Teens

by Lydia Mackeogh, Psy.D.

I have encountered almost every kind of resistant teen in my time as a mental health provider. Some of my favorite and most memorable clients first entered my office scowling, snarling, and proverbially swinging from the chandelier. There is no client quite as rewarding as the one who moves past the outward anger, resentment, and bravado to the underlying fear, sadness, and vulnerability. This journey takes time and patience. It requires a client to actually show up for sessions and to participate fully.

There are special considerations to be made for teens whose primary diagnosis involves a substance use disorder. Addiction alters brain function, attenuates perspective, and impedes judgment. It shapes thoughts and behaviors to ensure its own survival. The patterns of thought and feeling associated with addiction can result in behaviors such as manipulation, false promises, and deception, in order to avoid treatment at any cost.

To make matters worse, the teen may be either under the influence of a substance or experiencing withdrawal from a substance when the subject of treatment is introduced. Their brain is not functioning correctly, they are unable to process the subject objectively, and they slip into survival mode, guided by their addiction. This all but ensures the failure of any attempts to persuade them to accept help.

These treatment-avoidant, self-perpetuating behaviors are not reserved for teens who abuse substances. They may emerge any time a teen wants to maintain destructive behaviors such as self-injury, self-induced isolation triggered by depression, or violent, aggressive outbursts. In order to get a resistant teen to collaborate of their own free will and to help them create real and lasting change, the parent or caregiver must earn some initial currency with them.

In other words, they need to find a way to earn “buy-in” to get their teen to that crucial first session with a therapist. The following are my top recommendations for parents:

  1. REMEMBER YOU WERE ONCE A TEEN YOURSELF

Close your eyes and remember what you were doing, thinking, and feeling when you were the same age your child is now. Chances are it’s not much different from the headspace they’re in. From a distance, your teenage years might look rosy. But peer deeper into your memories and you’ll remember the fierceness of feeling that accompanied every relationship, the devastating highs and lows that felt completely rational at the time, and the certainty that you were already grown – an adult in an adolescent’s body. You desperately wanted to be treated as such.

You may have experimented with alcohol, drugs, or other risky behaviors yourself. If you did, you may remember exactly what it’s like to seek and try something new or illicit. Today, as a parent, it boils down to making an adjustment on your side: treat your teen as they feel and not how you feel about them. Consider their perspective. It really comes down to empathy; put yourself in their shoes and reflect back to them how it must feel to be them.

NPR interview image

Image from NPR.

  1. SHARE YOUR OWN EXPERIENCES

Openness about your experiences will earn you currency with your teen as quickly as will empathy. Of course, this only works if you’re drawing from similar emotional memories. The content does not need to be identical: for example, your teen may struggle with addiction while you have never experimented with drugs, but if you try hard enough you can certainly relate to wanting to feel good or wanting escape pain. And almost everyone recalls the strong desire to fit in with a group of peers.

If you do indeed have a history of substance use, use your judgment about how much you share, but keep in mind that your teen’s willingness to open up will match yours; if you hold back, they will, too. A good rule of thumb is to discuss feelings rather than facts. Share the difficult emotions you attempted to evade by using drugs or alcohol, without discussing the specifics of  what you actually experimented with or the extent of your use.  When you do this, you model vulnerability and willingness to be accountable, without handing your teen any justifications for their behavior.

  1. CHANGE YOUR APPROACH (BECAUSE THIS ONE ISN’T WORKING)

This rubric stands no matter how you’ve been approaching the issue thus far. You may have followed the playbook for perfect parenting. You’ve done all the things the experts advise: you’ve been understanding, you’ve been firm but fair, you’ve set reasonable expectations and described logical outcomes. But if it’s not working, it’s time to try something new. If you’ve been forceful, try being calm. If you’ve been cautious, try being assertive. If you’ve been critical, try taking responsibility for your side of things.

Try exaggerating your sense of your own wrongdoing in the situation. It models accountability for the teen and cues them up to do the same. This may also be the time to confess your own experiences of drinking too much – even as an adult – or share a story about succumbing to peer pressure when you were younger. Remember to share appropriately and avoid sanctioning unwanted behavior in a fit of radical honesty.

  1. NEGOTIATE AS EQUALS

Approach the topic of entering treatment – or going to that first appointment with a therapist – as if you were trying to find common ground with another adult. Compromise. Consider, or at least make a show of considering their wants and needs. However, remember that you are still their parent and not their friend. Find your line and hold it: every good negotiator goes in knowing exactly where they will and won’t give ground.

For example, don’t compromise by allowing your teen to marijuana in lieu of heroin. Don’t let them convince you they have a problem with pills but drinking beer is no big deal. That’s not good negotiation – that’s you being manipulated. For treatment to work, sobriety needs to be absolute. Not to mention the fact that your urge to be the “cool” parent might earn you a visit from child protective services.

If consensus about treatment eludes you, provide several options. For example, give them three reasonable choices: get assessed for a treatment program or attend five meetings a week or commit to one outpatient therapy session each week for two months. Make it clear that the next step will be one of these options, and the choice is theirs. Make sure the outcomes of reneging are crystal clear, and follow through with the consequences of it comes to that. Negotiations end when you have demonstrated good faith and they have not kept up their end of the bargain.

  1. BE TRANSPARENT ABOUT YOUR EXPECTATIONS FOR TREATMENT AND/OR THERAPY

When describing the type of treatment that you hope your teen will accept, highlight the positive aspects (e.g., equine therapy! snacks!) but emphasize that there will be therapeutic work to do – and they’re the ones who will have to do that work. If expectations are not clearly laid out, they may feel misled or betrayed.  Teens respond to clear expectations, especially when they feel their parents have faith in their ability to meet them. Tell them you have 100% belief in their ability to handle treatment, even if you harbor personal doubts. You may feel a little bit like you have to fake it ‘til [they] make it – but that’s okay.

Many teens with substance use problems say things like, “Do you actually think I’m going to stay sober forever? Do you really think I’m not going to drink and smoke when I go to college?” If this happens, don’t be afraid to acknowledge the legal limits of your influence over their lives. They are right–  once they turn eighteen, you can not longer decide what they can or cannot put in their bodies. Make it clear your goal is to help them reach adulthood in the best way you know how—healthy and happy. Your goal is to equip them with good decision-making skills and solid coping mechanisms for handling the ups and downs of adulthood.

  1. GET SIBLINGS INVOLVED

This one can go either way, but generally speaking, siblings are the Truth-Keepers of Teenland. They know what’s going on because they’ve either seen it themselves or heard it through the social grapevine. This is another example of remembering what it was like to be a teenager: it is almost certain you had secrets from your parents and made daily decisions about what you shared and what you kept to yourself. Siblings also see behaviors that are in plain sight, but which you may not want to or be fully able to acknowledge.

Hiding drugs has now become very easy; they may look like candy, stickers, or flavored vape pens designed for tobacco. Some vape pens – called Juuls – look exactly like a thumb drive, a perfectly legitimate item for a teen to have on them. It  can  also fairly simple to cheat on drug tests; one can buy fake urine along with a contraption that wraps around the thigh, allowing delivery of the bogus urine to a sample cup. Siblings can be  privy to the super-secret world of adolescent special ops, and they can be surprisingly mature in their willingness to speak the truth when they recognize that their siblings and/or friends need help. Also, the teen you are trying to reach is more likely to accept insights or reflections from siblings, friends, or anyone outside the parent-child dynamic.

  1. PRESENT A UNITED FRONT

This is especially important if you are divorced or separated. It  is important to work together in making decisions about your child, and critical that you don’t allow your teen to divert one of you from the mission. The latter  is called splitting in the therapy world. Much like the adage “she who has two bosses has none at all,” a teen who gets in trouble probably had a lack of clarity about who was meant to be paying attention. Make sure you are both on the same page about the severity of the problem and the need to take action before broaching the subject of treatment with your teen.

Discuss what drug(s) and how much you think your teen is using. Reach consensus about the ways in which their drug use is affecting their lives, and bring specific, factual examples to your discussions. If you see the problem differently or disagree on the level of care needed, find common ground first: don’t go in undecided or with any degree of ambiguity. Buy-in will be much easier to attain if your child senses that no amount of derailing, manipulation, or other divide-and-conquer tactics will upset your alliance and distract you from your common goal, i.e., getting them in treatment.

  1. DON’T THREATEN CONSEQUENCES; JUST STATE FACTS

We prefer the word outcomes rather than consequences. Use sentence constructions like “If you choose to do this, it will lead to this.” Examples: “If you continue to smoke weed in my home, you will have your car taken away,” and “If you attend three NA meetings this week, you will earn your car back.” Again, the crucial ingredient with any outcome is follow-through. If you don’t follow through, you lose credibility.

  1. MODEL SELF-CARE

It is a general rule of thumb that teens are much more likely to do as you do rather than do as you say, especially when your actions don’t match your words.  Teens are extremely sensitive to perceived hypocrisy. If you expect your teen to stop doing recreational drugs, then you should stop doing them, too. Same lesson as above: if you tell them to stop smoking weed but you smoke weed yourself, you lose credibility. The current trend in public policy toward marijuana legalization is irrelevant where addiction and substance use disorders are concerned. What is important is to model your own ability to cope with life’s challenges without the need for substances. Adopting a disingenuous zero tolerance policy is counter-productive.

The key is to promote balance and demonstrate a willingness to work on yourself in tandem with your teen. If you model self-care, it increases the chance they’ll do the same. This is particularly true for moms of teenage girls who suffer from anxiety, depression, and low self-esteem, especially if that mom has her own history of struggling with these issues. There’s no better treatment for a teenage girl than to witness her mother taking care of herself, seeing a therapist, hiring a personal trainer, discovering a new hobby, or even just reaching out to friends to socialize or talk through important issues.

  1. GET TIPS FROM THE PROS

Here are some online resources for parents:

Treatment Spotlight: Family DBT at Evolve

Articles about Motivational Interviewing, an effective technique used in psychotherapy to help the client get more involved in their treatment. MI can be adapted by parents of teens with substance use problems:

Substance Use Resource Center  provided by the American Academy of Child & Adolescent Psychiatry.

The SAMHSA Parents and Families page, and this 20-Minute Parent Guide.

Final Thoughts  

The essence of getting buy-in from treatment-resistant teens is open, honest, and clear communication that comes from empathy. Your teenager needs to feel heard and understood. You have to be willing to listen to them and adapt your responses to what they give you. You are the adult in the situation, and your word is final. There are certain positions from which you will not and should not budge – but as the adult, it is incumbent upon you to decide what those positions are, at their core, and recognize what types of compromises support versus impede your ultimate goal, i.e., getting your teen the help they need.

Lydia

Dr. Mackeogh is a clinical psychologist with over fourteen years’ experience in the mental health field. She has worked extensively with people suffering from substance abuse disorders, mood disorders, and problems associated with life transitions, bereavement, and ill health As Program Director of the Intensive Outpatient and Partial Hospitalization Program at EVOLVE in Los Angeles, Dr. Mackeogh is dedicated to working with at-risk youth and providing a safe space for teens who are struggling with life transitions.

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