Authority in work with young adolescents: a personal review

Authority in work with young adolescents: a personal review

~ournal of Adolescence x979, 2, 3 4 5 - 3 5 4 A u t h o r i t y in w o r k w i t h y o u n g a d o l e s c e n t s : a personal review PETER BRUGGE...

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.~ournal of Adolescence x979,

2, 3 4 5 - 3 5 4

A u t h o r i t y in w o r k w i t h y o u n g a d o l e s c e n t s : a personal review PETER BRUGGEN* INTRODUCTION--THE EARLY

THINKING

The importance of authority and external controls when working with adolescents was first put to me at the Tavistock Clinic by Derek Miller, in 1966 (Miller, i974). Three years later, when the adolescent unit at Hill End Hospital was being set up, this teaching was in my mind when I r~ad a paper on the control of behaviour in an all adolescent ward (Hendrickson and Holmes, 1959) , which argued that placing aggressive adolescents in an environment in which there is a strong expectation of response to verbal controls; of obedience and respect to staff; of reasonable standards of personal appearance and conduct, will enable them more easily to abandon their anti-social behaviour and constructively internalise their conflicts. Almost Victorian standards of behaviour were asked of the adolescents, and so limits set were likely to be easily met. "Easily" became the important word for me. It seemed increasingly evident to me that high or widely set limits were not easy; people got hurt. Holmes (1964) , in a later book, described the confrontation between a psychiatrist and the adolescent who called him a bastard. "Where did you get the idea it was all right for you to call me a bastard ?" he asked. The boy said he didn't get it anywhere but was just telling the psychiatrist what he was thinking. "That's fine . . . . It's O.K. to tell me you think I ' m a bastard or you feel like calling me a bastard, but it's not all right to go right ahead and call me a bastard". During the supervision of my psychoanalytic training, I discussed the setting up of the adolescent unit with Donald Winnicott and one of his responses was to give me a copy of "Adolescent Process and the need for Personal Confrontation", which was later published posthumously in the # Consultant Psychiatrist, Hill E n d Adolescent Unit, Hill End Hospital, St. Albans, Hefts. Based on a paper read at the annual conference of the Association of Child Psychiatry and Psychology, Dublin x979. r

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~) X979The Auoclation for the Psychlatric Study of Adolescents 345

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last chapter of Playing attd Reality (197,). In it he concluded that adults abdicate at their peril. Dr T o m Pitt-Aikens and I put some of these ideas together in a paper (i975) in which we emphasised the key role of the issue of authority with younger adolescents. Rule breaking, challenge, confrontation , seeking the limit, defiance, may be used, we suggested, as the ticket for seeking professional help for troubles of a deeper nature. In some cases, we argued, facing the issue of a confrontation firmly and offering the adolescent the model of an adult preiSared to stand up for his rights may, of itself, allow for the recuperative forces of the adolescent, family or institution to take over, and further professional involvement be avoided. This paper reviews my thinking on authority over the past few years since I became interested in a number of different things, including open communications in institutions, many aspects of the "new therapies" including body work (bio-energetics) and gestalt and much to do with the practice and philosophy of the meditations. ADOLESCENTS AND AUTHORITY

I feel much less clear than I did, when I ask myself now what the place of authority is in my thegapeutie practice. T h e answer, not surprisingly, lies in paradox. Authority isjust, as important to me but I am less authoritarian. T h e difference between the two, I shall try to work out here in reference to various issues, including punishment. T o put it descriptively , I still use limit setting, confrontation and sanction in m y work but raise my voice, give orders and shout far less. As a developmental Stage adolescence still appears special,' because of the extent and intensity ofchanges in size, feelings find strength. It still appears to me that the rate of this change can be alarming to the person who is changing and that s u c h a person will desperately seek for limits in order later to develop them from within. Not tO provide such limits, boundaries or containments from without, is to create, as Holmes (x964) described, the gieatest cruelty of all: Many of the tasks of adolescence have been made more difficult by adults (sometimes professional caters) who side with them, ratlaer than contain them. Such people act as if they believe that children are always right.* Informationi problems, secrets, anxieties, potentials, courses of action--are all shared With adolescents, piematurely, r a t h e r t h a n being held up and held back, caringly. "It wouldn't be half so difficult if only it was not so easy" could often besaid by the frightened adolescent whom no-one will stop. All the difficulties-of the present day adolescent cannot, of course, be p u t down to a loss of authority in society although some of the most marked o I learnedthis interpretation from Dr JoI'm Padel.

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changes over the last few years have been in changing attitudes to authority (e.g. Government, Unions, schools, picketing, censorship, marital vows, penal legislation). However, Turle in an early paper (i96o) on an adolescent unit, described the disadvantages of permissiveness; and the "overthrow" of a therapeutic community for adolescents was described ten years later by Crabtree and Cox (1971). The very words "therapeutic community" have become so strongly associated with the giving up of staff authority that I try not to use them in describing my own work, although it is significant that Maxwell Jones (1976) in his "Maturation of the Therapeutic Community" emphasises that staff authority may remain latent, but should not be relinquished. The experimental work of Berkowitz (1978) and epidemiological evidence of Belson (I978), (both of which show the causal connection between the portrayal of violence on television and its enactment by adolescent witnesses) and, lastly, the anecdotal reports of the democratic wish of some school children for more teaching, more structure and more examinations, are other things, all of which help me to continue to value my interest in authority. THERAPY After I had become seriously interested in the detail and theory of psychotherapy and was searching for something more than just being nice to patients (and of course being nicer than other therapists) and became intrigued and then impressed by the value of interpreting the hostility or the negative ("I think that your no t talking to your m u m and dad and your not talking to me, are your ways of being very angry and of making us all pay for it") and of the use of non permissiveness, structure and authority in clinical work itself---after I had become serious about all of that, I had little trouble in using authority forcefully with individual patients and families. I could lay down my terms, stick to m y side of contracts (e.g. by stopping seeing people or discharging them); I could confront, challenge or shout. The trouble was that I did not have any trouble. I see myself as having been helped to move from this position at three points: Firstly, when Harold MacMillan remarked of Edward Heath and his throwing his weight around that when you are Prime Minister you a r e the boss and do not have to tell everybody. Secondly, when I was angrily and not very coherently complaining about colleagues not mentioning negatives and all the things that people had not done, it was suggested to me that the "I statement" was "I wish that you would all confront each other more and then I would have to confront you less". Thirdly, when I realised how Salvadore Minuchinwas able to talk pleasantly and with enjoyment about the authority with which he was invested by families and to exploit this to therapeutic advantage.

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I was then able to see that, although in some of my work, I had offered passive fathers a model of a more assertive man, I could often go too far. IHy search was to be less authoritarian, but without being permissive in the hope that others might be able to take more authority for themselves. Other people being more aware of their authority might possibly make it easier for me to enjoy and use mine. And if I feltmore easy with mine then they might become more confident with theirs. And so on. I t then became more important than ever to try to support the authority of others by, for example, encouraging an adolescent to make an arrangement (to which we were both party) and then offering support. (On Sunday evenings at Hill End Adolescent Unit each adolescent is invited to decide what he or she is going to work on during the week and the list is available to all in the unit so that all may be able to offer support. "I want to work on my anger", "I want to work on my mother's death", "I want to work on how not to get into arguments", are examples). Working with families, it became even more important to realise, discover, define, support and develop whatever authority was there already. I started to return the authority invested in me, as a consultant, a leader and as a therapist, to the parents whom I see as the just arbiters of the rules for their own children. I decide less but help them to decide more. Clieh6s and platitudes from which I would have cringed xo years ago, I now recite without, it seems, driving people to boredom or to leave the room. Sometimes I rely on ambiguity in my attempts to communicate. What you have got to face is a statement which means what there is in front of you (as in what you have got in your basket). It also implies an injunetion (what you ought to face). Some of my earlier "I think that you are .trying to get yourself locked up" interpretations of a few years ago are now replaced by "what you have got to face is that if you are not able to take control of yourself and your impulses by yourself, then sooner or later someone else is going to take eontrol of the whole of you---like a court locking you up. The question is, can you get enough help out of yourself, O? other people or me, to do it before that happens". Perhaps, by havirig more confidence in my own authority--(that I will be heard) I do not need to make an interpretation like the throwing in a dart. With my realisation that I was using ambiguity, something happened also in the quality of empathy. My tendency had been to confront adolescents with the limits as discerned by me ("my" discovery, " m y " truth). Now, more often I assume that they do know all along and that all I have to do is to ally myself with that part of them that has the knowledge. Their trouble, of course, is that although they know, they have been protesting that they do not; they fear loss of face. If I am able to make such an alliance and communicate to them my knowledge of theirs ("We both know

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that things can't go on like this forever") then perhaps the two of us can face the change together and feel less loss of face. Within family therapy, my practice of using my authority, either to challenge the weak authority of a parent to goad them into activity, or to support the authority of the parents in controlling an adolescent, has also undergone some change. I rarely do the first now, unless I do it lightheartedly and that seems to be just as effective as having a good row. The second I still do often. " H o w can I support you to get him to be quiet ?" "Look it's very difficult for any of us to work with Ian shouting so much and interrupting. Can you, father find mother, get him to stop--or at least tell him to stop" and then I would add my own authority "Be quiet" or "Sit down.--Your father's told you to". But I say it more quietly and light heartedly than before.

THE INSTITUTION, THE LIMITS AND THE OPENING OF COMMUNICATIONS Hill End Adolescent Unit's reliance on authority and limit setting is illustrated by some examples of its structure:

Tile boundary Those in parental authority are expected to make all decisions about admission, discharge and weekend leave. No extra money is to be given over the rates fixed by the Unit. We will not become involved in new eases if there is a court case pending.

Medicines With very rare exceptions, no medicine is given in the unit unless it is to sedate an adolescent to relieve the staff's anxiety. ("The way you are continuing to behave is making us anxious and so we are going to sedate you to relieve our anxiety").

Meetings These are expected to start on time, with no smoking, eating, chewing, writing, holding bags or pencils. Participants are expected to sit up, keep still and to look into the meeting. Only one person should talk at once and point scoring arguing is not accepted. While staff do occasionally have business which takes them out of a meeting (if there is no secretary, the telephone must be answered), adolescents are not to leave meetings ( " I f you feel you are going to be sick, we will get a bowl") unless excluded by whoever is running it--and that may be another patient.

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Limits Within the day-to-day activities Notice may be taken of swearing, shouting, dropping ash on the floor or running. If any hospital property (say a cup or saucer) is broken, the hospital will bill the adolescent concerned.

The law No protection is given by the Unit if one of the adolescents commits an offence and the police are involved. The staff will call the police promptly if drugs or stolen property are found in the Unit. (This act takes place only every few years and yet seems well engrained in the culture of the institution).

Participation The adolescents are expected to share with staff, doing many of the dayto-day chores such as washing-up. They take it in turns to chair the community meeting, to give a handover report to both the afternoon and night shifts of nursing staff and share, with staff, in the weekly inspection of the building and contents. An adolescent unit leaning so heavily upon authority and limit setting sometimes seems strange for an open communications system of administration to have developed. We drew heavily on the development of Dingleton Hospital with Maxwell Jones in the 196o's (Jones, 1968 ) and have the involvement of all staff in decision making. The authority message to the adolescents living there may be symbollsed in the following cumbersome statement: We are in charge of this place and are paid to be so; we will make the decisions about how it is run but we x~511welcome your viexxz about those decisions and sometimes will consult you about them beforehand. Your parents (or your social worker if you are the subject of a care order) are in charge of where you live and have said that you should be here and for a reason which was stated in your presence. You are in charge of the rest. You are in charge of your bodies and your minds, or your feelings (whether they be pleasant or unpleasant) and ultimately, of course, of your life and whether you live or die. If you have any difficulties with these, we are available to be consulted about them all the time. Within this setting we decided that the handover from the morning shift of nurses to the afternoon shift should no longer take place behind the closed door of the nurses office but should be done in front of the patients in the community meeting. In t974 the adolescents suggested that they do that themselves. Later they suggested that they should chair the meeting as well. Our anxieties were great, but in each case the innovation has gone well and the adolescents have performed the task better than we, the staff, were ever able to do. Again, allowing the adolescents to use their

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own authority within a structure, was paying off. When it has been difficult to find voJunteers for these tasks, or when they have not been carried out responsibly, we have been able to remind them that it was they, or their predecessors, who had suggested it. In its turn, of course this reminds them that we still retain the ultimate authority which we have delegated to them. \Ve have not had to take it back. In a community meeting the chairperson will tell people to stop giggling or to stop looking out of the window. T h e most the staff have to do is to say to the conductor "Please would you do something about so-and-so", or "Please would you tell Jane not to chew in the meeting". T h e ultimate authority held by the conductor is to exclude somebody from the meeting, which is something which happens perhaps twice a year. The latest innovation to the community meeting has been the structuring of a point for the adolescents to comment on the staff. As we opened up our communications and it became obvious that no sanction, (such as excluding a boy or girl from the group or sedating one of them) should be administered except in an open meeting, it also became obvious that the adolescents, themselves, should have a right to call a meeting at any time (except during school time when only teachers may do so). Now anyone may call a meeting and the focus, at least at the beginning and the end, must be on the mental state of the person who called it. A teacher called a meeting saying "I've called this meeting because I'm anxious about what is going on in school with the group and you, David". David then cried and spoke about his distress at the letter he had received at coffee time. The focus changed briefly. "O.K. are you able to hold that until the next meeting, until the community meeting?" David replied with an affirmative grunt. The focus returned to the teacher who called the meeting: "And how is your anxiety now?.... It's less now, I feel reassured and I'd like you all to come back into school". The meeting closed. An adolescent, Andrew, called a meeting sa)qng: "I've called this meeting because I want support. My meeting ("review meeting" with his parents to review their decision to have him in the Unit) has been cancelled and I feel like running away". There followed an attentive and unrestless silence after which a staff member said "Well, do you feel just calling the meeting and having the group together has given you enough support to hold things till the community meeting? .... Yes, I don't think I'll run away". The meeting closed. T h e ritualised opening of these meetings (I've called this meeting bec a u s e . . . ) earmarks the person who will close it. We also feel that it is important to emphasise the simple reasons behind what we are deciding or doing; and that if it is a sanction which we, the staff, are administering that this be in terms of the needs dictated by our own mental state. " W e are excluding you from school", or " W e are excluding you from working

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with the group because we are too anxious about the way you are behaving". "We are excluding you and sedating you because we will not tolerate your violent threats and your hitting us". The decision will always be reviewed at a subsequent meeting, which will take place within a few hours. Incidentally, the only reason that we ever give for discharging somebody is that we cannot cope with their behaviour or will not tolerate what they are doing. Stating the reason for administering a sanction in terms of our own mental state (or the parents' mental state) seems to make it less likely that it will be interpreted as a punishment. Punishment, as opposed to penalty or sanction, is after all, the deliberate inflicting of pain or suffering onto somebody who is seen to have done morally wrong. The power of guilt is, however, so great (which of us hasn't said "sorry" when meeting someone in a doorway) that non-punishment is often experienced as punishment by the recipient (or the giver) of sanction. This remains an issue for indefinite work. The opening of communications with the group of adolescents living in the unit, has been followed by other developments of their authority. In a community meeting a girl angrily cried out "You know my mother's dead! Why do you go on talking about her?" "Because you don't and you need to" said a x5-year-old boy. She listened to him and his "sapiential" authority, when she wouldn't listen to me. THE NEWTHERAPIES The new therapeutic approaches of gestalt, bio-energetics, group fantasy, body work, "I statements", confrontation, massage and so on are other experiences which have jolted my authoritarian views and attitudes, whilst leaving me with a strengthenedrespect for the use of authority. .... I am impressed by the way in which the body finds it so hard to "lie" and, if I can be perceptive, then an authority greater than mine will communicate. "Your kickingfoot suggests to me that you are fee]ingveryangry inside" has been replacedby "I wonderwhat your foot is saying?"and now, more often, by '%Vould you try putting your foot on the ground". (The first time that I tried this in a familymeeting,the effectwhich was experienced and unleasedwas not the hostility, (which I had been holding myself in from interpreting)but grief. As she put her foot to the ground, the girl sobbed. Also, a running-awayboy, who had run away many times from many places and a few times from us in two days was, in his second community meeting, tapping his feet restlessly on the floor. He was asked not "}Vhat are you trying to run away from?", but rather "Try putting both your feet on the ground". He had seen enough other people use or talk "body language" in his two days in the unit to be able to try it. He cried quietly for 5 minutes.

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STAFF INTERACTION Of course we do not have to agree and there is nothing basically wrong about sharing our disagreements in front of the adolescents, but we do have to get on together and work together. H o w well we get o n together will affect how we make decisions, how we support them and how we guard against our punitiveness, all of which are important in influencing how much we are able to use our authority consistently and caringly. We have decided that we can work together better, if we make a commitment to respect the boundary between our professional lives and our private lives, not to have secrets about work and not to talk about colleagues except in their presence. CONCLUSION

In our society, individual liberty and authority are both important, and each can be taken to extreme. It is fashionable to say that authority can go too far, but more difficult to say it of the other. I think that in a society it is valuable and helpful to have an organisation (probably elected) which makes rules, changes some of them, bans things and draws some ridiculous lines. I think that between the majority of us and that group in which we invest authority, the interaction of protest, rebellion, argument, discussion, enquiry and change is a healthy one. For the younger adolescent (bursting with feelings of size and strength) individual liberty and authority are both important, but authority and the handling of it by older people who are prepared to receive hostility and confrontation without giving in, is especially important. I conclude that it is in the interests of the adolescents that we, the adults and the professionals, should be prepared to be authoritarian. Troubled by an inner world peopled by confusing forces and persons in contradictory conflict, it is essential for adolescents to find the firm boundary of the limit-setting elder, who can give reasons in terms of him or herself. It is within that relationship, that there may develop, in the inner world, the inner authority which is their own. For me to try to offer this to the adolescents that I meet, may be unpleasant for me but, of caring, it remains an essential part. APPENDIX

Excerpts from "'To the Parents from their Children" by an in-patient at Hill End Adolescent Unit. Don't spoil me---I know quite well that I ought not to have all I ask for. I'm only testkug you. Don't be afraid to be firm with me. I prefer it. It makes me feel more secure.

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D o n ' t let me form bad habits. I have to rely on you to detect them in the early stages. D o n ' t correct me in front of people if you can help it. I'll take much more notice if you talk quietly with me in private. D o n ' t be too upset when I say " I hate you". I t isn't you I hate but your power to thwart me. D o n ' t protect me from consequences. I need to learn the painful way, sometimes. D o n ' t take too much notice of m y small ailments. I am quite capable of trading on them. D o n ' t make rash promises. Remember that I feel badly let down when promises are broken. D o n ' t forget that I cannot explain myself as well as I should like. T h a t is why I am not always accurate. D o n ' t tax m y honesty too much. I am easily frightened into telling lies. D o n ' t be inconsistent. T h a t completely confuses me and makes me lose faith in you. D o n ' t ever think it is beneath your dignity to apologise to me and an honest apology makes me feel surprisingly warm towards you. D o n ' t forget that I cannot thrive without lots of understanding love, b u t I don't need to tell you that, do I ? REFERENCES Belson, W . A. (x978). Television Violence and the Adolescent Boy. Farnborough: Saxon House. Berkowitz, L. et al. (x978). Experiments on the Reactions of Juvenile Delinquents to Filmed Violence. In Aggression and Anti-Social Behaviour in Childhood and Adolescence. Hersov, L. A., Berger, M., Shaffer, D., Eds. Pp. 59-72. Oxford: Pergamon Press. Bruggen, P. and Pitt-Aikens, T . (x975). Authority as a key factor in adolescent disturbance. British ffournal of 3ledical Psychology, 49, x53-59. Crabtree, L. H. and Cox, J. L. D. (x972). T h e overthrow of a therapeutic community. lnternatlonal ffournal of Group Psychotherapy, 22, 3x-4x. Hendriekson, W . J. and Holmes, D. J. (x959). Control of behaviour as a crucial factor in intensive psychiatric treatment in an all-adolescent ward. American ffournal of Psychiatry, xx5, 969--73. Holmes, D. J. (x964). The Adolescent in Psychotherapy. Pp. 95 and x5. Boston: Little, Brown & Co. Jones, M. (x968). Beyond the therapeutic community. Social Learning and Social Psychiatry. New York and London: Yale. Jones, Maxwell (x976). Maturation of the Therapeutic Community. p. xoz. H u m a n Sciences Press. /~iiller, Derek (x974). Adolescence Psychology Psychopathology and Psychotherapy. New York: Jason Aronson. Turle, G. C. (x96o). On opening an adolescent unit. ffournal of Medical Science, xo6, I32o--6. ~Vinnicott, D. W. (x969). Adolescent process and the need for personal confrontation. Paediatrics 44. P 75z--756 in "Contemporary Concepts of Adolescent Development and their Implications for Higher education". Playing & Reality. Tavistock (x97x). (pp. x38-xSO).