Assisting sufferers at the epicentre of a fraying society
16 MINUTE READ
Despite the obvious challenges, working with teenage patients can be incredibly rewarding for a GP. To do this work as a Christian offers remarkable opportunities to help, challenge and invite young people to witness the relevance of the Gospel.
A Few Common Issues
Adolescence is a time of substantial complexity, self-consciousness and a growing desire for independence without much capacity for it. Countless ideas compete for attention. A myriad of pressures, thoughts and desires pull them in all directions: pride and performance, pleasure and sensuality, possessions, a desperate desire for approval and acceptance. Adolescence often ignites ferocious emotional upheaval. Teens are commonly defensive, resistant to correction, self-righteous and self-centred, focused on the present and seeking rapid sources of gratification, particularly through the misuse of sex or substances. Teens are exposed for the first time to a steady stream of complex, serious and deeply confronting adult problems. The future is deeply uncertain; daunting questions about vocation and friendship sit alongside many earnest doubts about self-worth, “Will anyone ever love me?”
Modern teenagers seem to be prominent sufferers at the epicentre of a fraying society. Marriages fail with alarming frequency, forcing teens to alternate between the homes of their two parents. Informal intimate relationships are normalised and celebrated though they rarely last the length of time to raise a child. Instead, many teens experience both parents in their own cycles of short-lived, low-quality relationships and are forced to accept less than ideal circumstances, including an array of non-biological adults passing through.
Problematic peer relationships are also prominent amongst the multitude of modern issues faced by young people. Isolation is common and most young people have very few healthy friendships. Sex is commonly the precursor to a potential relationship and typically results in varying degrees of disappointment, shame and the objectification of at least one participant. Committed, lasting, mutually satisfying relationships are rare, whereas transient, non-committal, openly promiscuous relationships lacking in trust with varying degrees of abuse abound.
“The ever-changing landscape of social media brings a variety of issues, including influencers provoking unreasonable comparison and triggering harsh self-scrutiny.”
The ever-changing landscape of social media brings a variety of issues, including influencers provoking unreasonable comparison and triggering harsh self-scrutiny. Content that compellingly coaches teens in disordered eating, harmful exercise, unhealthy messages around gender and identity, extreme forms of self-harm and suicide planning methods are easily found. Young people who have watched such content find that it quickly dominates their feeds and can take years to disappear. Scrolling through feeds can be quite addictive and offers an endless stream of content that naturally lends itself to social isolation, anxious avoidance and unhealthy disengagements from crucial parts of life, like school and family.
Despite the challenges foisted upon them, adolescents are particularly geared to adjust and thrive in unideal circumstances. As most of us have observed, the early teenage brain is specifically adept at being critical. Highly sceptical and negative analyses allow teens to observe, adapt and hopefully learn to avoid repeating the problematic dynamics they experienced in their childhood.
As they age, adolescents are particularly malleable and adept to change. Amongst the challenges of working with young people, one of the great joys is seeing their tremendous capacity to take suggestions and run with them. It is wonderfully common to witness supported young people develop agency, build momentum, conquer crippling addictions, leave behind unhealthy friendships and escape abusive relationships, never to look back. Adolescence is a journey of exploration and maturation within which it can be richly rewarding to offer support and guidance.
Engagement About Faith
Working in a secular clinic, most young patients have little to no interest in religion (1 Cor 1:18, 2:14; Rom 8:5-8). A number have negative experiences of historic family connections to church in previous generations. Far fewer have had contact with genuine believers. To most patients, enquiries about religion provoke immediate scorn and derision, at times followed by a nervous partial apology after a moment’s circumspection.
I have found that conversations related to faith are far more helpful when they come from a very personal lived experience or conviction as it relates to the issues arising in the consultation (2 Tim 2:24-26). Feelings are king in this age and generation; when I’ve got skin in the game, young people are far more likely to reserve judgment and listen with surprising respect and curiosity (Ps 34:8; 1 Pet 3:15). Here lies the role of the Spirit; for days and weeks of personal anecdotes, snippets of Scripture and ideas stemming from a Biblical worldview – some flicker into fascinated flame and others fade without memory or offense.
Although it may be surprising, I find the local church has a dominant role in my consulting room. The church is a wonderful place for non-believing young people because of its qualities and natural inbuilt witness. Together, we are the aroma of Christ (2 Cor 2:15-17, 5:20).
I may raise church as part of a discussion while exploring the paucity of healthy relationships in a young person’s life. I ask young people to nominate potential local groups and places where they might forge future friendships. Pubs and clubs are often volunteered as possible social options by patients. Sporting teams, the art scene and University social clubs are also frequently named. When focusing on the potential of each of these ideas, young people often feel they are likely to be fruitless. Here, I can offer with confidence what I commend as a strange idea, namely, church. I make it a priority to know the health of local churches in my area, so that I can explain gently and winsomely,
“There is a really great group of young people at the church just down the road from your place. They hang out all the time. They are super friendly. There is no pressure to hook up, get drunk or wasted. And they would be really friendly to you, and keen to include you in the stuff that they are doing.”
I will also often speak to reservations before they are spoken,
“There is no requirement for you to believe what is being taught, or to even be interested. You can come and go freely, and no one will hassle you.”
If there is enough interest at the initial discussion or in future consults, I will often offer to put them in contact with a young minister, women’s worker, or mature evangelistic young Christian. Simple things make a difference, like asking,
“Would you like them to give you a call, or for me to give them a heads up and give you their number for when you are ready?”
By seeking simple ways to invite young people to their local church, I know of many who have been brave enough to go. I can testify to young people who have come under conviction as they witnessed the love between Christians and heard the preaching of the Word in the local church, a place they had no likelihood of visiting (John 13:35-36, 1 Thess 4:9-12).
Teenage crises are a genuinely crucial moment of life that opens a fleeting window of opportunity to consider the relevance of the Gospel and to understand God as a tangible help in every time of need (Ps 46:1; Deut 4:7, 1 Pet 5:7). When the only default strategy for relief is one of retreat to the bedroom, it is profound to consider that the God of all mercy, our Creator, the Creator of the universe, the sovereign Lord of all, implores us to call out to Him and reminds us that He will hear our cries (Ps 91:14-15; Heb 4:14-16).
CCEF counsellor, Ed Welch, reminded me of this potent dichotomy in Hosea 7:14, “They do not cry to me from the heart, but they wail upon their beds”. When faced with such a stark contrast, crying to ourselves seems such a pitiable choice compared with receiving loving attention from the Living God. We want our patients to truly know God and run to him during the trials of life (Ps 18:1-6,16-19; Prov 18:10).
A Few Principles for Counselling Teens in General Practice:
Take good amounts of time to listen well, build the relationship and cultivate a space where substantial conversations are looked forward to by the young person. In an age of negativity, skepticism and limited openness, trust must be earned. Doctors aren’t inherently trusted by this group and any sign that you are in a hurry, distracted or being pushy will likely spoil attempts to build rapport. Consider booking generously long appointments for new teens, especially if they are coming for mental health, family or social difficulties. You will be glad to have this extra time and it will set up the foundation for making future progress.
Get to know the young person deeply. Whilst a DSM V diagnosis may be helpful, we want to understand a person in a far more profound way than that of a reductionist label – a description of symptoms which cannot possibly grasp larger questions of aetiology or greater meaning. As believers, we have the divine resources to help a young person wrestle with the deepest questions of life in a way that is not possible with even the most profound secular psychological approaches.1
Consider using a framework to build an understanding of the young person’s life. As one example, the HEEADSSS (Home/historical background, Education/employment, Eating/exercise, Activities, Drugs and alcohol, Sexuality and relationships, Suicidality, self-harm and safety, Spiritual interest and belief) assessment works well to prompt us to consider specific areas in detail. I would generally suggest keeping a shortcut template which allows you to let the conversation flow however it unfolds, but to remind you of things that have not yet been discussed. Using a framework helps the clinician to be thorough and the young person to feel well cared for. Most dynamics of concern can be raised when covering these aspects of life.
Parents are a very important part of a teenager’s life. They are very often the main driver for the appointment and the only reason the young person is sitting with you. Parents are often far more able to articulate what is wrong and get straight to talking about the issues at hand. I find it very important though to stop the parents from doing this (except for young children, or extremely anxious teens). Rather, invite the young person to open the discussion. I seek to help the young person feel that the appointment is not just about them, but for them, centred around their concerns and led by their priorities. I often have the chairs positioned so that the young person sits slightly in front of or angled away from their parent/s. In this position, the young person is more likely to engage well, and less likely to simply refer my questions to their parent/s. They are also less likely to be distracted when parents vigorously nod in agreement with things that I say. At an appropriate time, I would ask the young person’s permission for the parent/s to reflect on what their child has said and add their own observations. At the start of a consultation, I usually let the young person and their parent/s know that we will get the parent/s to pop out during the consultation (and that the young person can request this at any stage). Depending on the parent-child interaction I will often ask the parent/s to leave somewhere in the middle of the consultation. If the parent/s is overbearing or provoking distress, I may ask them to leave earlier. In almost all consultations, I will discuss the return of the parents and negotiate what we will discuss with them. I find the technical details need to be raised with most parents (suggested blood tests, negotiated follow-up times, options for counselling, and the full discussion about whether medications are recommended). I find this dynamic of empowering the young person and negotiated communication very helpful for unearthing and later discussing the issues with parents, which could not have happened if the parents stayed the entire consultation.
Teenagers lack wisdom and are particularly vulnerable to the temptations that spring from sexual desires. It is crucially important to be willing to talk openly about sexual matters, including pornography, unhealthy relationships, mistreatment, and the dynamics of sex outside of permanent committed relationships. Young people generally are surprisingly comfortable to reveal wariness, a lack of concern, or fears regarding sexual dynamics impacting their lives. When thinking about sex, don’t forget to consider matters of the heart. A focus only on behaviours will fail to grasp crucial dynamics, such as the deep desire to be loved, accepted and known. Where possible, conversations around sexuality and relationships should allow a juxtaposition of the ugly brokenness of modern sexuality with the beauty of a richly biblical, practical vision for healthy relationships and lasting sexual satisfaction. I have witnessed non-Christian teens being especially drawn to this radically alternative way of relating to others and through these conversations, become interested in the wider spiritual exploration and emboldened to visit a local church for the first time.
Look for Biblical Categories
Much of what medicine and counselling seek to address are also profoundly theological and addressed richly in the Scripture. Consider how the counsel of the Word could be substantially relevant to your patients’ relationship problems, issues of identity and personhood, suffering, abuse, addictions, destructive coping mechanisms, negative emotions, or a sense of meaninglessness. To the extent that sins and separation from God are never raised by us, we who believe are denying patients something crucial and doing them a tremendous disservice (Eph 2:11-18,4:18; 2 Cor 4:5-6,5:20).
“Much of what medicine and counselling seek to address are also profoundly theological and addressed richly in the Scripture.”
Raising spiritual things with an unbelieving teenage patient in a secular space requires great prayerfulness, wisdom and sensitivity, but should be our earnest desire as we attentively look for and walk in step with the work of the Spirit. When we do not seek to offer Christ, we leave patients floundering and fail to reveal the ultimate remedy to all that ails them (2 Cor 2:15). As you seek to know the young person, look for biblical themes and categories2 that can be observed from actions, thoughts, feelings, desires, fears and their story. Consider what philosophies and voices inform their approach to life and seek to understand their experience and the problems in their life, from their perspective.
How we approach communication with teenage patients is crucial. If we are seeking only to understand the most blatant presenting issues and undertaking to quickly fix the obvious problems of our teenage patients, most will quietly tune out and politely await the end of the appointment. Instead, we should seek to draw out the young person to speak from their heart. Our young patients should be facilitated to say far more than we do (Prov 10:19,12:18,15:23,17:27,29:20; James 1:19). Pursue teens with genuine curiosity, and simple, open-ended questions paired with demonstrations of concern and sincere optimism about their future. Rather than bequeathing our solutions to their problems, we should be helping them to learn how to develop their own strategies for addressing all that ail them.
Stay calm – don’t allow yourself to get flustered by disclosures of suicidality, self-harm, sexual brokenness, or even emotional tirades in the consultation room. Your young patient is watching you carefully, and your reactions to each of these moments serve to test your reliability, confidence, ability and your willingness to help when things aren’t easy.
On a superficial level, many issues may seem directly related to common dynamics associated with teens being motivated by short-term preferences or bodily feelings such as hunger or tiredness. Parents have often already zeroed in on these dynamics with heavy-handed criticism of apparent laziness, selfishness and refusal to participate in what is expected in the family. Rather than falling into the same traps already ensnaring the family, we do well to wisely recognise that this teenager has far more going on.
Despite blatant self-centredness and other effects of the fall, our patient is made in God’s image and has motives, longings and desires instilled by God that we can celebrate and appeal to. Using the wisdom gleaned from the book of Proverbs we can expect that most young people have substantial deeper desires. These desires might include: being thought well of, having healthy friendships, having proud parents, to find love, to be successful, useful, secure, confident or financially well-off. Most teens have deep desires not to be mistreated, exploited, tricked, or be characterised by anger, lying, or selfishness. Exploring and stirring up helpful, yet subliminal God-given desires can be incredibly fruitful in motivating change. Asking simple, repeated questions of “What do you want? What else?” can highlight helpful desires and their intrinsic motivation as helpful subjects for discussion, wise counsel and support to navigate out of current impasses. Be willing to highlight poor choices by showing how they are ultimately counterproductive to their most precious goals. Wisely approaching young people will help to foster a helpful relationship that may grow to be able to talk about spiritual matters, including our need for a reconciled relationship with God.
When thinking with biblical categories, we may find it easier to remember helpful responses from the Scripture in responding to common problems and the influence of unhelpful patterns of thoughts such as hedonism, materialism, unhealthy autonomy and entitlement. The Bible recognises that young people do experience great temptations to some sinful desires. Paul exhorts Timothy to be especially vigilant regarding sexual desires, arrogance, argumentativeness and anger as he encourages in 2 Tim 2:22, “‘Flee youthful passions…’ whilst pursuing all that is good, “… and pursue righteousness, faith, love and peace.” Teens from all backgrounds naturally question all that they have been taught and observed while growing up. This is an especially formative time where young people reformulate what they believe about the world, about people and about God. They also have a tremendous capacity for introspection and self-reflection, which allows them to be more open to helpful voices and challenges, such as those offered to Timothy by Paul.
Be willing to share from a personal perspective. In this precious window of openness and interest, seek opportunities to offer relevant Gospel stories. If this doesn’t come naturally to you, you may benefit from resources like those produced by Soma3. Teens are very sensitive in detecting any hint of inauthenticity, so be forthcoming and sincere. To speak the truth in love (Eph 4:15) catches the attention of young people. Approach them with God-given mercy and a commitment that involves a willingness to take extra clinical time, to negotiate family dynamics, to share personally, to persevere through discomfort and to stick with young people for whom progress may be slow.
Because there is no particular script for counselling teenagers, each of us who are given this opportunity must rely on God’s measure of wisdom, patience and hope (Col 4:2-6). I pray that in these consultations, you too would have the privilege of witnessing God drawing young people to Himself and to the local church amid their strife. May God enable you to be a wise and steady counsellor for your teenage patients and give you the boldness and means to point the teenagers to find their help in Him.
Dr Anonymous Dr Anonymous is a GP in regional NSW. They have worked in multidisciplinary adolescent mental health clinics for 15 years. As well as a deep love for their family and the local church, Dr A desires to boldly and prayerfully encourage young people to taste and see the goodness of God firsthand.
- I heartily recommend the ministry of the Christian Counselling Educational Foundation. They offer a biblical counselling framework in readily applicable ways. CCEF.org has a variety of audio, blogs, books, journal articles and excellent online training. GP turned counsellor Dr Mike Emlet’s book Descriptions and Prescriptions: A Biblical Perspective of Psychiatric Diagnoses and Medications is a helpful summary of the topic. Similar books on depression, anxiety, anger and the fear of man are equally excellent. Needing slightly more contextualisation is the training through ACBC https://www.biblicalcounseling.com/online-training/ which is very good and inexpensive, albeit blunt.
- A sampling of biblical themes could include: idleness, discontent, idolatry, anger, bitterness, fear, grief, despair, doubt, gluttony, greed, gossip, mocking, lying and sexual immorality which includes lust.