Child Psychiatry Consult

With a little help from your friends


 

Case: You are talking with one of your teenage patients, who has a history of significant suicidal ideation and an aborted attempt, and you ask her if there is someone she can talk with if she is feeling suicidal. “I call a friend,” she says. “That’s the only thing that works when I’m feeling bad.”

During difficult times, it is important to have a repertoire of coping skills to address stress, tension, frustration, anxiety, anger, sadness, and to help avoid dangerous behaviors. It is also important to have someone to talk to. For many youth, talking with friends is their preferred coping skill and contact when struggling with intense feelings.

Dr. Schuyler W. Henderson is a psychiatrist who treats children and adolescents at NYU Langone Health, New York

Dr. Schuyler W. Henderson

This is hardly surprising. Peer relations are central to adolescent development. The ongoing individuation-separation process means that adolescents are peeling away from the family and into a community of their peers, where they figure out who they are through social interactions in subtle and complex ways. Adolescents are often profoundly immersed in the world of their peers; they often spend more time with their peers in educational and social settings than with their parents or other adults; and their connections with peers are often pleasurable, engaging, supportive, and intense. It is natural that they would want to communicate with their peers during stressful times.

At the same time, they may also want to avoid talking with adults. They may identify adult figures with authority, expectations, and control. So much adolescent psychic suffering and so many mental health crises involve shame, guilt, and fear, and are associated with romance, love, disappointment, and trauma – all of which may be difficult to share with parents and adult figures.

Adults also struggle with these kinds of conversations. Even benign attempts at comforting the youth (“Don’t worry, it’ll get better,” “Everyone feels this way sometimes”) can be seen as invalidating. And in stressful times, a difficult conversation can be ignited by the fuel of adult anxieties about the independence and autonomy of the child that is coming, which can make charged conversations all the more inflammatory.

Reaching out to peers during stressful times is therefore developmentally appropriate and often feels far more comfortable, validating, and sympathetic.

One of the most important things we can do is to help kids understand when, how, and why they can support each other – and when they cannot. Whether we like it or not, for many youth, peers are peer mental health counselors. They have shared vocabularies and can share experiences in the mental health care system. In addition to relying on their peers, a great many youth we work with also see themselves as supports to their peers, so it’s not just a one-way street.

So we talk with them frankly about when, how, and why talking with their friends can be an effective way of getting through a hard time and when, how, and why they need to reach out to an adult.

Recognizing how positive peer support can be, we ask them to identify problems with it. Kids often recognize the drawbacks of relying on their peers for support. They can see how it can be a burden to their friends. They often acknowledge that their friends may be experts in some aspects of their lives but not in others. For example, they can have shared stressors in school, can have similar understandings of the drama in their lives, and can relate to each other’s worlds, but will also not necessarily know what to do if a situation becomes dangerous.

The youth also tend to understand that the stakes in these conversations are high. We have seen peer groups suffer terribly when the youth have felt responsible – and even been the last preceding contact – in bad or even fatal outcomes.

We need to open up conversations about different forms of communication: when teens need understanding, compassion, patience; when they need a good understanding of local, cultural contexts, and a sense of support without anxieties and stressors; and when they need support and adult capacities and connections to solve problems. We can help them understand how to access people – both peers and adults – but also discuss responsibility: who you are responsible for, how you cannot be responsible alone for your friends’ mental health, how they cannot be responsible for yours, and who can be responsible for you.

To this end, we validate the importance of peers and ask more specifically when the adolescent thinks it is helpful to contact peers and when they think it would not be helpful. Having teens explain the difference may help them identify the right times to connect with peers or adults.

We can then talk about how to understand that there are different kinds of crisis: the kind where comfort, understanding, and support from friends can alleviate the crisis, and times when it is imperative to involve adults.

We can then identify which adults in their lives they can contact and how they would do so, both in terms of method of communication (texting an older sister, speaking in person with a parent, calling a therapist) and what they could say.

Then comes a more difficult step. We help them think about how to identify adults whom they do not know: how to contact a hotline or go to an emergency room or call 911. It is important not just to provide the numbers or address, but to help them run through a brief script so they know what to say and would be comfortable saying in their own words (but effectively saying, “I really need to speak with someone right now, I’m not safe.”)

Helping youth understand the advantages and disadvantages of reaching out to peers, and when and how to reach out to adults, can be a constructive conversation. It is a chance not only to speak with and hear about a youth’s life and relationships but also a chance to give them a stronger and safer support network.

Dr. Henderson is a psychiatrist who treats children and adolescents at NYU Langone Health, New York.

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