INTRODUCTION

We can define the major changes that occur in adolescence on three levels:

• changes at body level;
• changes in relationships with peers;
• modification of the relational model with parents.

The psychological development of adolescents takes into account their personal history and their new sexual, cognitive and social skills. The family environment, like the social environment, allows us to bridge the gap between the psychic and somatic spaces, which are inseparable. What happens in one subsystem in which the adolescent is involved will disrupt what happens in others.

Knowledge of the milestones of psychological development and the study of systemic theories have greatly helped us understand the dynamics of the relationship between adolescents and the various subsystems in which they move.

The tasks of adolescence can be facilitated or, on the contrary, made more difficult by the family system. The family is an open system in constant interaction with the environment. The different phases of the life cycle imply the performance of specific tasks, and there is a need to restructure the system in order to perform them.

The family structure essentially has two aspects: one homeostatic, which promotes permanence and continuity, and the other transformative, which consists of the family’s ability to live through adaptive crises and find a new balance. Thus, we can understand the crisis as something that is not necessarily pathological in itself. The crystallization of the symptom , however, can be a sign of pathology.

In a family with teenagers, we see a change in the parent-child relationship, an increase in the flexibility of family boundaries, and a new focus on the couple’s life. This is usually a very demanding period of professional life for parents. There is also a progressive shift of family concerns to the older generations and, in the final phase, we see a preparation for the children’s departure, giving rise to the so-called empty nest syndrome . Currently, the tendency is for this departure to occur later, compared to what happened in the parents’ generation.

On the other hand, with the emergence of new forms of family, its concept has become something much more comprehensive, requiring a social reframing.

It is described that it is in the periods of transition between the different phases of the life cycle that signs of discomfort most frequently appear and that the family system, recognizing its difficulty in changing, may ask for help. The phase of the family life cycle characterized by the adolescence of children is recognized as a period of great vulnerability for the system.

When adolescents seek health services, they may be the bearer of the family symptom, the element that leads the family to ask for help. It is essential to place the symptom in the family context to help change it. How often does adolescence coincide with a grayer phase in life when parents question their relationship as a couple? It may then be easier for them to seek help through their adolescent child (who may even be having a perfectly normal adolescence!), rather than asking for it directly for themselves!

WHAT A DANCE OF MUTUAL ADAPTION… (STORY OF A FAMILY THERAPY)

Ricardo is 17 years old and an only child. His parents, in their forties, have a good relationship with each other. His father works in a computer company and his mother is a secretary. The three of them live in Lisbon. Ricardo is attending the 11th grade for the second time in a secondary school close to home. The reason for coming to the consultation was clearly stated by his parents at our first meeting: “Life has become hell!” According to them, Ricardo had never caused any major problems until about two years earlier, when he began to lose interest in his studies, to not respect the rules at home at all and to hang out with people his parents didn’t like. I tried to get them to be a little more specific. Ricardo had been a reasonable student until the 9th grade. He had great doubts about which group to choose, and finally decided, not very convinced, to go to the arts group. In the 10th grade, he began to lose interest in school progressively; He often missed school, lying to his parents about it, spent his days playing computer games, and didn’t respect the previously agreed-upon time he was to come home. He always went to bed so late that he couldn’t get up the next day, always missing the first period. His parents tried several ways to interact with their son, talking and negotiating, but nothing seemed to work. He went into the 11th grade and failed a subject, and that year was even worse. He started going to nightclubs on Friday and Saturday nights and returning late at night. He would agree to come home at 4 o’clock and get home at 8 o’clock in the morning. His parents then started a system of fines in which his weekly allowance was reduced or simply taken away, or they would forbid him from going out the following weekend. None of these measures worked. Ricardo went out anyway. The first time he left the house after his parents were already asleep and rang the door the next morning as if nothing had happened. He was punished and retaliated again. He stopped going to school for a week and threatened that if the punishment continued, he would stop going to school altogether. His parents, considering school to be a protective environment and afraid that if he didn’t go, Ricardo would have too much free time to hang out with bad people, suspended the punishment. On one occasion, his mother began to hide the most serious events from his father in order to protect him. He said that he had become afraid for his health, because he was completely disturbed by Ricardo’s nonsense.

While his parents were talking, Ricardo alternated between a defiant and somewhat embarrassed look. When we asked him to describe the situation, he said that what his parents had said was true, that he didn’t like to study, but that he thought they controlled him too much.

In the first interview, we began with the welcoming phase, in which each family member was given time to introduce themselves; this was followed by the problem-exposing phase, the interaction phase, in which it was possible to understand how the levels of power were defined, and, finally, the goal-setting phase, when a therapeutic contract was drawn up.

We realized that the parents were exhausted. It was clear that they loved their son, but that they were deeply hurt and disappointed with him. And, above all, they felt that they had already tried everything and that nothing was working.

The feeling of an apparent lack of solution, the symmetry of action on the part of the parents and Ricardo, and the need to avoid further problems for their son meant that, at the end of this session, our prescription was to ask that, until the next session, they do nothing different from what they had done up until that date. We suggested that, until then, they imagine how, in a given situation, it could be dealt with differently, in an unpredictable way. We asked them not to do it for now, to just rehearse it in their heads.

In the next session, it was the father who spoke first: “Right now, it seems to me that Ricardo doesn’t even belong to our family. He comes home at dinner time, sits at the table and, when we’re just starting, he’s already finished, gets up and goes to watch TV or play on the computer. And when we say to him: ‘You’re not going to get up at all, you’re going to stay there until we finish eating’, he seems to go crazy. One of these days, I said to him: ‘I heard you’ve been skipping classes’. And Ricardo replied: ‘I haven’t been at all’. ‘Yes, sir, they called me from school asking if you were sick’. ‘Okay, I skipped classes, so what? It has nothing to do with it. Is it me or not?’ ‘And what have you been doing?’ ‘Nothing.’ ‘But I want to know where you’ve been, with whom and what you’ve been doing. You don’t skip classes for nothing.’ ‘I haven’t been anywhere, with anyone, or doing anything.’ ‘I’m going to talk to your mother about this and ground you.’ ‘No big deal, you can ground me all you want.’

We asked Ricardo what he would like to see change in the family, taking his point of view into account, of course. He replied that he would like there to be less arguing. We continued: “The impression we got from the last session was that Ricardo has acquired a very powerful position in the family. We think that the way he found to maintain this power was by asking why whenever his parents say no, and, despite his explanations, never obeying.”

In fact, the parents were always eager to explain everything. They were both very rational. They came from very strict families and always wanted to educate their son in a spirit of dialogue. And that was Ricardo’s great asset. By getting them involved in an argument and persisting in their stubbornness, they would give up in sheer despair and end up letting Ricardo do whatever he wanted. Ricardo had the power to leave them completely at a loss for what to think and do. They could start by saying no, but Ricardo knew exactly what to do to turn that no into a yes.

In that session, we used circular questioning in an attempt to better organize the information. We asked the mother, for example, what she thought the father would like to say to Ricardo that he had never said.

We then told Ricardo that, from our point of view, it was stupid to give up this power that he had achieved so effectively. We made him see, however, that this power came at a very high price, since he would always have to show great anger and, in extreme cases, he would probably have to be institutionalized. However, he could get used to it and even not care. We added that all we had to do was help his parents get used to this idea and that, to do so, we did not need him to be present in the session, so we invited him to leave.

The prescription of the symptom (which Palazzoli called a paradoxical prescription) and the absurdity of the request for him to leave (so I, who am the patient, am I exempt, am I not needed?) made him astonished and left after a slight hesitation.

As soon as Ricardo left, we went to his parents and asked if they had been able to think of different ways of dealing with the situation. His mother quickly expressed her helplessness: “I can’t think of anything, I don’t know what to do.” His father said that he had oscillated between trying to be reasonable with Ricardo and, in the most extreme situations, showing him strength. He admitted, however, that both techniques had failed. Ricardo always seemed to have more strength.

We then agreed that we would change the attitude from strength to weakness, that is, the parents would appear very tired, unable to do things as effectively as before. The foods that Ricardo liked and that were usually available would no longer appear in the fridge; his mother would sometimes forget to make dinner; if Ricardo asked them to recharge his cell phone, the parents would say that they did not know where they had left their bank card; etc. They would also stop arguing with Ricardo.

Our intervention strategy, based on this benign sabotage technique, aimed to induce role confusion. We also used a positive connotation in which the symptomatic behavior was positively redefined. We also used a metaphor in this session. We told a story so that the parents could identify with it, in order to give them an alternative view of the consequences of Ricardo’s behavior. At the end of the session, we made it very clear that we strongly believed in the potential of the family.

In the following session, the parents showed a more positive state of mind. They said that Ricardo, faced with this change in strategy, had become completely frustrated. Having to question what was happening, without understanding, he must have imagined that his parents were not so powerful after all. It was necessary for them to simultaneously appear less understanding and less powerful so that Ricardo would also appear less confident and powerful. In Ricardo’s absence, in this session and in the following ones, the empty chair methodology was used, with the intention of externalizing the problem.

The therapy continued for three more sessions in this type of register. We tried to expand the symptom, from the perspective that the problem brought to therapy was not the only one in the family, thus ceasing to be so focused on Ricardo. Whitaker describes, in his experimental-symbolic therapy, the battles for structure and initiative that we used here. It was effectively with the latter that we were able to establish the therapeutic alliance.

For Whitaker, a healthy family, as an open social organism, is dynamic, there is a clear separation of generations, triangulations and coalitions can exist, but it has the capacity to use crises as a way of growing. According to this author: “All the mechanisms that we consider pathological and that are indicators of unhealthy families are found in all so-called normal families. The difference lies in the intensity, rigidity and timing of the emergence of the problems”.

In one of the sessions we agreed that, whenever Ricardo was rude to his mother, his father would give him two euros, without saying anything, and if Ricardo asked why, he would not answer and simply leave the two euros behind.

The parents thus stopped arguing with Ricardo. They responded to questions/demands with phrases like “let’s think about it, we’ll see”, or they looked helpless and lost, not giving any answer at all. This paradoxical prescription left Ricardo feeling immensely perplexed. According to his parents, Ricardo began to seem unsure of anything, much less of himself.

In the sixth session, the father said that it seemed like he had the son he had always known back. We then discussed the relapses and the danger of returning to the old relationship pattern. It was clear that the parents had become more confident in their ability to deal with the situation and also more united in how they acted in the face of their son’s behavior. As for Ricardo, it seemed that he needed these doubts and insecurities in order to find his way.

The structural approach understands the family as an open system in transformation. The family exists for the individual and the individual exists for the family, to which he has to adapt, often encountering difficulties. If we analyze Ricardo’s family from a structural perspective, we realize that there are three subsystems present: the conjugal, the parental and the filial. Transactional patterns have to do with the boundaries of a subsystem, the rules that define who participates and what they participate in. Looking at this structural map, the aim is to change to a functional system. It was important for both the parents and Ricardo to deal better with stress. The intervention strategies involved challenging the symptom, implementing patterns, focusing and intensifying it. In a second stage, there was a challenge to the structure, defining boundaries, creating imbalance and complementarity, in order to reduce entanglement. We thus attempted to reestablish the channels of communication, the dance with the family that Minuchin spoke of. The challenge to the family reality consisted of reformulating its construction, using the family’s strengths and paradoxes. The therapist joined the family in a leadership position, with the aim of promoting change. A phased therapy was initiated in which the priority was to establish boundaries between the generations. The theory of change was used, according to the strategic school (Haley, Palazzoli), and what Haley called the perverse triangle was worked on. There were effectively three people with different levels of power. The mother clearly formed two transgenerational coalitions, sometimes associating with the father to combat Ricardo’s behavior, and sometimes allying herself with Ricardo to protect the father.

THE SYSTEMIC APPROACH TO ADOLESCENT HEALTH (RETHINKING A NEW PARADIGM)

Some parents go through truly difficult times during their children’s adolescence. It is urgent to support them so that they feel less lost and less alone in their experiences.

When I see parents who are very desperate, I usually suggest that they do some memory work and try to remember their own adolescence. I also help them to reflect on this desert crossing, this shifting terrain in which the adolescent moves, with some advances and many setbacks. Often, it is to free themselves from the anguish and suffering that these setbacks cause them that they take out their aggression on their parents. It is urgent to find spaces where these experiences can be shared and where parents can find some support. They also learn how to be a mother or father to a teenager!

In the middle phase of adolescence, peer pressure is great, often constituting a cause for concern for parents. What we usually call a peer group is, in adolescence, a group of young people of similar ages, with similar interests and needs, whose members prefer to spend more time with each other than with their respective families. In the peer group, the adolescent dilutes his or her identity, dressing, speaking and behaving like those in the group. Here, they gain security by behaving in a similar way to others. By being integrated into the group, their self-esteem is also strengthened. Parents tend to see the peer group as something threatening, as a negative influence on the adolescent’s life. In some cases, this may be the case, but above all, it is an entity in which the adolescent can try out different ways of being an adult until they discover their own way, the one with which they feel comfortable. Most studies point to the fact that adolescents join a certain group because it meets their needs and interests. This was what happened with Ricardo. Contrary to what is commonly believed, adolescents will not choose a group that forces them to do something they do not feel inclined to do. Thus, if, for example, the adolescent needs to participate in risky experimentation, they will seek out peers who think in a similar way in order to gain support from the group. From this perspective, it will be difficult to point the finger at the group as responsible for behaviors that we do not like in our children. Which came first, the chicken or the egg?

The need for individuation in relation to the family of origin, which often reveals itself through constant opposition, becomes all the more evident the more difficult the separation is. The parents’ opinions are constantly questioned and questioned. If, for example, the parents want to go to church, the teenager of this age may say that he does not believe in God and that he sees no point in participating in those meaningless ceremonies. What the teenager wants with this attitude is, above all, to see how the parents react to this challenge and defend their convictions. Something similar happens with political convictions or even with the choice of clothes.

There is, however, an ambivalence on the part of the teenager between the desire to challenge and have a place in the adult world and the need to feel protected whenever difficulties arise.

A young child is happy if we feed him, if we take care of him and show him affection. In childhood, his representation of his parents is an absolute reference. In adolescence, a journey begins in which the separation from parental figures is an essential event for the construction of identity. However, the need for autonomy that characterizes adolescence can generate family conflicts, necessarily triggering changes within the family, with changes to rules and the discovery, on both sides, of new forms of communication.

Communication difficulties are at the root of many of the conflicts that typically arise during this period. There is also often difficulty in negotiating rules. Simple things, such as, for example, when to go out and when to get home or the amount of pocket money.

How can the family be a protective factor for the development of the adolescent? By promoting self-esteem, eliminating negative speech, allowing feelings to be expressed, to allow and give space for the adolescent to discover what kind of adult he or she likes for himself or herself. If we respond aggressively to an adolescent’s aggressive reaction, a cycle that is difficult to break will be created. If, on the other hand, there is too much tolerance, without defining rules and limits, the adolescent will be deprived of guidelines, which will harm his or her development. If the adult manages not to abdicate his/her parental responsibilities and tries to maintain a firm tolerance, the adolescent will benefit from this regulation.

Often, the health professional reveals some difficulty in moving from an individual perspective to a family perspective. There are difficult situations in Adolescent Medicine in which the transition from one perspective to the other allows the adoption of less classical models of intervention, sometimes quite effectively.

A well-conducted clinical interview will allow us to understand who the adolescent lives with, what their relationships are like within the family, who they have preferred relationships with, who they have particularly conflicting relationships with, and who they have become accustomed to counting on when they have a problem. According to the model we use, we then proceed to outline the problem, analyze the solutions already tried, define the specific change to be made, and formulate and implement a plan to achieve the change. The aim is to help the family enter this new phase of the life cycle and help the adolescent to achieve, by changing relationships with parents and peers, one of the central tasks of adolescence, which is autonomy.

In terms of primary prevention, we have essentially two objectives:

• help the family enter a new phase of the life cycle;
• help the teenager to carry out the tasks of adolescence.

In terms of secondary prevention, our objectives are:

• carry out early detection of psychopathological conditions;
• carry out appropriate referral and follow-up.

It is a challenge for all of us to be able to build a more flexible and adaptable healthcare model in which the relationship with the team is built according to the real needs of the adolescent and their family. It is urgent to find innovative approaches that allow us to meet the real needs of families!

We intend to demonstrate how there is exemplary applicability, in the context of adolescent health, of the systemic approach, which can and should play an added value in this area, introducing an innovative word in the interrelationship between the healthcare professional and the various subsystems in which the adolescent moves. For this to become a reality, professional training must be carried out, particularly in the healthcare area, as well as improving working conditions so that there is the possibility of putting systemic intervention techniques into practice. We believe that, in the medium term, a cost/benefit analysis, so dear to those who govern us today, will clearly show the advantages of this type of approach.

In this, as in so many other areas, there is still a long way to go. So let’s move forward, helping adolescents and their families!