Adolescent Health Care: Clinical Issues

life.

PART 1

INTRODUCTION: ISSUES IN WORKING WITH YOUTH

Outline

Chapter 1: Working with Adolescents in the Health Field

Chapter 2: Health Concerns of Youth: Multiple Perspectives

Chapter 3: Medical Treatment—The Legal Rights of Children and Youth

1

Working with Adolescents in the Health Field

GISELA KONOPKA

Publisher Summary

This chapter emphasizes the issues to be dealt by health professionals working with adolescents. Adolescence must not be perceived as different from any other stage in the development of the human being, but adolescents should not be seen as little older children or as beginning adults. There is something very specific about that age range that needs to be understood by adults. The key experiences of adolescence involve certain firsts that need to be worked through by the adolescent. A phenomenon particular to adolescence is the process of developing sexual maturity, which is different from the state of complete sexual maturity. Along with the biological maturity attained during adolescence come varying degrees of withdrawal of and from the protection generally given to dependent children by parents or substitutes. Adolescents engage in re-evaluation of values that they have either accepted at an earlier age or rejected because of individual resistance. Adolescents encounter their world with a new intellectual and emotional consciousness. While working with adolescents, as with anyone, their specifics and their common humanness should be understood.

Let us hear first, from an adolescent, words that have meaning to her and to all of us:

Looking to the wind

For an answer

Trying to find the way …

Traveling the uncharted road

I see my life a maze

Looking for the sun—

Fog covers my eyes.

Through the edges of my mind

Not really seeing me

They order my life

When I know not me

And to where do I go?

When do I know where am I?

She expresses the insecurity of adolescents, the searching so normal for that age. In preparing this chapter, I realized how much she also expresses confusion common to all ages and even to the members of professions to which we belong.

I QUESTIONS FOR HEALTH PROFESSIONALS WHO WORK WITH YOUTH

What are the questions we must try to answer when we work with adolescents? The range is wide: What is health? What are the boundaries of being normal? What is special about the age group we call adolescence?

And then: What is our role, the role of the professional? What are our boundaries? What are our values? What are our goals? The questions relate to philosophy, to our picture of the world, especially to humanity, and to the state of scientific knowledge in the health field. It is impossible to answer all this. I can only try to give a view from where I stand. Each person will have to rethink, reorder his or her own comprehension. My hope is that we can do it without becoming too separated and also without constantly reinventing the wheel. We must try to build on each other. The sciences and professions concerned with the inanimated world have done this. It is necessary for those of us who work with human beings to try to do this too.

II THE CHANGING NATURE OF THE HEALTH PROFESSION

One of the characteristics of our present concept of man and what constitutes health or illness is a certain insecurity. We are not as sure as we were in those periods when less knowledge was available. I frankly prefer this, because it makes us more humble and more honest in working with people. But, no question, how much easier it must have been to be a professional when one’s authority was unchallenged. For many centuries, the person struck by illness was seen as guilty. A bad spirit had entered the human being because of his or her sins. The dybbuk, the devil, had invaded the body. Only those in power, the priests, could drive out the evil spirit. Their knowledge and skill were seen as absolute, not to be challenged. In spite of the doubts mentioned earlier, this totally unquestioning attitude toward science and the healer still persists as our heritage. For instance, statistics that show many incidents relating cause and effect are frequently still accepted without questioning. Is this so different from the eighteenth century belief that life could arise spontaneously? The English naturalist Ross announced learnedly at that time: To question that beetles and wasps were generated in cow dung is to question reason, sense and experience (DeKruif, 1963, p. 26).

Anyone questioning such facts was considered not only a heretic, but a fool. Do we recognize this attitude in some of our present-day theorists in biology, psychology, or other social sciences?

Yet history also shows us the impact of the courageous questioners. There was the infinitely patient work of Loewenhoek (cited in DeKruif, 1963) who ground and reground lenses and discovered microbes. How exciting! How wonderful! The discovery eliminated some of the guilt that accompanied illness. Illness was seen thereafter as produced by an invasion of an outside natural force. It was a real thing, not an evil spirit that entered the body. And Loewenhoek "knew about the infinite complicatedness of everything that told him the danger of trying to pick out one cause from the tangled maze of causes which control life [p. 16].

If this had been understood, we would not have the still prevailing attitude that the professional in the health field is all-knowing. This image is based on the simplistic assumption of one cause–one effect. I recently experienced the conviction of the omnipotence of the healer in a young man who suffers from serious mental disturbance. He is crying for help from the torments that invade him and insists that we, the professionals, could save him if we wanted to: You can do it, you know what is wrong, but you refuse to tell me or to help me. You are all part of a conspiracy that wants to keep me sick.

He has total belief in the godlike image of the professional that has been created.

A great revolution in the health field, after the discovery of the microbes, occurred with the realization that mind and body are much more closely related than we had previously thought, and the word psychosomatic was born. It was an exciting insight, that the human being is influenced by forces other than those penetrating from the environment. But the tendency of turning each new bit of knowledge into an absolute continued. The understanding that there were psychosomatic attributes to illness was used as if now the psyche, the inner forces, were totally responsible for the problems of the body.

And then another insight occurred: the significance of the economic, social, and physical environment.

Poor health is not related exclusively to the microbes that enter a person’s, rich or poor, body. Illness is not produced by the anxiety derived from psychological turmoil experienced by wealth or poverty. Slums also breed sickness of both body and soul. Tuberculosis is not produced only by the invasion of that insidious little thing, the microbe we can see dancing under the microscope. It is there because people have to live in places without sun.

The young person screaming or shaking with anger and terror and attacking someone he hardly knows is tormented not only because of family problems; he is also influenced by having no hope for employment, by feeling the excrutiating loneliness of the discriminated and disinherited. Poverty and other society ills influence health.

III THE COMPLEX NATURE OF HEALTH AND ILLNESS

By this time, the reasons for illness or health have become exceedingly complex: Somehow, they lie in the constitution of the individual, in known and unknown forces in the total environment, in the influence of what we eat, what we do, how we live, and how we hate or love one another. And with this confusion—or with this increased knowledge—come doubt, anger, and despair on the part of the victim as well as to those who want to help. I have heard adolescents say, What’s the use of living if everything is harmful? They find more and more that whatever we touch can destroy us. And nobody knows anything anyhow.

I have heard professionals say that there was no use in doing anything because We’ll discover tomorrow that what we did today was wrong, and so why try? Or, At least I have to pretend that I know everything. Otherwise, I can’t live with myself and I can’t be effective.

What is the way out? I cannot give simple answers, but I think I have a responsibility to share my viewpoint with you and the way I believe we, in the health field, can be helpful to young people.

I, personally, welcome the knowledge explosion, in spite of its accompanying realization that knowledge will constantly change and that we do not know everything. To me it is exciting that the borders of knowledge are never closed, that one has to continue to search.

The complexity of our knowledge does not lead me to throw up my hands and say, There is nothing sure; therefore, I cannot act. We, in the health field, are always dealing with pain and suffering. It is the responsibility of those working in it to heal—if they can—but surely to alleviate or possibly to prevent more suffering. That is the task and the goal. Suffering in itself is not always destructive. Those who have no experience with it wither. Human beings need some pain to grow. But too much suffering can destroy or demean. It is especially destructive to the young who often have no experience with the overcoming of pain. They do need our help. Because of the enormous span of underlying knowledge, to do this well, we need a variety of professions in the health field. We need to pool our knowledge. In working as a team we must genuinely accept, as equally significant, each person’s and profession’s knowledge and skill. The old concept, that only medical knowledge is significant and all others are subordinate, should be long past.

IV COMMON KNOWLEDGE AND ATTITUDES FOR WORKING WITH YOUTH

Each professional must contribute from his or her specialty. Ideally, we all base our work on a common knowledge and attitude. Let me present some aspects of this:

1. We must understand that there is only one generalization we can make about people and that is that there is an infinite variety; although they have much in common, each has specific qualities. An adolescent said that beautifully:

I used to be

A grape in a bunch

And all the other

Grapes were the same.

But now …

I’m an apple, crisp

And fresh, and every

One is different.

My, how life has changed.

(Konopka, 1976, p. 7)

We therefore must always individualize, not treat by the book, not stereotype people.

2. We have to understand that culture, that is, the way we are brought up, influences our behavior and our actions, and therefore we must accept a wide range of behavior as healthy. It is not necessarily sick to feel depressed frequently, and to question one’s own capacity. Not only is this normal for almost everyone, but self-analysis and self-criticism are more prevalent in certain cultural groups or within certain subgroups of cultures than they are in others. It is the degree only that indicates whether a person needs special help, and this should be determined, not in comparison with everyone else, but in comparison with one’s own cultural group.

Yet, we frequently exaggerate and stereotype the impact of cultural differences. We must recognize, accept, and take them into account, but at the same time we must understand both the variety within various cultures and the extraordinary commonality among human beings. For example: I recently saw a teen-ager who had committed a serious offense. The cultural aspect of what he is, not what he has done, does not lie in the fact that he had been raised to do this, that his culture condoned violence, but in the fact that he had moved—at a crucial time in anyone’s life, namely adolescence—from one culture into another. He was not accepted in the new environment. He could not express himself in a strange language. The basic loneliness, characteristic of adolescents, was intensified by the wall that a newcomer frequently finds. Cultural factors had to be considered to understand his behavior. Yet underlying those factors, were also human similarities: the need of all of us to be loved, to be recognized as significant, and to be able to express ourselves, so that we can find others to love.

The stereotyping of cultural differences is often disastrous for the individual. For instance, a teacher told her class to bring various foods to school as an aid to understanding various cultures; Italians were to bring pasta; Germans, potato salad, and so on. What nonsense! Must I like potatoes because I come from a potato-loving nation? I hate them—I always did. The confusion with regard to ethnic variation and to genuine cultural understanding is great. There are people who sincerely believe that there is a vast difference between someone of Polish background and someone from Scandinavia. They can have no knowledge of European history, in which cultures have been mixed over centuries, or of the influence of various nationalities living together in a new country. Culture is not something to be pinned down by clichés. Culture must be understood in its variety, in its constant change, even within groups that seem to have the same heritage. It is related to economic circumstances, to family constellations, to individual variety. Basically, human beings are far more similar than they are different. Differences exist, and can be responsible for problems, mutual enjoyment, and even health variations; but the basic needs of human beings are the same.

3. The special basic needs of adolescents are also very similar all over the world, although, at times, they are expressed in various ways. Surely, adolescence must not be perceived as totally different from any other stage in the development of the human being, but we should not look at adolescents either as little older children or as beginning adults. There is something very specific about that age range and we must understand it. I was shocked to see how a psychiatrist, who had worked only with adults, diagnosed adolescents as devious when they exhibited sharp mood swings, so normal for this particular age. Some of the characteristics that I think adolescents have in common and that transcend cultural differences are discussed in the following sections.

V THE COMMON ADOLESCENT EXPERIENCE: FIRSTS

Adolescence is a fragile age, as fragile as the first days of infancy. It is almost a rebirth. Let me quote an adolescent girl who could write well:

I am a bottle sealed with feeling

Too deep for anyone else.

I am a bottle floating in an eternal ocean

Of people trying to help.

I am a bottle keeping my fragile contents inside.

Always afraid of breaking and exposing me.

I am a bottle frail and afraid of the rock.

And afraid of the storm.

For if the storm or rocks burst or crack me,

I would sink and become part of the ocean.

I am a person in the people of the world.

(Konopka, 1976, p. 2)

The key experiences of adolescence are certain firsts that need to be worked through by the adolescent. Their significance should be understood by any adult.

A Experiencing Physical Sexual Maturity

A phenomenon particular to adolescence and one that never occurs again in the life of the individual is the process of developing sexual maturation, which is different from the state of accomplished sexual maturation. Biologically this is a totally new experience. Its significance is due both to its pervasiveness and to society’s expectations. It creates in adolescents a great wonderment about themselves and a feeling of having something in common with all human beings. It influences all their relationships with each other, whether they are male or female. This maturity also stimulates them to a new assessment of the world.

You are a forest—my hideaway

When the city wants too much from me.

Your lofty trees surround me

And hold me tight when

Nothing goes right.

Your sea-green leaves let the sunlight

Filter through to warm my spirit

And I walk through you

Uncovering caverns and souls

That have remained untouched.

Let me continue walking

And I will not let you

Wither and die.

—Nancy Sykora (personal communication)

Feel the intensity, the sense of mingled fear and omnipotence, and imagine what happens when illness strikes and one feels impaired.

B Experiencing Withdrawal of and from Adult Benevolent Protection

Along with the biological maturity attained in adolescence come varying degrees of withdrawal of and from the protection generally given to dependent children by parents or substitutes. We know that some young people were never protected, even as children; but, whatever the degree of previous protection, the adolescent is moving out from the family toward interdependence (not independence but interdependence) in three areas: (a) with his peers, his own generation; (b) with his elders, but on an interacting or questioning level instead of on a dependent level; and (c) with younger children, not on a play level but on a beginning-to-care-for-and-nurture level. This process of moving away from dependency creates tensions and emotional conflicts. It should influence our practice in working with adolescents and the way we communicate with them.

C Reevaluation of Values

Although the formation of values is a lifelong developmental process, it peaks in adolescence. It is related to both thinking and feeling, and is influenced by human interaction. In modern cultures, where young people are likely to be exposed to a variety of contradictory values, questioning begins even in childhood. Adolescents engage in reevaluation of values that have been either accepted at an earlier age or simply rejected because of individual resistance. They move beyond simple perception (e.g., If I burn my hand, it hurts) to seeing things in a morally good or bad framework. They become moral philosophers concerned with shoulds and oughts, and they may be subtle or outspoken about it. Value confrontations are inevitable in this age period. The young, because of their intensity, tend to be uncompromising. They may clearly opt for a thoroughly egalitarian value system, or they may give up and become cynics. They often are true believers and therefore feel deeply hurt when others do not accept their value systems. In the health field, we meet this in attitudes toward food, toward sex, and toward handicaps (physical and emotional ones).

D Becoming an Active Participant in Society

Adolescents encounter their world with a new intellectual and emotional consciousness. They meet it less as observers who are satisfied with this role, than as participants who actually have a place to fill. I see this wish to participate as a most significant first in adolescence. In the old, mostly European, textbooks, it appears as the adolescent quality of rebellion, and for years we have considered rebellion as an inevitable attribute of adolescents. I think that this is true in authoritarian societies—and we are still partially authoritarian societies—but, basically, it is not rebellion that characterizes adolescence, it is this extraordinary new awakening to the fact that one must develop one’s own values, not only imitate those of others. This is a terribly hard task and brings with it enormous stress. They do become aware of reality and ideals. A 13-year-old in a war-torn country wrote:

I had a box of colors

Shining, bright, and bold.

I had a box of colors,

Some warm, some very cold.

I see no red for the blood of wounds.

I had not black for the orphans’ grief.

I had no white for dead faces and hands.

I had no yellow for burning sands.

But I had orange for the joy of life.

And I had green for buds and nests.

I had blue for bright, clear skies,

I had pink for dreams and rest.

I sat down

And painted

Peace.

—Tali Sorek, Age 13 (Published in Minneapolis Jewish Community, March 1975)

VI PROFESSIONAL VALUES

When we are working with adolescents, as with anyone, we have to understand their specifics as well as their common humanness. We have to respect their dignity as people. But then, I am often asked, "Does it mean that we accept any and all of their behavior, have we no values that we consider important?" In what direction do we go?

When the problem of the young person is predominantly one of physical incapacity or of a severe limitation of daily functioning, if we know, for example, enough about the disease, if we know enough about the realm of values as intensely as when it comes to another question such as, How do we approach the pregnancy of a young girl? What is our stand in relation to health services to adolescents without the consent of their parents? What do we do with those who come to us with serious drug problems or after a desperate suicide attempt? What should be the professional