Keynote Lecture - Richard MacKenzie

Usually the keynote speaker sets the tone for the conference - but as the last speaker on the schedule I wondered the wisdom of having the keynote speaker last - but as I sat here and dealt with my jet-lag I realised that as you people are falling asleep, I’m waking up - so the wisdom is really there, but it was also the wisdom of having the keynote speaker last because certainly we who come from different environments and different backgrounds come in with a lot of assumptions as to what exists and what does not exist, and I must say that the time I’ve spent listening today and the wonderful session that we had over lunch has certainly brought me up to date with where you people are and I’m very impressed with what has been accomplished in the UK. It allows me to take off from what I’ve learned about what you’ve learned, to share perhaps in some of the things that have been talked about today by the various speakers and perhaps place them in a context which is a little different from that which has been spoken about today.

I always say that if we had all the answers to the questions we raise in adolescent health, we would have no problems and part of not having the answer is often how we look at things. And I would like to suggest different ways of looking at the adolescent and their problems. I’m going to jump about seventeen pages in my talk, because I’m not going to get through them all and I promise I’ll end on time if not before time, but I’d like to put forth something for you all to think about as I’m talking and that is  - a lot of problems that we see in adolescents - a lot of what we call problems in adolescence - are really their solutions.

Their solutions to what? - their solutions to growing up.  Their solutions to attaining their development - to getting out of their transitional period called adolescence - the best they know how - so what become problems for us, become solutions for them.

Let me elaborate a bit more before I build up my case. I look at adolescents giong through the supermarket of life. They are pushing their baskets down the aisle and they can’t afford once in a while, because of their socio-economic status, because of lack of family support, certain kinds of growth experiences which we feel would be healthy for them so they end up in an aisle called drugs - suddenly they are reaching out for peer group acceptance, that’s what their need is, that’s what their hunger is and they’re in the aisle called drugs - so they reach up and take the drugs and that’s the way the accomplish that transitional event which is so necessary for growth. And you could think the same way about their sexual behaviour how they choose to do those things because they are in that aisle when that need comes about. They don’t have people with whom they can sit down and talk about what’s going on They don’t have models of healthy roles of what you do in relationships, they don’t have places to go and release their stress over what they are experiencing because of the demands imposed upon them by the adult or the conventional society. So they reach out and they reach out into the aisle of the market that they happen to be in.

I would now like to go back a little bit and talk about Diana - she said something about me and I would like to say something about her and what she’s doing - because there is a tremendous wisdom in what she’s doing. Fifteen years ago, ten years ago, the technology of working with adolescents was very primitive. We had basically psychiatric technology - of sitting down, hands on our chins saying ‘Aha’ .. ‘Hmm, aha’ .. ‘Well that’s because when you were two years old …’ 

It doesn’t work.  And so what we had to do ten years ago was to sort through what we were doing and what was going on with adolescents in those days and see what was best going to help them. Adolescents became our teachers, adolescents became our resource and we began to develop the technology of working with adolescents.

The second issue that came up in Diana’s work is that she named her programme ‘Youth Support’ in other words, within that terminology, there is an inherent belief in the goodness of Youth. We are to support that natural process which is going to go on in young people. It is not ‘Youth Guiding’ - it is ‘Youth Support’ and that is one of the basic assumptions which has served me well in working with adolescents over the past twenty five years - it is that within the individual there is a good which is attempting to be expressed in the best way that it knows how from the environment that it is allowed to express itself in - with a thrust from that individual to become the best person that they can be.

Now put that back into the context of problems and solutions - you begin to get that dynamic view of an adolescent - not going out trying to do things bad, but trying to do things well. I have not met an adolescent yet who is there trying to do things ‘unwell’ - they are out there to do things in the best way that they know how, but perhaps it is in a way that is going to be problematic to them as individuals. Adolescence then becomes a time of change a time of transition, another way to look at adolescence is to look at it as a time of crisis because I am told that in Chinese the character for crisis also means change and also means opportunity. And anybody who has worked with young people, who has worked with families or has worked with adults - you know that the more settled they are, the more difficult it is to create change in them - it is when they are in chaos, when they are unsettled, they are uncomfortable, when they are going through a process of change that you can now effect some kind of input into a healthier position for them to be.   Adolescence then as a crisis is opportunity to change so it provides a great opportunity for us as providers, as health supporters, as health promoters to help that individual to become a better person , for themselves and for the people around them.

One of the things that was mentioned earlier, which I wrote down - because anyone who works with adolescents will realise that there is a tremendous meaning that young people give to words - and one thing I always say to our people in training - pardon my vernacular - is what is the difference between making love and fucking  - is there a difference? But when we couch the terms with adolescents and we use the phrase ‘making love’ is it really making love? After all when they ran the surveys finding out why people had sexual intercourse no-one answered ‘it felt good’. But isn’t that why a lot of people have sexual intercourse? It feels good - it’s a recreational experience - put a hyphen between the E  and the C - it’s a re-creational experience - it allows you to have this intense feeling of pleasure and to move on from that. It’s an ‘in body’ experience - something which is often deprived in adolescence - and if you look at what adolescents do, they seek out ‘in body’ experiences because they have this intense accentuation of their ability to appreciate pleasure, something not talked about as a developmental task - they have this increased appreciation of pleasure.

So another thing that I have learned in talking to adolescents is that you have to choose your words. The term juvenile delinquency has no meaning any more - a delinquent was seen as someone who drifted away from the fold of adult value therefore had to move into some kind of corrective action because of age and back into the value of the dominant culture - it’s not to approve juvenile delinquency or what has been referred to as juvenile delinquency - in today’s environment Juvenile delinquency really does not have any meaning - you could make every kid over twelve a delinquent by imposing a seven o’clock curfew on every child over twelve years of age. You suddenly become a juvenile delinquent, you report to the delinquency court for that, so really as was well pointed out it’s an administrative term, so we have to watch the words we use, we cannot say I understand that you’re a  juvenile delinquent and that’s why you’re here today, or you’ve been involved in delinquent acts and that’s why you’re here today - choose your words carefully when you talk to adolescents and listen carefully as to how they choose their words in response.

Let’s look at adolescence as a resource. I’ve been sitting out there all day looking up at this picture (of a group of  happy young people on a ‘Youth Support’ trip to the Russia) - they are not youth as a problem - they are youth as a resource. Resources not only for things they can do to help themselves, but a resource to us in general as professionals. I can say that I have learned more about adolescents from adolescents than I have from all the reading and all the lectures and of the teachings that I have had from all the experts around me - but you have to listen - and you do not only listen with your ears, you listen with your eyes. You see what they are doing, you see how they are behaving, how they are responding - listen to everything and not just to their body language , but to their group dynamic because they are doing what they are doing for a reason, they are doing it to resolve some issues, some driving forces within themselves,  they are attempting to accomplish their tasks of adolescence.

I always say , we must catch our young people in doing something right - we spend so much time in catching them doing something wrong  - why didn’t you put the garbage out? , why didn’t you get a better mark in your exam?  Why are you going dressed like that? Why did you put that ear-ring through your nose? It’s all these judgmental views and we really must in our interaction with young people, separate the action from the individual. Again focus on the goodness of the resource within the individualo because that is what will guide their way down through the supermarket of life to attain their adolescence. I’m frightened now because I think the supermarket has become quite complex for the adolescent - I would not want to be an adolescent today. I think there is a miraculous process going on within each individual as they negotiate those teenage years. Because just look at the supermarket around them. The facility which they have to adopt, what we know as health compromising behaviours.

They are really there - they have to circumvent those things - and again we have to remind ourselves that the majority of young people do. The majority of young people negotiate those adolescent years with no problem. Or maybe with a few little crises here and there a few problems, maybe some intra-familial  kind of conflict that goes on as they begin to shake away the dependance that they have on some kind of family structure. We are biased because we see the problems, that’s kind of obvious because we see the kids who are not doing it well. But the majority do do it well and those that do not do it ‘unwell’ are not in any one socio-economic groups.  I can tell you that being in Hollywood I see a lot of kids who come from very affluent families - they call it the poverty of affluence - by giving you are taking away. By constantly giving to young people you take away from them that opportunity or that ability to do it for themselves. And by doing it for themselves they attain some measure of competence, self esteem and confidence.

But if every time someone says well I think I would like … someone hands them money or the response is  well here have a car or an apartment - I have seen fourteen year olds living in apartments on their own because they wanted it .. and the family could afford it. But of course those pathologies do not come to our attention, because those pathologies do not come to anyone’s attention they are often hidden or seen very  privately  and taken care of in ways so that we don’t really realise what the depths of the problems are.

The other thing that I have been taught by adolescents is that youth is not really a time of life. Many people have got up here today and I’ve watched them, that there is a youthfulness in the people that are working with youth. Youth is not a time of life, it is really a frame of mind. It is how you think about yourself in relationship to the world around you and we tend to think about the world around us by being influenced by the people around us - if we spend a lot of time with young people we keep that sort of questioning value about what is going on around us. Questioning view about - why are we doing things this way? So  youth is not a time of life it is a frame  of mind and we grow old but we grow old by deserting our ideals. Young people carry their ideals with them - not by expressing them clearly but expressing them in the best way they know how.

A little on adolescent development - let me reframe that for you. An exciting way to think about adolescents - G Stanley Hall in 1904 conceptualised adolescence as that storm and stress of transition. I think that is an over simplistic view, a superficial impression of behaviour. It does not take into account the dynamic event that young person is experiencing. I have a much more dramatic view and I take my view of it from Clouseau who said ‘We are born twice over , once into existence ..’  - we never existed and now we exist - ‘… and once into life’ - and the birth into life was adolescence in his mind. Now isn’t that a fascinating way to think about  that process  that we are seeing before us, that storm of Stanley Hall now becomes the pangs of birth and we become the obstetricians. We guide this birth, we do not create this process, and what is going on before your eyes is not a product of the moment but is a product of the incubation period that this individual has been since their moment of existence. So we see the pain of labour as this individual moves out into the peri-adolescent toxicity, the perinatal  toxicities that we care so much about in the new born  but the peri-adolescent toxicities of the environment and society around them. That can influence not only their biological growth but can influence their psycho-social growth - their ability to function within their environment into which they are being born. So here we have a new dynamic view and we know that organisms under going change at rapid rates are most susceptible to negative influences - when we expose the human body to negative influences it is those parts of the body that are going through rapid change that are most at risk .   So we see the adolescents reflecting back to us as their ‘obstetricians’ the difficulties and stresses in the society - and we blame them. It’s like blaming the child for the perinatal mortalities, for the obstetric mortalities - ‘it’s your fault .. sorry kid, you can’t live .. it’s your fault’.

With this view we can now invest ourselves in a partnership with young people, a partnership  in which they are moving through this period of change, they are moving through this period of crisis, and the problems they bring to us we must aptly see as being their solution. What it has done, interestingly enough, is that we have developed a whole new what I call adjectival palate - a palate of words to describe what we are seeing. For example if you are a wine taster, you can’t be a wine taster without learning a whole new vocabulary - what the nose is, the taste is, the finish is - you have to learn that palette of words to be able to be a wine taster. And to work with adolescents we have to learn to develop a palette of adjectives or words to describe what we are seeing - and not only that but also to talk about what we are describing scientifically. And many new words have come into the vocabulary since I started to work with adolescents in 1970. The concept of ‘at risk’ and ‘high risk’ was not around - it existed for heart disease. But not for behaviour. Now more and more we are looking at kids who have behaviours that are high risk and placing them at risk for negative outcomes to their health. But these are behaviours and not physiological phenomena, these are not blood lipids, these are not uric acids, these are behaviours - and modern medicine does not have ways to measure behaviours, so it pooh poohs it - although it accepts it for heart disease lack of exercise, or smoking, but for adolescence it is difficult to get this total biosocial approach into the modern medical jargon - to have it accepted on a co-equal basis with a lot of the other issues that are goig on in medicine today because working with adolescents today is not high tech - it’s high touch. It’s high touch - it’s touching them with your words, touching them with your person, touching them with your understanding.

Touching them with your caring - not high tech - we don’t need a Cat scan to diagnose substance abuse. We have also come to hear the words like ‘co-morbidity’ substance abuse and sexually transmitted diseases have a co-morbidity, substance abuse and underlying psychiatric disorder have a co-morbidity - they exist together, as a balance for each other or as a consequence of each other.  We hear things like ‘sentinel behaviours’  What are sentinal behaviours when we read the adolescent  literature? Sentinel behaviours are  behaviours which put them at risk, or may be describing a process or natural progression of events which put them at risk . We know that kids drop out of school -  the main activity of adolescents, is  a sentinel behaviour, to put them at risk because they are integrated into a peer group which is already at risk because they are not involved in the dominant culture. Why do they not get a job you ask? Did you know that those who have a job are more at risk from drug abuse than those who do not? Why ? - They are exposed to adult society and now have the money to buy the behaviours of the adults. So employment is not the answer - much better for self esteem, and sense of value and self , but it does not solve the problem of substance abuse.

We hear terms such as surrogate symptoms or problems such as with HIV disease we measure a lot of surrogate  markers which tell us about the progress of the disease. It is not the disease we measure, it is the marker of the disease. A surrogate for what we are trying to follow. Why am I talking about these things? Because a lot of times we cannot prove the value of what we do unless we look at the outcome or consequences of our intervention. To do that we need to look at surrogates, sentinels, markers of charge. I cannot go around checking if kids are putting condoms on - I do not want that job! So we have to develop surrogates for that. Surrogate markers to see if kids really use condoms - so all this language becomes important.  I talked about l5 years ago saying that you cannot counsel kids in the rain -  kids who are greatly disturbed, or uncomfortable;  having just broken an arm in an athletic event for example you cannot sit down asking him to tell you about his family. The kid will say Come on, Doc! I’m in pain.  Many things we cannot do until we wrap around the individual their immediate needs, short of an Abraham Masell concept - the hierarchy of needs. You can’t do therapy in the rain - give them some shelter first. You cannot talk about security to someone who does not have a place to hang their hat or sleep. They cannot sit and talk about any period of time. And they are not going to talk to you about sensitive issues unless you can assure them  confidence - and you mean it . You are not going to break that confidence - and you mean it - you are not going to break that confidential relationship by some kind of behaviour which is non verbally going to communicate a reason why they come to you.  If you send them out to your waiting room with a drug test urine bottle to send off to the lab Mum and Dad waiting are going to wonder why - you are breaking your confidential relationship. So these are things you must wrap around your relationship with an adolescent in which you couch, in which you carry your expertise, your special knowledge and commitment and your caring.

One of the things I would like to reframe  for you  -  We hear the scream of the new-born as they go through this painful labour, as they are squeezed through the passage of life so to speak, and  we watch the scream of the adolescent as they begin to react to the demands put upon them of responsibility, of  moving away from those childhood behaviours, those child like behaviours - what Ashley Montague called the artless traits of being a child. I’ve listed some of the things that we could put look at as traits of the child.  I think if there is a rebellion in adolescence - it is not a rebellion against you or me but a rebellion against having to leave things behind, this awesomeness,  this need to learn all the ways that we say now don’t question, just move on, just do it!. Gone are the days when the little kid could pick up the flower and say ‘Oh Mummy Mummy look at the pretty flower’ and Mummy says ‘That’s a daisy’   and now when the child picks it up he sees a daisy and he no longer sees the flower. He just sees the word. And that is what happens in adolescence - you are told to accept all that and see what you are told. To accept what some would call the adult value - to accept what value the adult puts on that. But the screams of the adolescent do not have to be the screams of a painful labour but they have to somehow be guided, guided within the boundaries of their experiences of transition and boundaries which are somehow defined by the support systems around them - and the support system around them for many adolescents includes you.

Another concept from Sheryl Perry’s work on sex education but which has a lot of value in working with adolescents is that when a young person comes in to you they will often come in with some kind of complaint - or perhaps someone else will have that complaint. This happens particularly with those young people whose ‘problems’ are their solutions. They will not come in with a problem - their ‘problems’ are somebody else’s problem - they are happy with them. Anyone have a drug problem? Drinking problem? Adolescents don’t come in saying they have a drug problem. When I first moved to Los Angeles in 1970 we had a hot line ten, twelve thousand calls per year. I had an interest in substance abuse and I went up and I got them to pull all of their calls on substance abuse - only 98 calls - Los Angeles obviously does not have a drug problem. Kids in LA don’t us drugs  - of course they do - they just don’t see it as a problem. They are part of what we saw as being an adolescent in those times and that is what goes on today - they have a drug solution - not a drug problem - it is we who see objectively the significance of what they are doing.

So health could fall into at least four domains and probably more. But these domains do not come nicely classified by the young person. With regard to physical health - if you have something wrong with your physical well-being ,you can come in with a sore leg or say ‘I’m really confused and I can’t think straight’ - they won’t come in and say ‘I can’t get a date - will you help me Doc?’. 

They don’t see that as a problem relevant to what you do. But they will come in and maybe say - ‘I just can’t seem to get it together’ - while not spelling out how they really feel - but all these things are part of an individual. But what happens in the human organism is that a psychological problem may be expressed in one part of the body here, a personal health problem may be expressed here, or vice versa. The human organism does not have the wisdom to separate out these  factors and such is the basis for psychosomatic - or what I prefer to call psycho-physiologic illness - the body saying - I don’t feel good - I feel dis-ease. I feel uncomfortable and what we have to do in our process of evaluation is to somehow sort through these issues and provide the support, to provide help, to provide intervention in the growing organism.

Some issues discussed today that I would like to comment on in view of this new model of adolescent development - I will not comment on teen pregnancy which was so well covered by several speakers, except to say that of course there are controversies still in terms of whether competing nutrition during pregnancy leading to low birth weights. But what we can say with fair confidence is that adolescents who do experience a pregnancy do less well in terms of  psycho- social adjustment than adolescents who do not - unless they have intense support by programmes that take into account the interaction that is going on between this adolescent who is coping with birth into life and the foetus which is going through it’s birth into existence.

Substance abuse - let us look at this as initially a lubricant to transition - to attain the identity of the peer who is moving on through substance abuse. I had the unfortunate experience early in my career to work with an individual who was a substance abuser. I was proud of the fact that he stopped taking his amphetamines, but dismayed by the fact that he committed suicide. Because I did not provide an alternative for him. The drug was playing a role in his life and when I took that away, he stopped taking it for respect for me, he then turned on himself and felt so uncomfortable with himself that he ended his pain through suicide. So drugs can be and usually are used in that transition through adolescence.

It’s like that with eating disorders. They start off almost as a voluntary behaviour but they then get driven by biological events. In the USA today we have an epidemic of disordered eating and eating disorders. Twelve year olds, ten year olds, eight year old girls,  fat phobic - going to the supermarket looking at the labels, and saying Mum I’m not eating that it’s got fat in it and they won’t take anything that has fat. Now when you start with those behaviours you begin moving on to a spectrum of disorders which may lead you into a series of disorders which have a significant mortality and morbidity. Such as the starvation disorders and the binge purge disorders. And although they start as disordered behaviour they become driven by biological factors and then they end up just like the situation we have seen in substance abuse or being addicted to alcohol. It becomes a bodily driven event and then you can’t stop. They can’t just stop - they have CNS physiological changes in their endorphins which drive their behaviours and even when they want to stop, they can’t stop. But if you can reframe that and have the ability to support them in that desire to stop and maintain that position until their physiology and their endorphin level can adapt and return to normal, whether you do that by pharmacological therapy, by inpatient treatment or by any other means.

One of the things that I reframe for them is that I say to them - you have a gift, you have a gift that has come to you in the form of an eating disorder , what you have to do is to unwrap that gift and see what it means to you. And they look at you, because everyone else has said you have a disease, … you have a gift  .. and when you work with them on that gift they will unwrap it and find out things about themselves they never knew. And when they discover those things they will be able to move on and they will find themselves back on the route of change and transition. As long as you tell them they have a disease, they will cling onto that disease, but these are high achieving individuals who will often be able to make that shift for you.

Having an eating disorder is a bit like being Humpty Dumpty - use language they are familiar with - they know the metaphor about Humpty Dumpty - he sat on the wall and Humpty Dumpty fell off the wall and all the King’s horses and all the King’s men couldn’t put him back together again. And you as an eating disorder were sitting up there - nobody ever said who pushed Humpty Dumpty off the wall and no one ever said what knocked you off your wall and pushed you on the ground and you fell into pieces as a bulimic or as an anorectic and what you are trying to do is to put the pieces back together again and to use your eating behaviour as a glue to keep the pieces together. But what’s going to do it is you from inside - and that’s what were going to do, we’re going to work on that - and that reframes their position and gives them the momentum to make change and to get back on the right trajectory which is going to lead back to a healthy adulthood.

Diana talked a little about my work with street youth which is a small part of our programme in Los Angeles but a very important one. We went out to the streets and said why are you here? Can we learn a bit about adolescents if we look at how they react to this environment. When we look at why youth are in the streets there is usually a reason and that reason is usually abuse. R it may be sexual identity issues - they were thrown out of their house because they told father they were gay, or he found out they were gay , or they were doing things their family totally disagreed with and they said - you cannot live in our house - get out!  Or one of the fairly common ones in Los Angeles is that with high divorce rates the parent with whom they are living has a new relationship and with children around, this takes away from the spontaneity of their relationship and tells them to get out or abandon them - we call them throwaway kids. Their parents will go on vacation and the parents get up early in the morning and leave the kids there in the motel room - abandon them there - so the kids wander out onto the streets of life so to speak.

One of the things we found when  you’re dealing with this kind of population is that they go through a phase when they’re out there on the street a period of adaptation - they are in this new environment and they are looking around - they may be frightened or feel street cool but they have never been in this situation before so they are looking round checking how do I find a place to sleep, where do I find something to eat, who do I trust - that’s a period of adaptation. That’s the time you have to get at them within six weeks of living in that sort of environment - because after they go through that period of adaptation they begin to become assimilated - kids get to know them and they adapt them and mover them into the peer groups of the street and they begin to develop the mores of the street - they get a ring in  their ear and a ring in their navel and a ring here and a ring there - they’re everywhere they have become assimilated into the rules of the street and then they become acculturated - they become street kids.  That’s their identity -that’s who they are - they’re street kids and they become acculturated into the street. These kids are very difficult to get off the street - despite all the other underlying positive behaviours and inner resources they might have to get them off the street. They see the street as being their natural environment.  So under the influence of the toxicity of society - they become mutants in that second birth - they become mutants in that acculturation process. They feel  this is the way they have to live, this is all they have and this is all they deserve.

So how do we begin to draw upon youth as a resource? I have talked about language; about reframing the transition and how we think about them; about acknowledging the positive behaviours and down playing the negative behaviours - a sort of ying and yang thing - there is only so much room in that circle - if half the circle is positive - the other half is negative - so the more we emphasise the positive it will grow and eventually squeeze out the negativity of that individual. I’ve mentioned that youth want to do things well, they don’t want to do things wrong and  we need to accept that as part of the natural process of growing up and when they do things wrong that may be part of the toxicity of the environment or the toxicity of their second go at birth.

Youth do use services responsibly if they are allowed access to services and they do process information that you give them, they may not change their behaviour on the basis of it but they do want information and withholding information from young people makes them suspect of you as a provider in a sense that knowledge is their greatest friend and ignorance is their enemy because if you don’t give them that knowledge they are going to reach out somewhere to find that. One of the ways to build on positivity and the resource of youth is to include Youth in things that we thought before were not possible - youth advisory boards, involve them in the decisions of clinics, of organisations that are going to affect them - involve them in those decisions, not necessarily rest on them as the only input into the decision but allow them to be involved in the decision making - it is a process of empowerment of letting them feel valued for their opinions.

It is a process we are all involved in, we are all dependant on the politicos for deciding what we do and they hold the purse strings - so if possible we should organise youth to be politically active. If they are within the voting age range - we should encourage them to register to vote - if we can get young people organised politically - they can be a powerful force that others will listen to - it happened at the other end of the age scale with retired people who used to be largely ignored , but when they organised themselves - they are now a force to be reckoned with and everyone addresses them for their vote. So we should ask politicians when they are campaigning - what is your position on young people? I once had a young physician who trained with me  who was so turned on to political issues that when there was an election near his home he asked every candidate - what are you going to do for young people - and nobody had an answer - until someone said - Stan, why don’t you run - and he did and he won - he became a member of the state assembly on the basis that he spoke up.

Let us look at the future - it is always difficult in today’s environment because there are so many influences upon the future. I wish I could say that by creating a better environment - taking the toxicity out of the environment - depoluting the adolescent environment we could create a healthier adolescence. I think we probably could, but I think the pollution has to be modified rather than taken away or the person who is receiving the pollution must make some sense of it and put it in perspective, we can’t take the pollution out of the media, we can’t take the pollution out of the hearsay, it’s there and we have to deal with that. But we must give young people a sense of meaning somehow and I don’t know how to do that but that is our and their future, we have to give young people a sense of meaning so much of what gave young people a sense of meaning has been taken out of their environments.

In the USA because of legal reasons they do not have after school sports any more - nobody wants to be responsible for someone who hurts themselves in a high school game. It takes away a sense of meaning and a way to prove self - we must help them to participate in whatever process they are able to participate in legally to change their environment and their society and the toxicities we talked about. We need to enfranchise young people - someone talked about lowering the vote to sixteen - that might be difficult - but certainly enfranchising by encouragement - that is important.

What of the family? The family is that second womb, providing the nutrient for that second birth - how are we going to nourish the family - to make it the placenta which is going to nourish it’s offspring - how are we going to do that.  We need to look at ways, we can’t just deal with the foetus during that first birth into existence, we can’t just deal with the child in adolescence during that second birth - we have to deal with that thing which is providing the sustenance for that individual. We must work with the community and work with the community as partners in creating an environment which is youth friendly - big measures, but at least we need to move out and work with agencies and between agencies. When we started the service in Hollywood in 1982 the most powerful part of that service was the fact that the agencies talked to each other and co-operated looking at the problems with a common language and a common view.

We need to educate professionals - there is still a need for knowledge among professionals who are having primary contact with young people - I’ve been doing this for twenty five years and I still have people coming up to me and saying - what’s this thing I hear about adolescent development? They accept the physical changes - but have difficulty with the developmental emotional changes. We need to help them understand not only what they are seeing but how to respond to what they are seeing - to understand the unique problems which adolescents have - we need to show them how to function in a time effective way to use their skills to help. We cannot spend an hour with every adolescent, we need to learn and we need to show and transmit to other people how we can do this in a time effective way - and that’s a whole other topic of conversation.

We need to speak up - to be advocates for youth - it is amazing that sometimes just a voice that is heard will get people thinking - a lot of what policy is made of is ignorance. We started a newsletter and sent it to the legislature - this was well received and they then knew how we stood when we were asking for changes.

So what I have learned after 25 years is that you have to value what you do - people who work with adolescents often have the reaction form others of ‘how do you manage to do that’ - others say - ‘I just am happy to see my adolescent leave for school and I dread him coming home at night’ . So we have to value what we do - you have to value yourself as the obstetrician, to believe in what you do - adolescents are not the sort of patients who will come back and thank you for what you do - they won’t come back and say’ Thank you doctor’.  They somehow show it in how they behave - that they come back to see you. But after they have got themselves off the ground, if you keep at it long enough - they will sometimes write you wonderful letters. When they have got up back onto the wall, they have put the pieces together again, they are feeling back together and they are sitting happily on their wall - perhaps ten years later after they finish school - then maybe they will send you a letter that you were a most important thing in their lives.  They say some of the things you said and that is their thank you - it doesn’t come right away - but it helps you believe in what you do. You have to be committed to your work and it’s not a commitment that is 9-5 sometimes.

I’m almost afraid to say this last thing but I’m going to say it - there is no such thing as a resistant adolescent. The only thing there is - is an ignorant professional. Not ignorant in the sense that we can’t learn - ignorant in the sense that we don’t know how yet. We used to have a lot of resistant tumours, cancers, but their number greatly lessened as we got smarter, as we began to understand more about tumours, less were resistant - the same with adolescents - as we become smarter and smarter and watch for what is before our eyes, there will be less and less resistant young people out there and we will be more effective as professionals.

So I challenge you to leave here today with the new knowledge that you have and perhaps to take some of the reframing that I have peppered in at the end and go home and look at what you are doing - perhaps not so much through new eyes, but perhaps through a new set of glasses. And perhaps you will come up with some different ways of doing things and of feeling the true joy of working with adolescents.  Thank you.

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Published by “Youth Support”

ISBN 1 870717 09 0