Enaging with reluctant teens requires building trust, but consults can still be brief

GPs may be seeing a rise in the number of teenagers self-harming or with suicidal ideation as a result of COVID-19, but as clinical and family therapist Andrew Fuller explains this is often a phase that can be navigated. The therapeutic relationship is key–and Fuller has plenty of practical tips.

COVID and the related lockdowns have affected many people’s mental health across the globe, but adolescents and young adults appear to have borne the brunt of it. Without doubt it has been a period of upheaval, but it can be managed, Fuller says.

“What we’re finding in a vast number of our young people is a major shift. This is a period of transition where we move from our way of normal being to being in a phase of confusion or bewilderment, and then finally return to reintegration. They’re in that middle twixt, ‘all at sea’, confused state where the world’s changed and they are confronting that,” Fuller says.

This can result in clinical depression, heightened anxiety and a tendency toward self-harm and suicidal ideation. Fuller says it can help to view this as a phase of adaptation or changing times.

1. Build trust

While concerns of physical safety may cross the mind of practitioners first, asking for the patient’s trust is vital in helping them get through this stage.

“It’s firstly about asking them for patience. Would they be prepared to trust us enough to work with us as we try to figure out with them how to get to the other side of this difficult period of time?” he says.

He suggests GPs explain that this period of turmoil is one that has been imposed on us all, rather than a choice, “and we will get through the other side but we need to be patient. And it means that while we’re taking the time to unravel what’s happened to us, we create a different future.”

2. Keep checking in, even if it’s brief

Regularly checking in with the person is vital, he says. The conversations don’t need to be lengthy but the sense of being there helps support the patient and builds trust.

Of course, “if the young person is finding it increasingly difficult at a particular time, we can then call emergency services should we need to do so. But recapping of that basic conversation reasonably regularly – every week or a couple of weeks – will make a major difference,” he says.

3. What to say when teens are reluctant to engage

Young people are often brought in by concerned parents or carers but may be reluctant to engage with the GP.

“The first thing to say to a young person is ‘your parent or parents have some concerns about you. And I’m wondering whether you share any of those concerns about yourself?’” he says.

Sometimes they will tell him they’re fine. “I’d say, ‘Okay, I’m heartened to hear that. So, tell me if you can, what you see your parents’ concerns as being, and then which of them do you believe are not actually accurate in terms of your own life?’ And then ask them to explain so that you’ve got a good understanding of their perspective.”

4. Help them express their perspective on the situation

Generally, Fuller says he finds that by helping young people to express their perspective on issues that their parents are concerned about, threads emerge that you can talk about.
He then reassures them that he can see that they’re functioning fairly well, but adds “I’d like to check in with you again, if that seems appropriate, to have a further conversation about these aspects because it sounds to me that while you’re doing okay, you could be doing better, and I like the people that I see to function at optimal levels as much as they can.”

5. Build resilience

Building resilience is also key, and a large scale study he did showed that it boiled down to three things—connecting to each other, protecting each other, and respecting each other. “If we have those elements, people tend to do well,” he says.

“So, the biggest resource in the room for a general practitioner is themself and their humanity. It’s not necessarily about being infallible, or being able to refer on rapidly, particularly after the last couple of years…as they are desperate to connect with somebody who they can, to some extent, rely on and trust their advice.”

“They also need to feel protected by you in some ways— in terms of their own well-being, but also in terms of the privacy that they need as a patient, so that they can be honest with you.”

“It’s also about respecting their intellect, respecting their capacity. Now, obviously, all young people that are in trouble, to some extent, have a limited repertoire of behaviours to engage in. Sometimes those are negative, and our role is to look at the discarded resources within them and then to help them to utilise those.”

Then we can focus on adding more to their repertoire so they have a flexible range of options.

“Life is an innovative art and you have to have a range of different ways to overcome the difficulties that life will throw at you,” Fuller says.