Journal
of Adolescent Health and Welfare

Volume 8
- No 2 - Summer 1995

Incorporating
the Newsletter of the International Regional Chapter of the Society for
Adolescent Medicine

- Letter
from the editor -

Dear
Colleagues,

Working
with young people we can sometimes fall into the same trap that they do in
terms of believing in their invincibility. It is therefore always a shock when
a young patient dies. Kelly had a short life of hardship, neglect and abuse.
During her stay with us at Youth Support House she struggled bravely with her
addiction to lighter fuel and attempted to heal some of her pain. Sadly she
died of cardiac failure precipitated by solvent use. She cared deeply for her
little baby, Joshua and tried hard to be a good mother to him. We all miss her
jokes and wicked humour!  At Youth
Support House we have made a ‘quiet garden’ where residents and
staff can sit and remember absent friends. Kelly’s garden was mainly
funded by a generous donation from John McCarthy, who spent several years as a
hostage in Beirut and can thus empathise with the abuse and torture
suffered by many of our residents. Kelly and Joshua figure on the cover of this
edition. We intend that a copy should be included in Joshua’s folder
which will accompany him to his adoptive home so that he will know that his
mother loved him.

This
year we have our tenth forum meeting at the RSM in October and are planning our
tenth anniversary celebrations for 1996-do join us!

Best
wishes,            Diana
Birch

Director
Youth Support

Contents

cover
photograph - Kelly and Joshua

1

Heterosexual
abuse in Adolescent Males, Cultural Differences

14

Letter from
the Editor

2

A-Crack-nophobia

14

Family
Resource Centre

2

Using  Drama in the healing process

15

Tenth Forum
Meeting

3

Multicultural
Issues in Adolescent Health Care

18

Comment -
Youth and Violence

4

Inner Worlds
and Outer Challenges

21

Bonds and
Boundaries

6

Equal
Opportunities and Prejudice

22

International
Chapter News

7

News News

23

Incest -
Where are the boundaries

8

Youth Support
Animal Day

25

Interactive
Exercise - Boundaries game

8

Forum on
Adolescent Health and Welfare

26

Boundaries,
Enmeshment and Identity

10

Are you my
sister, Mummy?

27

The Sexual
Abuse of adolescents in the United States

12

Youth Support
1986 / 1996 Tenth Anniversary events

27/28

Youth Support
Forum on Adolescent Health and Welfare

Tenth Annual
Meeting

at the Royal
Society of Medicine 1, Wimpole Street London WC1

Wednesday 18th
October 1995   at    6-9pm

“Working
with Youth - Ten Year’s progress”

Subject matter includes
-
The scope of Youth Support’s work

School age pregnancy -
advances and trends.
Self Esteem - Can we achieve change?
Bonds and Boundaries in Child protection.

I would like to attend the Tenth Annual Meeting of
the Youth Support Forum on Adolescent Health and Welfare at the Royal Society
of Medicine on Wednesday 18th October.............

I will bring ......... guests.

I am a Forum member ......
(attendance free + guests free)

I would like to join the forum and enclose
£20 annual fee.

I am not a member and enclose fee of £5 per
person for attendance - total ......

Name
......................... Designation
...................

Address
...................... Tel no
........................

..............................  (Admission free to students and

..............................   young
people under 21)

Comment - Youth and Violence -

The
last issue of the journal dealt with the topic of ‘Youth and
Violence’ as discussed at our 1993 Forum meeting at the Royal Society of
medicine. It engendered a wide response. Articles on the subject have appeared
in a number of journals over the past year and this does unfortunately appear
to be one of our ‘growth areas’. In view of this general concern I
felt it worthwhile to reproduce here a comment which was originally included in
the newsletter of SAM the Society for Adolescent Medicine, relating to an
incident which took place in our residential unit last summer.

The
incident made me reach an unwelcome milestone - for the first time in my career
I had to use a Judo technique on one of my patients. Of course I didn't hurt
him, but I normally pride myself on my 'hands off' psycho-therapeutic approach
- however when you have a scenario of a young girl (his sister) being kicked
near senseless, a nurse being laid into and two other staff powerless to stop
him 'hadakajime' (a hold from behind which can be
tightened into a strangle) was very effective. The police were impressed, but I
was not. Ian has witnessed too much violence in his life and I did not want
such scenarios to be replayed in our unit.

Ian and his family had
been with us for three weeks, on a residential assessment and rehabilitation programme.I did not hold high hopes for success - what do
you do when you are presented with a boy who was rejected at birth by a mother
who had been so abused herself that she hated the thought of having a male
child who could grow up to be an abuser; who regularly witnessed and received
beatings from two alcoholic stepfathers; who was abused in children's homes;
who ran away and was buggered on the street and who then came back 'home' to be
further abused by his teenage uncle ... and so it goes on. All we can really do
is continue to pour in unconditional love and affirmation - but is that enough?
Such a boy is aching to have that from his mother - and that he can probably
never have.

Some hours after the
incident I was able to talk to Ian - a very likeable boy - I also examined him
as part of a routine check and discovered that he had been beaten prior to his
outburst by his mother. Violence is the most stable and immutable behaviour
pattern for transmission between generations - nothing perpetuates like
violence. This is what worries me when I hear of programmes to reduce teenage
violence like "Removing antisocial elements and providing psychological
counselling" ... or the Texas idea of group therapy in schools ".. to instil the concept of remorse
in teenage criminals". ("The Deadliest Year Yet" David Ellis  - Time
January 13 1992) Well intentioned, but perhaps too late?

Another of our residents
had a threatening telephone call saying that a teenage gang were 'coming to get
her' and that they had a gun. I was able to dismiss that as an empty threat -
so far our gangs in London are unarmed. We get bricks through windows, eggs on
the ceiling, the odd condom water bomb thrown at the front door - but no
bullets! But it did set me thinking about how different I would be feeling if I
practised in the United States?.

Our gun laws are
fortunately tight but we are usually just a little behind in the development of
teen cultures. We have not yet reached the stage of it being ".. a rite of passage that you must
go to prison", but we have certainly seen a tremendous rise in violence on
a general level. We decided to make violence and youth the subject of our 1993
scientific meeting at the Royal Society of Medicine with psychiatrists, social
workers, physicians, teachers and politicians contributing to the debate. Our government
is getting increasingly worried about youth crime and is planning special juvenile
detention centres - a step forward or a leap into the past?.

Looking for ideas to
put forward, I was interested to read "Deadly Consequences - How Violence
is destroying our teenage population and a plan to begin solving the
problem" by Deborah Prothrow-Stith (Harvard
School of Public Health). She describes a developmental model, Kohlberg's theory, which she reduces to three stages. In
stage 1 - the Punishment stage (age 5-10) children view relationships in terms
of fear and punishment - victims deserve what they get. Violence is on an
individual level. She believes that the teenage offender is stuck in this
phase.

Stage 2 is the
'fairness stage' - (10-16?) when there is concern for others, Youth are enraged
by unfairness - leading to  revenge, gangs, and thinking
relates to group level. What we need to work for is the development of Stage 3
- moral reasoning, the 'safe zone' when they can see beyond themselves and
understand moral and legal contexts and relate to a community of which they can
be part.

I find this model
useful - but surely we are still stuck with the fact that children learn about
individuals, about groups and about the community at large 'at their mother's
knee'. The family is the basic group and when the family is disorganised and brutal,
when there is no love in your 'community' then the future is bleak. That's why
today I will hold another group session with my 'hurt children' recreating a
family where they can find positive 'strokes' .. and that is why tomorrow we will go through a psychodrama
with Ian's mother enacting the birth of a wanted, loved child.

Family work is hard, ... living with the results of not doing it is harder.

New  Stress Assessment  Programme Hits Youth Support!

One of
our resident fathers was referred for investigation of ‘concealed
anger’. It was thought he was liable to become agressive
and dangerous under stress. He in fact gave every impression of being a quiet,
equable, sensitive person -  how could this be tested out? A
gale force wind brought the answer - at the end of a very stressful week, the
tree at the front of Youth Support House blew over and crushed his car .. did he react violently? ..
NO!  We had our answer.

Picture of squashed car.

- International Chapter News -

The International
Regional Chapter (IRC) of SAM (Society for Adolescent Medicine) held
various events at the 1995 SAM meeting
in Vancouver. Our International dinner was very
successful and hosted the largest turnout yet with eighty participants! The
venue, the Prow restaurant was fantastic with sweeping view across the water in
central Vancouver. The restaurant staff are very much
to be thanked and congratulated for the way they adapted to our invasion! A
room had originally been booked for 30 people and numbers were updated on a
daily basis - finally the whole of the main floor was turned over to us. -  Numbers have been increasing gradually
over the last few years and it is great to see how many US members of SAM are attending our dinners and workshops - Can we top 80 next
year!

Of course the scope of the Vancouver meeting was
somewhat different since the week began with the IAAH international symposium and merged into the SAM meeting with
an overlap day devoted to Multicultural
issues in Adolescent Health care. I have attempted to include snippets of
these meetings in the following pages but the scope and multiplicity of subject
matter and speakers make that an impossible task.  SAM
chapter representatives held their usual workshop at which I represented
the IRC and it was heartening to hear how supportive the chapters were of the
international chapter and how emphatically they conveyed the message to SAM
that they wished us to continue as a chapter.

The SAM
meeting 1996 will be in Arlington Virginia - close to Washington and site
of the military cemetery. This is obviously a convenient site for US members
wishing to be at the hub of the Washington lobbying scene but perhaps not such
an attractive venue for international members. We should therefore perhaps
concentrate our efforts next year on showcasing our international views and
experiences for the US members rather than ‘networking’ between
ourselves. This seems to be rather the trend in the workshop recently anyway -
last year the US attenders outnumbered the
international and this year it was very much a case of almost the whole
audience being USA based.  The 1995
workshop was entitled “Incest,
where are the boundaries?” and the content of that session is
described below. The workshop was interactive with contributions from Gustavo
Girard; Elaine Yordan and Diana Birch. Ideas for the 1996 workshop are not refined as yet
and we would very much appreciate ideas and volunteers to contribute. The SAM
theme is going to centre on “Assuring Quality health care for
Adolescents”. I would like to suggest that we make our workshop quite
clinically oriented with presentations
of cases illustrating how each contributor managed the case and commenting
on the level of health care available to such cases in their country.

The IRC officers for the present continue as before
with Gustavo Girard and Diana Birch as co-chairs and Aric
Schichor as treasurer. Please bombard us with ideas
for future meetings! Please send chapter dues to Aric
and encourage colleagues to join.

Enquiries to - Gustavo Girard - (Argentina) - Fax
54 1802 6962

Diana
Birch - (England) - Fax 44 181 659 3309

Aric Schichor - (USA) - Fax 203
548 5439

“Incest - Where are the
Boundaries?”

- An International Perspective on Sexual abuse of
teenagers.-

Sexual abuse can be looked at as a boundary issue -
but where are the boundaries? Who sets the limits? Do our boundaries vary
across international borders? This workshop focused on the difficult area of
sexual abuse of teenagers, including incest and sexual abuse within the family.
Contributions covered experiences in a variety of cultures and highlighted
varying approaches to the subject. This included differences in perception of
what constitutes abuse, legal issues and management of cases.

Warm up Interactive Exercise

‘Boundaries Game’*

The ‘boundaries game’ is an exercise
which was devised for use at Youth Support in London for exploration of family
structure and boundaries. It is a very simple tool which can give a lot of
information regarding disordered boundaries and dysfunctional families in a
short time period, without overtaxing the patient and which is easy to use with
patients who have problems with literacy and communication.

Each member of the group is given a number of
coloured sticky dots and two sheets of white paper. They are asked to place a
red dot on the paper to represent themselves, they
then can add blue dots to represent family members and finally are asked to
place green dots to represent friends. The first sheet is configured to
represent early childhood relationships and on the second sheet they are asked
to show what life is like now.

Workshop participants were invited to try the game
as a warm up exercise in order to focus their thoughts on bonds and boundaries
within their own families or to imagine what the situation would be for one of
their patients.

The following examples were discussed -

A.
‘Debbie’ - A socially isolated young
woman with virtually no bonds.

Debbie -
Early life

Family rejected her, they were depicted as almost
off the paper one sister was closer.At boarding
school teachers were her substitute family. Family life was boundaryless
with step father sexually abusing her at age 8 after which she became disturbed
and institutionalised at an early age.

No containment - No close bond.

Debbie -
Adult Life

Alone, socially isolated.
Childbearing from early age to fill void and provide focus
for attention. Dot for newborn daughter who she
colours in same as self -symbiotic relationship.

Only other dot is her social worker.

Debbie -
Early life               Debbie - Adult Life

B.
‘Gerry’ - a very controlling person
with psychopathic features. His baby daughter sustained life threatening
injuries.

Early life - enmeshment - family
members engulfing him. Friends
closely adherent. No individuation - everyone overlaps.

Adult life - Extreme enmeshment
- almost centrifugal force - tremendous control and power.
Not allowing anyone within his sphere to be individuals. No
clear idea of self - abused daughter not defined. Three separate dots
represent threats- people he wanted to ‘get rid of’  police, social services, doctor.

Gerry -
Early life                Gerry
- Adult life

Self (red)

Family
(blue)

Friends
(Green)             *Copyright
Youth Support

Boundaries,
Enmeshment and Identity - Diana Birch

The
following case study was presented and used as a focus for discussions of
principles of boundaries and identity.

.............
In the end she set fire to the place.

I had said that she would sabotage
herself - but I drew no solace from that as the children wiped tears across
their soot streaked faces with blackened blistered hands -

"Why,
Mummy, .... why??".

The air stank of smoke and the sort of
acrid, cloying smell that pervades from a wet, smouldering dustbin. It seemed
to cling to everything and brought with it a sense of despair - an unhappy but
somehow inevitable ending. A shivering, pathetic group that
could have been a family, huddling against the melted black plastic bin liners
holding their last few possessions.

Had I misjudged the situation?  Had I underestimated her degree of
disturbance?

No - not really. I had known how difficult
our task would be - but I wanted her to succeed - she deserved our putting in
every last effort to reach her - giving her every last chance to respond. With
more resources, more time to work - who knows? But sadly time was not on our
side and she knew it.

Unable to face the uncertainty of
waiting for the result of the final court hearing, she found a certain security
in precipitating the outcome. She found a way of saying - "Here you are, you were right all the time. Stop making me jump through
hoops for you. I'm not a fit mother, I'm not worth
bothering with. Just get on with it and take my kids away".

Difficulty
of establishing an identity.

If
you are unclear about your own personal identity you have no clear boundaries
of your psychic space - where does your identity end and another's begin? You
cannot 'bond' with others or with your children if you are symbiotically linked
with them. You cannot bond without first separating.

Separation
/ individuation results in 'this is me'. - Hence 'you are not me' - leading to
'I can be close to you and care for you if I want to'.

Disordered
boundaries have long been recognised as symptomatic of a number of 'abuse'
situations - particularly when boundaries are ill defined between members of a
disorganised family. This is the classic scenario when sexual abuse may occur -
family roles are ill defined, and normal taboos and codes of behaviour are
obscured. In such a situation the distinction between having sexual relations
with your wife and your daughter - or with your girlfriend and her child is
blurred.

In
that case it is the family identity which is unclear and individuals are lost
within the fused structure. On an individual basis however, the damage to the
ego can be quite catastrophic.

How
can a child brought up within a disordered fused family mass operate when
separated from this - albeit disturbed part of herself?
A child 'plucked' from such a situation, without adequate, intensive help, will
be forever searching for the missing parts of her 'self'.

Such
is Caroline's lot - removed from home at an early age, bereft of love and
understanding, she has very little concept of 'self'. Her identity seems one
empty void ready to soak up the pathology and behaviour patterns of others like
a sponge. She has a craving need to associate with disturbed individuals who
both represent and allow her to achieve some measure of usurped closeness with
those original family members whom she 'lost'.

Her
misfortune is that her 'lost family' were so harmful to her. A hated father who
was violent, drank to excess, mistreated her and rejected her and finally
acquired a 'girlfriend' younger than his daughter who he had sex with openly in
the family home in front of his children. A mother who had not one ounce of
mothering in her, who rejected Caroline, had several violent relationships
resulting in children she could not care for. Who was an alcoholic and drug
user and who expected her daughter to care for younger siblings - even after
she had four children of her own.

Caroline
became torn between being the 'good mother' that she never had - trying in
every situation to care for those around her - despite her obvious inability to
do so effectively - and being or associating with the 'bad mother' in an
attempt to understand her own. The end result was that rather than become a
mother - she in fact became a needy child - in a family which she created
herself. Repeated pregnancies resulting in four delightful children - who
became her siblings - while the eldest child at six years of age, became
'mother' to them all.

This
little mother was quite unable to protect her errant 'child/ mother' from her
continuing self destructive relationships. Each 'hurt child', delinquent and
disturbed young boy or girl who came within Caroline's sphere were 'absorbed'
as part of her deficient ego.

The most damaging personalities however were those where
substance abuse and self destructive behaviour was a prominent feature.
Caroline completely identified with such disorder - mimicking their behaviour
patterns and attempting to almost entirely assume their personalities.  This resulted in Caroline's attending
Alcoholics anonymous and 'confessing' to being an alcoholic - when she hardly
ever drank - and the most serious event of all - setting fire to her flat in
order to identify with her closest 'friend', Dora who had survived an arson
attack by her incestuous father. He had tried to kill the family but died
himself in the blaze when she disclosed - and so ended - their relationship.

Caroline's
first attempt at arson coincided with Dora wishing to break away from her and
her second with a final separation. During the first she was on the telephone
to Dora throughout the advent of fire-engines and police - having to be
forcibly removed from the phone to answer questions. Prior to the second, more
serious incident her children remarked - 'We're going to be on television, like
Dora'.

A
prominent feature of Caroline's behaviour during such episodes is her total
absence of appropriate affect. No emotion, no remorse, almost one would say, no
involvement. Complete detachment from the consequences of her actions. But - of
course ....

...if you do not know who you are

-
how do you know what you are doing?

{The above case study is taken from “Bonds and
Boundaries” - Child Protection and The Family - Published by Youth
Support - ISBN : 1 870717 05 8}

THE
SEXUAL ABUSE OF ADOLESCENTS IN THE UNITED STATES

Elaine Yordan -
University of Connecticut School of Medicine

In the United States the topic of sexual abuse has
become an issue of prime importance in adolescent medicine. Victimisation can
occur at any age - often it is not until the victim develops the independence
of adolescence that he or she has the courage to disclose a situation that may
have begun many years earlier. When dealing with the issue of sexual abuse, I
prefer to define adolescent females in terms of pubertal development. Sexual
abuse can be any form of sexual activity where the perpetrator takes advantage
of the adolescent’s vulnerable stage of psychological development. Sexual
abuse can involve physical contact and can also exist without physical contact.

Physical contact: touching the sexual areas of a
victim’s body including genital and anal regions, breasts or the victim
touching sexual regions on the perpetrator’s body; penetration of the
vagina, mouth or anus by a penis, finger or foreign object; fondling the sexual
areas of a victim’s body, sexual kissing, or having a victim touch the
sexual parts of the perpetrator’s body.

Non-physical contact: exhibitionism, voyeurism and
pornography. Verbal sexual propositions are considered to be sexual activities
as well.

Abusive: When the perpetrator has a large age or
maturational advantage over the victim, position of authority over the
adolescent or a care giver relationship; carried out against the victim’s
will or by the use of force or deception.

In the United States
the National Committee to Prevent Child Abuse reports for 1993 that there wee
150,000 substantiated cases of sexual abuse of persons under the age of 18
years.

A federally funded project, The National Incidence
Study of Child Abuse and Neglect, demonstrated that between 1980 and 1986 cases
of sexual abuse known to professionals grew more than 17% each year for a total
of 166%.

Surveys of adults concerning their experiences as
children and adolescents probably provide the most complete estimates of the
actual extent of child sexual abuse in the United States.
As a result of this type of research there is considerable accumulated data to
suggest that at least 20% of American women and 5% to 10% of American men
experienced some form of sexual abuse as children or adolescents. Estimates of
child and adolescent sexual abuse involving penetrative acts range from 25% to
as high as 50% of cases.

Abusers can be classified by their relationship to
the victim into 3 categories: family members, acquaintances or strangers. in the United States
sexual abuse is committed primarily by individuals known to the victim. Who are
the victims of abuse? Although there are no clear cut markers, girls between
ages of 7 to 13 are considered in a generalised way to be the group most at
risk of being the victims of sexual abusers. About one third of all victims are
boys.

Socio-economic class status does not seem to be a
strong factor to place an adolescent at risk for sexual abuse. The risk factors
that do show up most consistently in epidemiological studies are those elements
of the adolescent’s environment related to parental inadequacy,
unavailability, conflict and a poor parent-child relationship. Those with
alcoholic or drug abusing and emotionally unstable parents are also at risk as
are those with parents who are punitive or distant.  These factors appear to increase the
adolescent’s risk for sexual abuse in two ways. First, they decrease the
quality and quantity of supervision and protection that the adolescents
receive. Second, they produce needy, emotionally deprived individuals who are
vulnerable to the ploys of physical sexual abusers who commonly entrap them by
offering attention,affection
and friendship.

In the United States
in 1963 the State of California
enacted the country’s first child abuse reporting law. By 1967 every
state in the nation had followed suit. All medical professionals are required
under state law to report suspected cases of child sexual abuse.  In 1985, The American Academy of
Paediatrics established its committee on child abuse and neglect. In 1991, the
committee published its Guidelines for the Evaluation of Sexual Abuse of
Children for use by primary care paediatricians. In 1992, the American Medical
Association published the AMA Diagnostic and Treatment Guidelines on Child
Sexual Abuse. In 1987 the American Professional Society on the Abuse of
Children was established joining child protective service workers, therapists,law enforcers  attorneys and others.

Because the consequences of child sexual abuse vary
so widely in severity in duration and in form it is unlikely that a single
treatment program exists that is uniquely suited to all victimised populations.

It is not sufficient to merely tell a child to
resist inappropriate sexual interaction; as an effective intervention system
should also address the conditions that lead an adult to consider the use of
adolescents for sexual gratification and should strengthen the environmental
elements that discourage abuse.

Currently,sexual
abuse prevention is virtually synonymous with group based instruction for
children and adolescents on personal safety. However,despite the laudable goals of universal primary
prevention many have questioned its utility in reducing sexual abuse rates. To
date no rigorous scientific work has been completed examining the degree to
which the accomplishment of these programs to improve the adolescent’s
ability to recognise and respond to threatening situations has led to a real
decrease in the rate of sexual abuse. These programs offer an individual an
opportunity to reach out for help thereby preventing continued abuse.

The general public must be made aware that child
sexual abuse, like all forms of maltreatment, is everyone’s
responsibility an everyone’s problem. Beyond
increasing the public’s recognition of the problem we must change the
social environment that allows child sexual abuse to flourish.

Reference:-The David and Lucile Packard Foundation.
Sexual abuse of children. The future
of Children. 1994’ 4(2)

“Heterosexual abuse in Adolescent
Males, Cultural differences”

- Gustavo Girard - Argentina

Gustavo Girard gave a very interesting presentation
to the IRC workshop. He presented two cases of young men who had been sexually
abused by older women. The concept was an important one and something which is
easily forgotten - we speak often of female sexual abuse by male perpetrators
and less often perhaps of male abuse by male homosexual prepetrators
- but the heterosexual abuse of males is seldom
discussed. The premise is that in Latin American cultures - where the male is
‘macho’ strong and in control - there is little room for the
concept of the male being ‘out of control’ and abused within a
heterosexual relationship. It is hoped that the entire text of the case
histories will be printed in our next edition but perhaps we should pause here
for reflection.

Is the situation much the same in other cultures? and do we make provision for such young men to come forward
for help?  In Britain such
cases are more likely to come to light via the tabloid press rather than in a
counselling or medical setting. Each year a number of scandals are reported in
the popular press of boys seduced by their teachers or by the mothers of their
friends - this is often ‘covered up’ by the boy in a desperate
bravado attempting to give the impression that he sought the relationship and
is a ‘real man’ having an affair with an older woman. The film the
graduate made comedy out of the seduction of a college boy by the mother of his
girlfriend - is this really how we feel about the situation? How would it be if
the boy was a little younger - would it still be funny? In reality the woman is
often inadequate, dependant and manipulative at best and frankly abusive at
worst. Society conspires to shy away from these difficult scenarios - is it not
time we protected our young males?

A-CRACK-NOPHOBIA

Seen in the newspapers recently an article titled acracknophobia
relating to the fact that NASA has been testing drugs on spiders and found that
their web characteristics change ..... just wondered if we should be monitoring the shape of spider
webs in Youth Support House when we are checking on smuggled drugs??!

USING DRAMA IN THE HEALING
PROCESS

This formed the
basis of a workshop in the IAAH symposium in Vancouver. Peter Chown
and Julia Tressider from Sydney contributed a story telling exercise
which they have used with teenagers in Australia. The ‘Youth Support’
contribution consisted of a series of videotape segments illustrating an
ascending level of psychodramatic intervention - role
play ; using a ‘story’(Cinderella) and changing the outcome; using
a real situation and changing the outcome; ‘Magic shop’ ending.

Many
thanks to the young people who contributed even though unable to be in Vancouver themselves. Thanks also to Alistair and Leon for
producing the ‘Rapid Tour’ video of Youth Support House. Which was shown at the start of the IRC workshop.

The
nature of psychodrama

Psychodrama, according to  J.L. Moreno, was born in the
“Viennese cradle” in April 1921 as the “Theatre of
spontaneity” (Moreno, 1946.)  Moreno had experimented
with group analysis in 1921 when he placed the group of couches in a circle and
tried free association. This produced a disordered mix of individual
associations which did not gel together.
He believed that psychodrama was essentially a group process, and that
the group and the individual are never really separable except by artificially
ignoring the one or the other.  (Davies, 1987).
His idea was that psychodrama was, in some way, the
antithesis of psychoanalysis and reported saying to Freud “You analyse
their dreams, I give them courage to dream again.  His ideas were going against the current
flow of thought at that time, counter to the ‘fear of neuroses’
which he felt prevailed in Vienna.
“After
purging nature (Darwin)
and society (Marx) from creative cosmic forces the final step was the purging
of  genius by psychoanalysis”.

The Italian Comedy form “La Commedia Dell’Arte” provided Moreno with a
model of a semi-spontaneous drama whereby the roles of Arlecchino,
the Carabiniere etc. are fixed but the dialogue is
improvised.  Moreno used
roles to “enter the unconscious from the social world to bring shape and
order into it”.  By allowing  actor
and later the general public to enact roles without a script their own
subconscious world was brought to life on the stage.

Aristotle (c.350 B.C.) provided the model for
catharsis in theatre “A tragedy is filled with incidents arousing pity
and fear wherewith to accomplish catharsis of such emotions”.  Breuer used
hypnosis to recall feelings from unconsciousness to produce a catharsis.  In psychodrama, however, we see
catharsis in action.

Using
Drama with young people

The  classic format
for psycho-dramatic intervention involves use of warm up sessions during which
the protagonist is chosen; a great deal of emphasis is then placed on this
particular protagonist  who
undergoes an interview and  contract
forming as regards what he or she wishes to get out of the session; thereby
setting the scene and moving from one scene into another.  The scenes are generally linked by a
theme and often the contact becomes more and more poignant and challenging as
one moves from perhaps an initial low-impact, less threatening general theme,
to a highly threatening and very intense emotional scene during which a great
deal of catharsis of emotions takes place.

During this part of the psychodrama the members who
are playing roles or doubling for the protagonist are very much expected to be
a carte blanche on which the experiences and feelings of the protagonist can be
painted; in other words - it is the protagonist who puts the words in her mouth
and, with the help of the director organising the scene, all the emphasis is on
the protagonist. The psychodrama may focus on this same person over the space of  one or two
hours, or even longer.

In working with young people it is often not
possible to keep within the formal format. Very often some blurring occurs
between the protagonist and the accessory ego, or people who are playing other
roles.  Many of the young people we
work with have experienced similar backgrounds of abuse and deprivation, and it
is thus very hard for somebody who is playing, say, the role of the
protagonist’s mother not to bring into this role aspects of her own
mothering.  This is something which
is deliberately avoided by the Director in classic psychodrama, but something
which we can work with when dealing with young people.

Similarly, with our particular drama group, it is
often impossible to hone in on one group member for long periods of time.  We also need to avoid some of these more
intense cathartic moments that can be engineered in classic psychodrama. The
depth of hurt and pain which can be brought out very quickly in some of our
young people is too much to be dealt with and contained within our kind of
group.

In view of these features, drama work with abused
and young people has to take a lighter level. We use a great deal of warm up
sessions and games which help break the ice and help give young people
confidence to be able to open their mouths and speak in company of others. Even
a simple game such as I Spy to begin with has value. Other techniques to use
involve role play in varying situations.
As these people start on a fictitious level, i.e. a less threatening
level, they then work towards an event that has actually happened either within
the unit or in the patient’s background.  Fairy stories also form a fertile ground
for psychodrama in that we can pretend that a character in a fairy story is our
protagonist and work on their stories in parallel to our own.

Psychodrama is par excellence a group activity. Moreno was in
fact the first exponent of group psychotherapy. Thus, although at first sight
it might appear that the protagonist is playing out his or her situation alone,
the group issues are extremely important and are seen to influence the choice
of  double accessory egos as well as
the flow of the drama.  Within a
residential unit such as ours these features tend to come to the fore.  Our clients live together, and re-enact
group / family dynamics on a day-to-day basis. These can then be brought out
within the drama.

Moreno
is credited with the remark: “Don’t tell me, show me”. In the
drama the protagonist is showing the group how he feels and relates to the
world. The protagonist is bringing his or her inner world onto the stage, and
it is left to the rest of the group to pick up words, phrases and gestures of
significance and amplify such points in directing the action.  The transference and
counter-transference issues come alive and form an integral part of the drama.

Young people who have been hurt, abused and
deprived often have enormous problems in communication. Hence classic
psychodynamic psychotherapy can be difficult  in this group. Young people can
be very creative and need different avenues in which to express their feelings
and emotions.  At Youth Support we
use Art therapy, Movement therapy, Drama therapy and these different vehicles
maybe more acceptable to one person than another, but do allow different ways
of expression. The importance of drama is that we can play. Winnecott
said that  therapy
occurs in the overlap of the play space between the therapist and the patient.
This is particularly true with young people.  Deprived youths have often not been
allowed to be children and to play - they have often had to be little adults in
childhood and have not been allowed to enjoy themselves or express themselves.
Playing can often be difficult but it is an extremely valuable tool in the
healing process.  Games such as the
Magic Shop Workshop , with which we often finish a session, bring people very
much into the child ego state; in other words, it helps to bring us into
contact with our inner child which carries our hurt and pain, and which needs
to be nurtured, contained and loved in the healing process.

References

1    Aristotle “De Poetica” Aristotle and the Art  of Poetry, Bywater
1909

2    Breur
& Freud, “Studies in Hysteria” 1895

3    Davies M.H.,”Drama
Therapy & Psychodrama in Drama Therapy” Jennings     Croome Hill 1987

Indonesia has
many different attitudes to health and disease. The culture takes a lot of
understanding as it is so different from the West. People are encouraged to
have two children only; there are signs in the streets saying that two children
is best. The religion influences the attitudes. There
tends to be a passive acceptance of illness as sent by Allah. But the people
live in the present, rather than being concerned about past or future. They are
very happy people, always smiling, although they are very poor. Indonesians
take great pride in their children and care for the family. If one person is in
work he buys shoes etc. for parents, children, aunts, uncles and all the
extended family.

People in dominant
cultures probably do not tend to spend time and trouble in understanding nondominant cultures.

I didn’t learn the
language so there were many issues which I didn’t get to grips with

(MAGGIE)

Multicultural Issues in Adolescent Health Care

This very important subject was the stimulus for a
whole day joint IAAH/SAM workshop in Vancouver.
Contributions were many and varied - an interesting collection of comparisons
of health measures, disease concepts and service provision in varying cultures;
but perhaps leaving one ultimately more than a little perplexed as to
‘where do we go from here?’This is a
subject that I had pondered over for some years - from the personal viewpoint I
knew how it felt to be ‘between’ worlds in cultural terms - brought
up in England
but with Italian family. Some of my experiences are echoed in the contributions
below. I have also

Culture
denotes a system of inherited concepts expressed in symbolic forms and
transmitted through a pattern of meanings by which people communicate,
perpetuate and develop their knowledge about and attitudes toward life. (Geertz 1988)

attempted
at intervals to raise the issue of culture with staff and residents in our unit
(see workshop results below). Nevertheless making concrete and useful changes
rather than debate issues is difficult.

One inherent difficulty lies in the fact that
cultures change - there tends to be a drift towards others norms - particularly
in the adolescent sphere where life moves fast, boundaries are shifted and
‘cultures’ are exposed to American films and media heroes. Many of
the ‘cultures’ which I have studied have been subject to this
movement - in Italy youth were previously much more repressed and controlled
than in England, much to my consternation as a teenager - now drug taking,
abortion, divorce etc. are part of the scene and Italian teenagers are if
anything freer than UK peers. Russian youth were until recently shining
examples of polite school pupils who stood up when the teacher entered the
room. The groups I brought over to England suffered
‘culture shock’ in London
schools. Now Moscow
youth have a very high rate of truancy, teen pregnancy, drug abuse, drinking
and prostitution. Something unimaginable ten years ago. The comparative work I
have attempted between Jamaican youth in the Caribbean
and those who live in UK
changes with great fluidity - looking for similarities is more rewarding than
looking for differences.This concept of cultural
drift is echoed by Bob Blum in his article
“Global trends in adolescent health” (Blum RW. JAMA.  265(20):2711-9)  .... Increasingly, morbidity and mortality
trends for young people in developing nations are paralleling those in the
industrialised world. As infectious causes of mortality diminish, unintentional
injuries, suicide, homicide, war, and maternal mortality represent the primary
causes of death in the second decade of life for most nations where data are
maintained. As developing nations increasingly place priority on the education
of their youth, early marriage and precocious child rearing are discouraged,
and other problems, such as out-of-wedlock childbirth and illicit abortions,
emerge. Problems such as substance abuse and suicide arise with the urban
migration, increased unemployment, and disruption of traditional social
structures that are experienced as developing countries industrialise.

Unfortunately it often seems that cultures learn
the ‘negatives’ from each other before or instead of the
‘positives’. In my travels I have attempted to learn what the
positive, coping strategies are for a given culture which could be extrapolated
for ‘use’ elsewhere - but have generally been frustrated in this
task as such norms ‘do not travel well’.

With regard to youth of Jamaican origin - in our
last journal Dr Aggerey Burke (one of our few
Jamaican psychiatrists working in London)
made the point that emotional disturbance and the diagnosis of psychiatric
illness among black youth is much higher in England  than
in Jamaica.
The level of arousal seen in London
is much higher than in Afro/Caribbean countries - he described the most
commonly seen syndrome as ‘..Sadness, fear, hatred, anger constituting confused
emotions - emotions that cannot be balanced; and in it’s
extreme form it is fury. Extreme and confused emotions are mixed with extreme
and confused thoughts in the most extreme and confused persons.’  This situation we discussed,
was partly brought about and confounded by the fact that half the children
going into care are black and in boroughs with a 20% black population 62% of
young offenders are black and 65% of school exclusions. This perpetuating
legacy of the care system is something which is not seen in Jamaica where
very few children ever go into care. Why can’t we in England learn
from and use the Jamaican system of intervention?

Dr Frederick Hickling, a
psychiatrist in Kingston,
Jamaica
views the emerging Jamaican system of community care for the mentally ill as a
great improvement on the ‘colonial style’ mental hospital and the
idea of institutionalisation. Generally this underlines the difference in
philosophy - greater community acceptance of emotional illness and diverse
lifestyles, coupled with greater reliance on community or extended family
support in personal or family breakdown. Dr Hickling’s
centre in Kingston
has many similarities to Youth Support House - using a multidisciplinary
approach and utilising drama, music and media - however there is still
something inherently Jamaican in his set up and something inherently British in
ours which is hard to define. Basically we do not have the extended family
network to rely upon for support of our patients and have to
‘create’ an artificial support system. Is this support system
breaking down because of increased reliance on ‘capitalist’ values
- i.e. an acquisitive industrial society?

This view is argued in the article “Psychiatric morbidity in developing
countries and American psychiatry's role in international health”.
(Sugar JA.  Kleinman
A.  Eisenberg L. Hospital & Community Psychiatry.  43(4):355-60, 1992) “.... Economic and social change in the developing countries of Asia, Africa, Latin America, and the Pacific Islands is associated with increased
rates of behaviour-related illnesses, including psychiatric disorders,
alcoholism, and substance abuse. Between 10 and 20 percent of the presenting
problems in primary care settings in those countries are psychosocial. The authors
provide an overview of the epidemiology of
psychiatric and psychosocial morbidity in developing countries and summarise
its effect on medical care systems in those settings. They suggest that
American psychiatry increase its involvement in improving mental health care in
developing countries.

Consultation should be directed toward
priorities determined locally in those countries, including assessment of
current clinical practices, applied epidemiological research, and training of
indigenous researchers. “

Support systems vary depending on the type of
extended family and the role of the family in society. Japanese family
structures are based on different value systems from those prevailing in
British families as evidenced in “Connectedness
versus separateness: applicability of family therapy to Japanese
families” (Tamura T.  Lau A. Faculty of Education, Tokyo Gakugei University, Japan. Family
Process. 31(4):319-40)  This
article, a product of the two authors' multicultural experiences, contrasts
British and Japanese families in order to examine the applicability of the
Western model of family therapy to Japanese families. Areas where the Western
model is incompatible are identified, and modifications to fit the Japanese
indigenous model are suggested.

“ .... The most significant
difference in value systems between the two cultures is the Japanese preference
for connectedness. The Japanese person is seen as a part of the embedded
interconnectedness of relationships, whereas British norms prioritise
separateness and clear boundaries in relationships, individuality, and
autonomy. This value orientation is manifested in the Japanese language,
hierarchical nature of the family structure, the family life cycle, and the
implicit communication style.

Systemic thinking, which deals with the
pattern of relationships, is valid for all families regardless of cultural
differences. But therapists should note that the preferred direction of change
for Japanese families in therapy, is toward a process
of integration--how a person can be effectively integrated into the given
system--rather than a process of differentiation. An authoritative therapist
style, the use of individual sessions, silence, and other non-verbal techniques
are relevant to bringing about the desired change toward better integration of
the individual with his or her networks.”

Bob Blum presented an overall view of culture
health and illness in adolescence which to an extent brought together some of
the themes expressed in the workshop. He drew attention to the recommendations
of the Wingspread conference on Culture and Chronic Illness - to

·      Include
persons from diverse cultural and ethnic groups in all aspects of research,
training, service delivery and policy formation

·      More
understanding needs to be developed of distinct cultural groups and variations
within ethnic groups rather than focusing on aggregated racial groups

·     More
attention should be given to the way language is used in communicating with
persons from diverse cultural groups.

FROM
CAIRO TO ENGLAND

My father is
Maltese/Italian and my mother is Egyptian/Italian. They married in Cairo and
came to England
just after the war with a boatload of other relatives and immigrants. My
father’s parents and sisters settled in Somerset and
they went to live in Kensington. I don’t remember English being hard to
learn; I understand Italian, but it sounds awful if I try to speak it.

School dinners were a
shock. I was used to Mediterranean food and found them dull and tasteless.Tea at friends homes was
an experience I was used to food and eating being social.My
English friends had to eat and not talk (and no wine!) My best friend was a
Jewish girl, I liked eating at her house (me a good
Catholic girl). Religion was a bugbear. I hated it. It seemed so unfair, even
at my young age.I learned to keep my mouth shut and
not to question too much. My own children are not christened, much to my parents disgust. Clothes were also different. I have lots of
photos of me dressed for the Arctic
in trousers dress and jumper even though the photos look as if they were taken
in the summer.

The only real problem I
had was when I was older. My father wouldn’t let me go out. He would have
liked me to meet a ‘good Italian’ boy but there were few and far
between. So I became a home girl. To make matters worse I was a teenager during
the sixties and they were worried I would go on the Pill and run away with a
hippie. I was allowed to go next door to a wedding party and met my future
husband. His saving grace was that although English his stepmother was Italian.
He was my first boyfriend and I was 20. Our children are English and have no
Mediterranean traits, so the era ends.

(ANNE)

Equal
Opportunities and prejudice.

The recommendations of Youth Support
workshop and working party of residents and staff.
Autumn 1993

PREJUDICE.

1
Definition of prejudice.

Coon[1982] defines prejudice "as a negative attitude or
prejudgement tinged with unreasonable suspicion, fear or hatred."  When this happens there is a danger that
sterotyping may occur.

2
Issues.

Most people have,
or had prejudiced views. These may be around the following issues - age,
appearance, disability, dress, education, handedness, H.I.V.status,
housing, money, occupation, politics, poverty, race, religion, sex, sexuality,
size, speech, success.

Have you come across any other
examples?

3 Feelings.

These prejudices
can be expressed through insults and name calling and also in other hurtful
ways. When this happens, it may stir up difficult and painful feelings and
emotions for example, anger, confusion, disgust, embarrassment, hurt,
isolation, jealousy, loneliness, pity, rejection, repression. There are many
others.

4
Reasons for prejudice.

At the meeting
there were 18 residents and staff,  from over 26 different ethnic
backgrounds and a cross-section of social backgrounds. We think that it is true
to say that the majority of people present have prejudices around different
issues. Rather than concentrating too much on this, it is important to try and
gain some understanding from where this prejudice comes.

- Many
prejudices are passed down from a parent to a child. When a child reaches
adolescence s/he
has their own / parents view. These ideas may be conflicting. It
is important to recognise that everyone has a choice as to whether or not to
hold on to these prejudices or to let go of them and to become open-minded.

- Prejudice is
a two way process. A person may be prejudiced as they know it will hurt
somebody - it is connected with power.

5
Education .v. Ignorance.

We discussed
that people with qualifications may still have prejudices. We talked about
"education" in the broader sense of the word as being a way of
overcoming prejudiced attitudes. If a person continues to have a prejudiced
view having being educated then this should not be tolerated.

6 Positive
strategies to overcome prejudice - The way forward.

- Positive
images around the community i.e. Nursery, Baby Unit, Schoolroom.

- Celebration
and discussion of multicultural festivals.

- Review of our
Equal Opportunities policy to see if it meets the needs of residents and staff
at Youth Support House.

SUMMARY

We are
all human beings. We all deserve to be respected and should respect others.

- We all have
the right to equal opportunities.

Reporters:
Rachelle, Wendy, Alistair, Viv, Karen, Rosie,

Compiled
by KAREN and ROSIE.

I am an Indian living in Britain. I was
born and brought up in India.
I come from the upper middle class and hence led quite a similar lifestyle as
here. I have experienced a variety of differences due to the cultural
backgrounds being different.

My meeting with my husband
was arranged. The compatibility between families was checked out and
photographs were exchanged.  I had
the full freedom of saying “yes” or “no” and was
engaged within a week, married in three months. I am now a mother of two living
in a joint family and have a part-time job.

Pre-marital sex was a
taboo.  Joint
family systems is a very usual aspect of India but not
common here. I play the role of a modern, Eastern working mum outside home and
am a typical Indian daughter-in-law inside.

Kissing, cuddling and
even holding hands is considered disrespectful if
performed in public especially the In-laws. We have family meals, discussions
and outings.

There is plenty of give
and take which is the essence of our family stability. Broken families, broken
homes, divorced parents, broken engagements and separated partners are looked
down upon.

Obedience, care, love,
togetherness, plenty of giving in, loads of patience is the secret of our type
of family unit. This is not the normal practice here and hence I face a
cultural conflict and am constantly debating within myself as to what is truly
good for me

Interference in the
bringing up of children is another common thing in Indian families. This is
annoying but any argument or questions lead to the breaking up of the family
unit. Thus we need to strike a balance and enjoy both situations. This is tough
but can be achieved.

Cultural conflicts and
confusion should be dealt with very carefully especially with kids to avoid big
and major personality problems in the future.

(PRIYA)

NEWS      NEWS      NEWS      NEWS      NEWS      NEWS      NEWS

New York International Conference on
Eating Disorders - April
26-28 1996 Details from Preston
Zucker Montefiore Medical
Centre 111 East 210th Street
Bronx NY 10467 tel 718 920 2176 FAX 718 920 5289.

Youth Support Tenth Annual Forum
Meeting at the Royal Society of Medicine Wednesday
18th October 1995 6-9pm.

Advance Warning - 1996 is
Youth Support’s tenth anniversary year - Whole day meeting on Adolescent
Health at the Royal College of Physicians - October 24th 1996 - keep the day
free.

Youth
Support Animal Day

Animal
day was enjoyed by all in typical Youth Support manner! The animals were all
into their animal therapy keeping everyone happy. ‘Warm Fuzzies’ pet shop project was officially opened -
TWICE! There was a mix up over the arrival of the mayor and so one of our
visitors, Anne Widdecombe MP for Maidstone kindly
declared us open and cut the ribbon ... which was deftly sellotaped
together again when the Mayor’s car was spotted approaching.
Embarrassing, yes .. but good
fun too!

Opening
Number 1   Anne Widdecombe MP

Opening
Number 2 The Mayor gets in on the act

Winners
of the ‘Draw a Pet’Competition receive
their awards

Youth  *   1986 / 1996   *  Support

Don’t
Forget - The 1995 Forum meeting is the tenth meeting and we hope it will prove
to be a special event ..... but 1996 our Youth Support
Tenth Anniversary year will be marked by a Scientific Conference on Adolescence
- social events and fund raising exercises - please let us know if you are
interested in helping or participating - Watch this space for developments - or
contact Youth Support House for information ... Coming up .. a
‘Blues Brothers’ event we hope! For information ring Lisa or Sonia
0181 650 6296

The Tenth
Anniversary of Youth Support will be marked by a

Conference
on Adolescent Health

to be held at the Royal College of Physicians

St
Andrews Place, Regent’s Park, London

on Thursday
24th October 1996

Conference
9.30am
- 4.30pm

Followed
by Keynote Lecture 5pm-6pm

Followed
by Tenth Anniversary Dinner

The
conference will highlight advances in Adolescent care over the last ten years
and will deal with a number of important areas of young people’s health.
Sections include Teenage pregnancy and sexuality; self harming behaviours and
substance abuse; eating disorders; emotional problems; youth and violence.

Our
speakers are renowned experts from the field and we hope to include some of our
international colleagues.

Please
write in now to :- Youth Support Conference
Administration

Youth
Support House, 13 Crescent Road London
BR3 2NF or FAX 659 3309

if
you wish to receive further details or to make advance bookings

The Journal of
Adolescent Health and Welfare

is published by:-

Youth Support

13, Crescent
Road, London BR3 2NF

Charity No 296080

Tel No 0181 650
6296

Fax No 0181 659 3309