Parents Matter: Four Brief Cases

From Volume 52 Number 1

Dee Apple, Ph.D.

Abstract: This article discusses the basic role parents play in the treatment of their adolescent’s substance abuse. In these four cases this role was crucial regardless of the degree or intensity of substance use. When the parents were capable of responding contactfully and authoritatively to substance use, progress was made. When parents were less aware emotionally and more permissive, even “experimental” marijuana use worsened. This is important to recognize as marijuana disrupts and arrests adolescent development, a serious problem for young people. How parents respond to their child’s interest in and use of drugs is as significant as their response to any other emotional or medical illness their child might suffer. With great confusion about the effects of marijuana, and widespread use of marijuana in our society, the role of the parent is more important than ever. Parents matter.

*This article is based on a presentation at the open-to-the-public ACO series, A Different Kind of Psychiatry, January 19, 2019.

CASE # 1

Martha’s mother, a professor, referred her 17-year-old daughter because of Martha’s anguish and depression over her boyfriend cheating on her. Martha was unable to finish any schoolwork. With only a month before high school graduation, Martha’s mother was concerned this might jeopardize her standing at college. In our initial interview, her mother was cool and intellectual, her father seemed hardly in the room—I could not establish eye contact with him, much less emotional contact. The parents did not look at each other, either. The subject of marijuana was not mentioned until I asked.

Martha struck me as anxious but working hard to act as if she was in control and everything was “peachy.” She was a beautiful adolescent dressed in provocative, tight, inappropriately short, cutoff jeans and a skimpy tee shirt a size too small. I wondered to myself, “Where are her parents? How could they let her leave home dressed like this?” I soon found out.

Martha said, “My dad trusts me and lets me do whatever I want. He’s really cool. He smokes pot while cooking pancakes for me and my little sisters.” It was here that I first saw the destructive disruption of ocular functioning and social contact that was rampant in the family—how, for example, the father was clueless about the effect of his behavior as a model for his children. Given this, how clearly could he perceive his daughter and the nature of her problems? How effectively could he set limits and healthy boundaries for her? In short, act as an appropriate authority in her life?

Martha continued, “Mom and dad are separated emotionally. Mom’s busy with her own things. They leave me alone a lot.” She started to cry as she told me this. She could not stand to be alone. It was terribly painful and made her very anxious.

Martha smoked pot frequently, nearly every day, to quell her anxiety and emotional pain. She said, “I tried to win my boyfriend back by getting stoned and drunk with his best friend, but he sort of took advantage of me sexually.”

I told Martha, “I’m concerned about you, and about your use of marijuana and alcohol, and the dangerous situations you put yourself in.” She left for college after 11 sessions.

Martha’s parents thought she only needed a change of scenery, and did not insist that she find a therapist at college, as recommended. Again, this represented contactlessness on the part of her parents and the defensive function of denial. These results of disturbed ocular functioning led to a compromised ability to perceive the reality of their daughter’s situation. Thus compromised, they were utterly unaware of the personal and socially destructive effect their misguided actions and inactions had on their daughter and her life.

Later, I learned that Martha had to leave college after continu- ing copious use of marijuana and progressing to hallucinogens, cocaine and opioids. Despite providing for her every material need, a form of substitute contact, her parents had clearly neglected her emotional needs. Here we see that when contact is disturbed, social interactions are characterized by substitute contact activity. In an ineffective effort to break through the wall of contactlessness, Martha’s parents provided her with substitute gratifications and distractions, maintaining an illusion of care and effective parenting. In this and similar cases, contactless parents take a distant and/or distorted role and permissive attitude about marijuana, largely abdicating their parental responsibilities, rendering them ineffective in their interactions with a young person in trouble. They are demonstrating an anti-authoritarian parental stance rather than acting as the caring natural authority their child requires and needs for guidance.

CASE #2

Bobby was a private school student referred after his parents noticed references to pot in his text messages. He had become argumentative, less organized and was no longer doing as well at school. His mother valued her close relationship with Bobby. His father was a high functioning but angry man. He varied between being critical of Bobby or withdrawing emotionally and not participating in providing structure or discipline.

Bobby was not interested in stopping marijuana use. He said, “I like smoking. It makes me forget the stressors. Everyone else is either drinking or smoking, and I don’t want to be the only one not using.” He was quick-witted with multiple rationalizations for use, such as, “I have a friend whose father smokes pot. He’s really cool, and totally successful. He drives a Porsche! And how bad can pot be since they use it to shrink tumors and cure cancer?”

Bobby’s attitude about pot was slippery. He told me, “I talk a lot with Mom about ‘being honest.’ I told her, I’m not going to drink alcohol, Mom. I know it’s bad for you, and we have alcoholism in our family.” He was nearly as dishonest with her as he was with himself. Mother reported, “I was thrilled. I told Bobby that trusting him and his being honest means everything in the world to me.”

I recommended drug testing Bobby, but his mother said, “Whenever I considered testing him, he ‘confessed’—in the spirit of honesty—that he’d smoked once in the last few weeks and would probably test positive.” It was clear that his mother was willing to see only just so much of the truth of her son’s functioning. This bright, intelligent woman was choosing to collude with her son by “looking the other way.”

I knew from Bobby that he sometimes smoked daily. Often his “confession” was enough for his mother to drop the idea of testing him altogether. She clearly did not want to “catch him,” and hoped her trusting him would be enough.

After several sessions, Bobby told me, “I found my mom’s ‘stash’ and smoked some of it.” Later, his mother admitted with embarrassment, “Since I occasionally smoked pot over the years and was ‘fine,’ I figured Bobby would be too. Everybody’s doing it now.”

To her credit, Bobby’s mother saw the hypocrisy and poor example she was setting for Bobby, and from that point she stopped smoking. As her self-perception cleared, she realized that she was, in fact, “not fine.” She was lonely and estranged from her often-absent husband.

Nonetheless, Bobby was caught smoking at the home of a friend. I asked his mom, “Have you been testing him?”’ She admitted, “I sort of haven’t been.”

“How did Bobby’s dad react?” I asked.

“I haven’t told him.”

One could see how her own problems with contact were creating blind spots in her family and marriage, and preventing effective responses to Bobby’s inappropriate behavior.

I confronted her with how her collusion with Bobby endangered her marriage and Bobby. I told her, “You have to put your foot down or this won’t get any better.”

After she informed her husband, and after much arguing and a few difficult therapy sessions, Bobby’s parents came together and imposed recommended restrictions and testing, cooperating at least temporarily to provide the authoritative boundaries and guidance their son needed. Over the next few months, Bobby’s emotional and academic functioning improved and later that year he graduated from high school.

However, just before leaving for college, Bobby learned that his parents were divorcing. He was upset about this when he left home. When I saw him again at Thanksgiving, it was clear he was smoking pot again. The relatively new contactful structure and boundaries his parents had finally provided had not been adequately internalized by Bobby, and he went adrift with the lack of structure at college. Near the end of the academic year I learned from his mother that he was stopped by campus police for going through a stop light, charged for having marijuana in his car, suspended from his university, and dropped by his girlfriend. Then, according to his mother, he stopped smoking marijuana. It took that much for him to begin to see, to make contact with, the harm that marijuana caused him.

Bobby’s parents’ responses to his crises were all too typical. They were partially cooperative with treatment recommendations but compromised by their own problems, including not wanting to upset Bobby by “being too hard on him.” Due to their own limitations, they were unable to consistently implement recommendations and limit setting. They presented a parenting style that was confusing to Bobby, with elements of a caring, authoritative style, undermined by permissive and indulgent attitudes, mixed with harsh authoritarian ones. Bobby’s continued use of marijuana during parts of his treatment prevented consistent attention to his underlying emotions and problems. Treatment that was more effective was not possible until his substance abuse, at great cost to himself, created circumstances that compelled him to stop.

CASE #3

Jenny was admitted to the honors art program at a fine university. By the second semester her grades were slipping. She hid from her parents that she was smoking pot more regularly than attending classes. When her parents caught on, they required her to return home and commute to college. They started her in therapy with a female therapist. Jenny took one summer class and did well enough, satisfying her parents, and was allowed to return to live at school for her sophomore year. She soon returned to smoking pot, however, and got into trouble drinking alcohol. Her grades again declining, her parents again required her to return home and commute to school.

After much discussion, Jenny’s parents allowed her to go back for her junior year, and to rent a house off campus with a group of friends. Again, by October Jenny was smoking pot and had all but discontinued classes. Her parents seemed able to see the problems their daughter was having once they were obvious enough, and to take action, but unable to remain in contact with the serious destructiveness of the issues and their need to continue acting as parental authorities. They did know they and their daughter were in trouble and needed assistance, and they contacted me in mid-October.

After meeting with her parents and then with Jenny, I told all three of them that I had reservations about working with her. I recommended referring her to an inpatient rehab program as the better option.

Jenny’s parents were worried that she would lose her place in the honors program and her financial scholarship if she left school. So she could continue her scholastic program and financial assistance, I agreed to accept her into treatment, but only under defined conditions:

• Jenny had to immediately stop smoking pot.

• She had to return home, commute to classes, and take a full course load.

• Her parents had to agree to conduct random drug testing.

• Jenny had to agree to cooperate fully and honestly with testing.

• She had to work on weekends and summers to pay for most of her car insurance and her college tuition with the proviso that if she achieved a 3.2 GPA, her parents would resume paying tuition.

• Jenny had to meet with me for therapy at least twice weekly.

• Finally, she was required to share a Google document with me in which she wrote, on a daily basis, her experiences and perceptions during treatment. I would read the journal and respond by either writing back or by addressing issues in her sessions.

If these conditions were not all met on an ongoing basis, I would stop treatment and her parents would insist on her entering rehab. Jenny and her parents agreed to all conditions.

Jenny has not used marijuana in over a year. She is taking a full course load and working as a waitress. During late spring and summer, she was functioning the best I have seen, cutting back on her drinking, making sure that she was getting enough sleep, exercising regularly, eating a healthy diet, and being interested in her own health. She achieved a 3.2 GPA in her last semester, so her parents are paying her tuition and she has entered her final year at college. There is work remaining for her in therapy, but so far, so good.

Case #4

In a similar case, Alvaro, a 16-year-old public school student, was described by his parents as smart, empathic and musically talented. More recently his parents observed that Alvaro was moody, less social at home, and losing interest in things he used to enjoy. After several confrontations by his parents, Alvaro admitted he had been smoking pot. In therapy he revealed to me he had smoked 20–30 times in late 10th grade, increasing to near daily use in 11th grade.

Alvaro’s parents were divorced. His mother had remarried, and all three parents were present for our first meeting, capable of setting aside differences, presenting a united front out of concern for Alvaro. They immediately accepted all suggestions and recommendations offered. This not only expressed their respect for authority, in this case, the doctor, but also their ability to quickly and accurately perceive the need for them to act with authority regarding their son.

Alvaro stopped smoking after his parents’ interventions. Five months later, his parents noted “dramatic improvement.” He was more present and responsive, less argumentative, more willing to participate in activities and less withdrawn.

By six months, Alvaro and I were no longer talking about pot in sessions. We moved more towards HIS goals in therapy: “I want to enjoy more things, things I used to do, like outdoor things, soccer, going for walks, hanging out with friends.” He agreed to exercise and went out for track.

His grades improved from one A, two B’s and four C’s to five A’s and two B’s. Alvaro graduated high school and began his college studies in physics, earning straight A’s.

Summary

From my experience, the response of parents to an adolescent’s marijuana use matters more to the outcome of the case than how much or how long the young person has been using. In the two most successful cases I presented, use had been nearly daily over several months.

When parents are relatively contactful, accurately perceiving the nature of their child’s difficulty and taking definitive actions, including consulting with a therapist if needed, the outcome is more quickly and clearly a positive one, even despite a serious degree of substance abuse by their child. However, when the parents are lacking awareness of their child’s healthy needs, and lost in denial, substitute contact and gratifications, their child is likely to be lost in a similar manner. The progression of the substance abuse problem is nearly certain to worsen, often to a dangerous degree, along with serious compromise of the adolescent’s development. In this case, due to the effects of marijuana, therapy is limited in scope and significance until use of the drug has stopped altogether.

To the extent parents cannot act authoritatively, there is little hope therapy can help, or the patient will even engage in the therapeutic process, as we saw with Martha. Her parents seemed oblivious or unaware, not thinking her drug abuse mattered, and thus their contactless parental responses prolonged and extended the destructive effects of marijuana abuse.

Often the parents’ own problems become a deciding factor, as in the case of Bobby’s parents. If the parents can accurately perceive problems, and their contributions to the problems, progress is more likely.

Even if they are not in therapy themselves, parents have to be an active part of the treatment. Things proceed most effectively when parents are able to be clear and compassionate, firm but gentle from the start, as were Jenny and Alvaro’s parents. Here, the focus of treatment moved from the complex issues surrounding drug use and the family dynamic system, to the adolescent’s underlying troubles. By stopping drug use these teens were not yet “out of the woods,” but they were no longer hiding or lost in the woods. They are making progress finding their way. Treatment is not easy, but it is genuinely hopeful. Moreover, the parents really matter.