Book Review
Treating the Unmanageable Adolescent: A Guide to Oppositional
Defiant and Conduct Disorders
by Neil Bernstein; 1996, Northvail, New Jersey, Jason Aronson, Inc.
Reviewed by Alvin I. Gerstein, Ph.D.
This 300+ page book reads almost like a novel. Once you pick it up you find yourself avidly reading about complex treatment situations, diagnostic issues, and theoretical formulations in a rapid, smooth flowing fashion with little need to sit and ponder the meaning of each sentence. In essence, this is an exceptionally clearly written book presenting complex issues in a straight forward fashion with many examples and vignettes to concretize the concepts being addressed. Along with such clarity the author writes with humor, verve, and vivacity. He discusses a patient population which can vex the practitioner, but nevertheless, is one with which he seems intimately familiar, and at ease, and about which he is very much concerned.
The book starts off with a brief, but very practical formulation of disruptive behavior disorders mentioning many of the co-morbid factors such as attention deficit disorder, learning disability, organic dysfunction and family dysfunction, that are frequently found in such conditions. Although this book is geared almost exclusively to describing the use of various psychotherapies, the author does mention, in passing, the use of psychotropic medications. Following the description of the typical unmanageable adolescent, the author systematically takes us through the process of creating a therapeutic alliance with an individual who feels no need to change, defusing the resistance to change, and ultimately entering the treatment phase. Treatment can include individual, family, or group therapy techniques, specialty programs such as Outward Bound, or focused activity groups. Bernstein addresses at great length the limitations such patients present to therapists, such as, poor self control, limited interpersonal skill development, low self esteem, inadequate development of empathy and morality, poor school performance, and the failure to see a need for change.
Bernstein presents separate chapters on the need for confrontation and limit setting, and constructive ways to do so. Given the fact that these patients can test the best of us, it is well that he gives so much attention to confrontation and the need to avoid being either too provocative or too passive or permissive. Vignettes demonstrating limit setting abound and stimulate the reader to review his/her own treatment approach with such patients.
Much attention is given to therapist variables and attributes. A therapist who hopes to be effective with such a patient population must maintain a balance between authoritative and tolerant stances. He/she must have a sense of humor, must be willing to engage appropriately in self-disclosure, must have an active and genuine interest in adolescent culture and finally, must be thick-skinned, always keeping the long term goals of therapy in mind.
Considerable time is also spent on the need for development of trust, especially through self-disclosure, a topic that is rarely accorded the importance it deserves. Bernstein encourages a straightforward and proactive way of dealing with conspicuous therapist attributes such as a speech impediment, pregnancy, surgery. Of all the issues in therapy which are most typically ignored, boredom of the therapist heads the list. An excellent vignette was presented showing how this could be constructively handled with the patient.
Anyone working with this population would find great value in becoming acquainted with Bernstein's extensive work on the development of interpersonal skills. The author presents his own thoughtful training program which relies heavily upon modeling, lavish reward, and limit setting.
The theoretical thrust of this book is heavily cognitive behavioral with a family orientation, and relies on behavior modification. It is clear that this approach is based upon outcome data presented in the literature review. The orientation to the cognitive behavioral model seems driven by the fact that there is more empirical outcome data on the effectiveness of this approach in contrast to psychodynamic formulations which have been traditionally evaluated anecdotally. An extensive up-to-date literature review is included in this book.
One negative feature of the book is the relative absence of interest in psychodynamic theory and approaches. This decision seems justified in light of the author's desire to focus upon those approaches which have outcome data as to their effectiveness. More significant, however, is the failure to mention the treatment of co-morbid conditions involving organic features. None of the vignettes addressed this. However, a seasoned clinician will recognize that the stated emphasis on structuring, setting of limits, and reducing the difficult social situations to smaller behavioral bits is equally important in dealing with people with or without learning disorders or other organic conditions. What is missing, therefore, does not reside in the treatment approach as such, but in the author's failure to incorporate "organic" issues in his understanding of the adolescent.
In sum, we have a "how to" book with a solid grounding in theory derived from proven practice. It is laced with vignettes that stimulate the reader to reflect on his/her own experience with this type of population and provides a solid grounding for the clinician to this population. It addresses many of the unspoken topics that seasoned clinicians are aware of but rarely discuss, for example, boredom, as well as other countertransference issues, and clarifies the importance of therapist variables. In so doing, the author makes it clear what types of people should avoid this population. In truth, the statement, "A guide," appearing in the title, aptly describes this book. Yet it is far more than that in the richness of the treating experiences and vividness of the description. The library of every mental health practitioner who deals with this population should include this book. You can be assured that it will not gather dust.