The prevalence of mental health issues among young adults remains disturbingly high. But in our profession, we find great success by referring these clients to experiential therapeutic programs.
These programs help clients develop a sense of well-being and the ability to handle challenges using positive coping mechanisms, find meaningful ways to be productive, and establish satisfying social relationships.
I interviewed several leaders in therapeutic programs to discuss their approaches for working with young adults, including Greg Burnham, MS, LMFT, program director at Gemba Gap, Boise, Idaho; Josh Altschule, PsyD, co-founder and director of Cornerstones of Maine; Josh White, MA, LPC, LCMHC, CGP, WPA, founder and executive director of Red Mountain Sedona, Arizona; and Sean Fievet, owner and founder of Cascade Crest Transitions, Bend, Oregon.
Each of these individuals defines what makes their work with young people effective in slightly different ways, yet they share an emphasis on connection and helping young people to find their own locus of control. Through their various approaches, they aim to help these young adults embrace their strengths and live in healthy ways.
Every program handles structure and expectations somewhat differently. However, programs fairly universally aspire for relationships with staff and clinicians to be a foundational force in helping participants to grow and thrive.
“Messiness”
Greg Burnham emphasizes the importance of allowing, or even fostering, “messiness” and using it to explore both the relationship with the intervenor, caregiver, or parent and the young person’s values, goals, and needs. He feels that too much externally imposed structure impedes the connection between caregiver and young adult. Instead, he strives to help participants find their own structure and their own way to a healthy life. To maintain “messiness” in the relationship between caregiver and client, he provides therapeutic and educational support regarding boundaries, rules, structure, freedom, and autonomy. To foster healthy development, he feels the intervenor must be able to ask potentially challenging questions.
Loving is not the same as developing a strong relationship because love can include imposing or going along with things that have negative effects. To develop a sustainable, positive relationship, intervenors must notice when they “get tied up in knots”—perhaps feeling withdrawn, angry, nagging, or lecturing. Efforts to change someone’s choices, for example, can lead that person to feel worse about themselves and feel guilt and shame rather than to develop healthier choices. Even advocating for something like eating fruits and vegetables, for example, can backfire; a young person with disordered eating or OCD may want to please the intervenor and at the same time not want the food.
To foster a healthy relationship with the young adult, caregivers must embrace the nuance of messiness and honor micro-changes. Structure can relax the nervous system, but it can also cause increased anxiety in the young adult. Intervenors must challenge themselves and remain aware that structure can cause relief for the wrong reasons or even create performance anxiety or OCD. It is important to work with young clients to determine on an individual-by-individual basis whether structure is helpful, and what form of structure the clients want and need to thrive. This is a slow, methodical process. Intervenors need to continually assess whether the client is involved in the process of setting structure that reflects their values—and stay open to their needs.
Attunement
Josh Altschule describes the most effective approach as that based on attunement. He feels this is one of the most essential components in supporting clients—or anyone for that matter. Attunement is based on the ability of the intervenor to set aside one’s own beliefs and initiatives and truly understand the other person. This can extend beyond listening. For example, people often refer to their “gut reaction” or “sensing something” when communicating with others. Attunement comes from being “messy” in the sense that we let go of our preconceptions and predeterminations and embrace what comes our way.
Setting limits and establishing structure is essential when creating boundaries and containment, though it can be challenging. We’ve all been in relationships and environments with too much structure, too little flexibility, and no room for anything outside of the clearly set expectations. We’ve also been in the exact opposite. Both have their place and time. How does this relate to messiness versus structure? Where does attunement come in? It’s through attunement and checking in with the client that we determine how much structure and flexibility are necessary. Like driving in highway traffic, we need to use the brake and gas, look ahead and behind, all while making sure our passengers are safe and secure.
We also want to offer the experience of mastery and ownership to the people we support. None of us are free of self-sabotaging in the name of internal control. So, intervenors sometimes need to engage in what foresters call a prescribed or controlled burn. That is, creating a safe space where those we support can own their mistakes and experience their own injuries. When this is successful, young adults can own their experiences and come to their own conclusions. They build ownership and investment in wanting something better on their own accord.
Understanding Consequences
Josh White emphasizes the importance of helping people to understand the consequences of their actions. He feels that building a relationship of understanding with the young person is a crucial foundation for this to occur.
Within a program, establishing phases through which participants progress allows them to know what to expect and get into flow. It makes it easier for participants to develop a consistent rhythm and routine, and thus to learn new habits. He also points out the difference between expectations and structure. For example, sleep hygiene and safety motivate the establishment of a curfew and the need to stay sober. Acceding to these expectations enables participants to develop new practices which become internalized. He sees attunement as the ability to empathize and notice what is going on with their students. Staff are given extensive training to help them develop this skill.
Learning Space
Sean Fievet focuses on how to facilitate clients entering and remaining in a learning space—assessing what is necessary to help people stay open, so they can eventually internalize their strengths and growth. There are different approaches to that end; he explains it as a dialectical process with opposing tensions. Connection, attunement, and structure exist together with one another. Initially, he found structure helpful in enhancing the client’s ability to learn. This exposed them to new experiences out of their comfort zone, and seemed to help them feel safe while being challenged. Staff listened to what clients tell them directly or indirectly. And clients were encouraged to see the value in what the program offered.
His approach has evolved, and now the client’s way of doing and seeing things is more tangibly honored. Structure is created according to what the clients need—scaffolding is developed to support them; attunement determines if their needs are met.
Community is another essential aspect of healing and development. Structure is used to support students’ feelings of safety with one another within the community and to foster connections. The question is: if a client is struggling with old behaviors, how much room do we have to give them to get “messy” so they can learn without it damaging others’ sense of safety? Ideally, participants connect with one another and form or join in a community; this community is then there for them to lean on later. At the same time, it is important for participants to learn how to develop and practice establishing community outside of the program, on their own.
We have thus delineated a variety of approaches, manifested in different programs—all within the framework of helping young adults to figure out who they are and to thrive in their independence. It is important that all of us do what we can to foster young adults being engaged in the world; this is both the route to and the sign of good mental health. We are fortunate to be part of a diverse community that, together, works toward strengthening the capacity of young adults.
By Cynthia Cohen, MSPH, IECA (CO), Pathway Partners