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Working with teenagers in an inpatient

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thought and practice.
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Working with teenagers in an inpatient hospitalization. A

systemic look in nursing thought and practice.
Bletsos Constantinos1

Psychologist-Nurse. Adolescent Inpatient Care Unit (AICU), Dpt of Child and

Adolescent Psychiatry, Sismanogleio- Am Fleming General Hospital, Athens Greece.

Acknowledge

Special thanks to Emmanouel Anagnostopoulos for his kindly offer to translate this
article in English

Summary

Systemic thinking has caused a revolution in clinical practice, through the paradigm shift
(Kuhn, 2000), from the individual and internal medicine, in relationships and broader social
networks. The application of systemic belief in the working environment of

Adolescent

Psychiatric Inpatient Care Unit (AICU) provided the opportunity for the fullest consideration of
the therapeutic reality, offering interesting cases and reflections on the interaction between
young people and the health care team members. Alongside, the systemic practice offered the
tools and techniques for the theoretical application in everyday clinical practice.

Introduction
According to the first order cybernetics, the patient/ therapist system is perceived as a
given objective, which can be studied, separated and manipulated. On the other hand second
order cybernetics perceives the relationship as an inseparable system, as a therapeutic process
the outcome of which depends on the quality of interaction (Heylighen, 2001). The concept of
autopoiesis, introduced by Maturana & Varela (1987), provides the operational autonomy for the
systems and therefore renders problematic the notion of therapeutic guidance. From the moment
that both the therapist and patient are perceived as subsystems of the undivided therapeutic
system, reductionist guidance / non-guiding separation is considered as a devoid essential. Thus
we do not speak of the possibility of a system that can affect another autonomous system, but for
a new treaty that is determined by the therapeutic relationship and defined by the context in
which social events evolve (in our case the nursing facility).
In this sense, therapy is a meta-condition (a higher level condition) co-construction of
meaning (Bruner, 1990), with the use of language as a basic taxonomy and mediation of complex
communicational processes (Watzlawick et.al, 2011).

Based on the above sayings the therapist is not perceived only as a guide, but also as a
companion that when conditions require guides or treads along or follows the teenager in the
recovery path. The purpose of treatment is not so much a guide as to invent together how to build
roads.
Nurses accompany teenage identifications sometimes as alternative parenting models, or
as authentic substitutes for physical absences or even as transitional objects of teenage
compulsions. The therapist and the patient work together to build a therapeutic -via speechreality. This translates as a dispute towards power, which was the result of the different
knowledge possession (Foucault, 1980), as well as a shifting of the therapist from a knowledge
position to a curiosity position and ultimately a irreverence2 position against the predetermined
shapes of knowledge and practice (Cecchin, 1992)
The old, embedded and in a vast degree functional shapes (of direction and control) are
naturally dominant. 3However, it is now more open to post review and revision momentum. The
change of position (and viewing) allows evaluation of attitudes not-exclusive-as a linear result of
basic and unvarying personality attributes, but mainly as a result of cyclical relations of
interaction between individuals (Selvini et.al, 1980).
Although this perspective is "narcissistic blow" in the complacent therapeutic
omnipotence, it can affect the merciful dynamic balance system, to the degree that allows a self
reflexive consideration -if possible-free from myths of causal explanations. Self (Tsekeris,2010),
is rather reflectively recreated, necessarily intertwined with the ' real world ' and dialectic

Of course, as Cecchin warns us in order for us to be disrespectful towards a theory we

should first know it very well.

We must not forget that from an institutional standpoint, the nursing team doesn't work
based on the political and institutional gap but within the larger physician centred health model
specified by the political requirements of the statutory organs of the State (Government,
Department of Health, Hospital Administration, etc).

reassembled through continuous, reciprocal and synergetic (chaotic) self-organized interaction of

the ego with:
1. The emerging of the social structures.
2. With the significant others (real, imaginary, or implied).
With the above, it is understood that the systemic thinking and practice does not replace
other opposites, it expands previous models, suggesting new ways of flexible consideration of
therapeutic reality, in which the behavior is not a result of static characteristics of personality,
but the complex and interactive relationship with the Person and the context.
The theory of complexity refers to systems that exhibit complex, universal behaviors as
a result of local interaction of components, or factors that constitute and whose behavior is
determined with relatively simple rules (Cohen & Stewart, 1994).
In a static, homeostatic" world, therapists can agree to observe, to interpret, to classify
on the basis of prefabricated shapes describing how must the "normal" teen be. While possessing
the ability to determine the degree of divergence of specific adolescent than the norm, the
therapists can easily suggest ways for restoring balance.
Contrary in the fluidity of complexity, there is no way to know how the normal
teenager must be. What we do know is that we must remain available and curious to understand
the distinct reality of each teenager. We (nurses), with our knowledge and our values, operate as
prototypes of possible options and not as knowledgeable of the sole road for each "truth." With
the use of collaborative dialogues as an invitation for an eventual path towards change while
maintaining therapeutic responsibility as a guide to protect from arbitrary interpretations and
abusive practices. This condition protects the therapeutic relationship from the risk of extreme

arbitrariness 4 where all versions are just as good as the others, without at the same time allowing
the effortless return to the past simplified "knowledge".
According to Anderson (2013), a cooperative dialogue is a communicative process that
has the following characteristics:
It is a natural, spontaneous activity that takes place each time.
It includes the collaborative design, which requires an invitation, the learning and the
respect of the other person's experience.
Each dialogue is only for attendees, situations, circumstances and the daily layout.
Differences, such as the intensity, clarity, uncertainty etc are necessary for a productive
dialogue.

The dialogue is multidimensional.

Each meeting discussion and relationship is part of the past, present, and future of the
participants.

The dialogue implies of a multiplicity of voices, present and absent.

The context is the backdrop for the debate: The historical, cultural, organizational and
relational context.

As stated by Schweitzer & Schlippe (2008), in the treatment reduction there is the risk of
arbitrariness and the (subsequent) deficiency in discussion (p. 99).

 The cooperative dialogue premises:

To talk, to listen and to respond.

The full confidence and ability to be open to the opinions and diversity of others.

Not to assume that you know what the other person means, not to fill in the gaps or
the elements of the story of another person that you think is behind the story.

Check to make sure that you understand the other persons perspective as best you
can. Understanding does not mean agreement.

Time for internal and external debate.

Time for interior and exterior reflections.

The use of pauses and silences provide opportunities for reflection, internal debate
and preparation for speech.

Thus we suggest that within the framework of the cooperative dialogue, the use of
alternative explanative shapes and to look for differences, exclusions, and twists that
could cause a first-and minimal yet-crack in the concrete wall of the narratives of the
disorder.

Application of systemic ideas into everyday practice

In every organization there are two channels of communication flows. The formal and
the informal. The formal is expressed by the official organizational chart and its institutional
roles of people (Patient, Physician, Psychologist, Nurse, Head, Subordinate) and unofficial that
specifying the informal communications among members. According to the et.al Allen, (2007),
the informal network of communication is most important for the formulation of the dynamics
within the organization.
Taking the above into consideration, we believe that the transformation of informal into
formal communication helps to manage emotional reactions and impulsive operations, it gives
voice to negative feelings, it satisfies the sense of law, it demystifies, and dedramatizes reactions,
it clarifies misunderstandings and above all it recognizes the teenager patient as person, in
accordance with Rogers (2012) philosophy.
From the very beginning of the operation of AICU working in small groups is used
widely in the therapeutic process. Teen group meetings are created for crisis response
procedures, for expressing emotions and for conflict resolutions.
There is no clear structure in these group meetings5. In addition to the basic rules of
decent social interaction, there are no specific procedures, strict targeting, typical or essential
programming, nor of course challenging and exclusion procedures. Everyone is free to join or to
withdraw from these group meetings at any time they wish in a completely voluntary basis, even
during the session. Even so, the basic element in the standard treatment group context, changes
when and if circumstances so require. Group meetings have taken place in the
Multipurpose(recreational) room, in the nurses office, in Head Nurses office, in the dining area,
in the children's rooms, in the courtyard, day or night, with 2 or 10 kids where and when the
needs require.

The adolescent group meetings are not therapeutic teams with the standard meaning of
the term. They are consider more opportunities for conciliation and interaction based on the here
and now, in other words in the everyday reality that the border sets. Of course in the daily
operation of AICU there are formal groups e.g. focus groups.

We believe in the direct use of the small ad hoc group as an effective conflict resolution
and regulating emotions mechanism. In its core it is as if there is a potential group meeting that
runs so without schedule from the very beginning of the unit operation. The only thing that
changes (or Is what remains permanent?) is the constant rotation of members, in a never-ending
apposition of narratives and persons who concoct the thread of Ariadne in the space-time
continuum, creating a sense of intimacy and safety even for the most isolated social group
members.
The adolescent narratives6 are followed by silences. The support glances are alternated
with interjections, the emotions are shifted, and the long-past silenced voices emerge in
consciousness. In this way the silence of the mental disease is abolished, it liquidates the ultimate
dysfunctional reality and ultimately it becomes a more manageable weight of psychic pain. This
reframing7 process allows "safe" approach even to the deepest wound8 as it clothes with reason
even the most intimate and repressed experience, that of nakedness and sexual abuse. All this in
an environment of safety and empathetic understanding which is promoted through the following
mechanisms:
The acceptance of the teenager as who he/she is (Rogers, 1995).
Absolute freedom to express thoughts and emotions, even the most judgmental for
the treatment group.

Bulimia in any instance can be a lifeline in the deep sea of emotional emptiness

During an adolescent team meeting, one of the girls reported obvious feelings of shame
and guilt for her arrest for prostitution outside of the Omonoia Police Department. The
Coordinator reframed the incident saying that "Only a deeply moral person like you would
choose to hustle the corner outside a police station".
8

Although coordinators try of course to focus discussions on the here and now and the
relationships amongst adolescents

 The non-judgemental attitude.

Of the self-disclosure.
On the other hand the reflective speech of the therapeutic group. The explanation, the
experience, the example, the apology for any wrong practices and the healing power of
forgiveness. Yalom (1983), believes that the groups, within the hospital, have a time duration as
a session. For us there seems to be a continuous group since the beginning of operation of the
AICU.
The concept of circular causation, a momentous meaning of the systemic thinking
allows us to move away from the unproductive game of recriminations and conflict. The
relationship is not linear, it gets co- constructed in (concentrated)9 the hospitalization period and
unreel spirally in space/time. The fundamental skill of empathy becomes an objective for
process, like the disclosure of individual responsibility for the relational gaps in the here and
now of every teenagers life.
The coordinator of group meetings will look at the differences that make a difference
(Bateson, 1972). He / She will try to harvest information from a dataset, he/she will find the
different perspectives of teenagers, he/she will try to synthesize the different voices of the group,
he/she will look for exceptions, the cracks in the robust telling of the disease. The purpose here is
to highlight a reason for yesterday, the recasting of history of pain, the staple of mnemonic gaps,

Dense in sense of disproportionate burdened communicational messages and emotions,

in respect to a normal teenager's life.

providing hope and of course the consolidation of a sense of continuity for adolescents suffering
from unbearable lack of meaning10.
The concept of scapegoat helps us observe with critical look towards our preferences in
taxonomies, classifications, on the axis of DSM 211. What are the reasons that some children are
more engaging than others? How come, to some teenagers, we are available for more
concessions and greater tolerance? Are beauty and intelligence as a Halo phenomenon (Nisbett
& Wilson , 1977), able to blur our judgment? Are the tragic stories of some children the reason?
Is it that they look like us? Is that we share with them common fate?
What is the nurses role in all this? The systemic wisdom tells us that when we see a
child, deep down inside, our stories meet. Voices of our significant others inside our heads. Our
own wounds and our own gaps. The dead ends that we have experienced, the solutions we gave,
choices and errors in which we might have fallen into.
Our actions have, of course, a multitude of effects. We develop special relationships with
some children, we become their person of reference, but we do not cease to be members of the
treatment team. Our presence is completed at the end of our eight hour shift, but the child will
naturally continue to stay, even after our departure. 12

10

A particularly useful exercise for groups of teenagers is the Tree of Life, which comes
from the Narrative School. The Tree of Life has been used successfully in the treatment of
childhood trauma in particularly hard and violent environments (e.g. wars, pandemics and AIDS)
... more about the Tree of life can be found on the following hyperlink
http://dulwichcentre.com.au/the-tree-of-life/

11

12

Axis 2 of DSM includes personality disorders.

Based on the perspective of the Person of Reference, I had once developed a special
relationship with a "difficult" child who felt so safe with my presence alone, that he slept
peacefully when I worked the night shift. I considered my presence therapeutic for the child and
highly productive for the placement. Not much time went by for the living hell that the child was

Naturally AICU, like any similar organization, is based on the basic dictates of
Behaviorism (reward, punishment, operational learning etc.) in an effort to put under control the
deviant behaviors. Behaviorism has some advantages, which are important in clinical treatment
of acute incidents. The main advantage is that it acts effectively in a short period. On the other
hand, modern developments of psychoneurology 13 disputes much of what we take for granted.
The "difficult" children aren't necessarily "difficult" because they want to be, but because they
cannot act otherwise. The brain is not able to correctly perform the complex task of emotional
regulation, resulting in a reduced ability of social interaction. The comforting here is that the
brain has the ability to learn a new ways of interaction, using the mechanism of neuroplasticity 14
(Rakic, 2002).
What is needed is to give voice to the teenagers actions of imulsivity and after to help
them gain problem solving skills (Green, 2008).
The phenomenon of revolving door (Haywood et.al, 1995), frequent re-admitted
incidents and the frequent adjustment difficulties of the adolescents in other environments
15

brings skepticism towards how rewards and punishments are likely to cause substantial and

long-term sustainable change in the lives of teenagers. Most children who are hospitalized in
AICU have suffered in the past a number of reprimands and punishments from different contexts
going through (as well as my colleagues), when I was not working, to be discover. All nurses
have similar stories to tell based on their experiences.
13

For example we finally know that human behavior is formed in the prefrontal cortex and
that many of our adolescents belong in Clinical classifications (ADHD, ODD, PTSD) showing
deficits in normal development and functionality in the according brain area.
14

The neuroplasticity refers to the ability of the brain to recreate nerve synapses and to
restore functionality.
15

For example the return home or school after being discharged.

(home, school, legal system) with rather poor results in changing the behavior. The specific
teenagers seem to have acquired immunity to punishments (Lewis, 2015).

Construction of meaning
Life of course could contain its meaning. Faith helps in that sense. The belief in the
indestructibility of soul, the belief in the afterlife and their heavenly vindication. Christians
believe that all these exist. But not here and not now. In contrast the existentialist philosophers
such as Nietzsche, and Kierkegaard, (McDonald, 2005), do not believe that life has any
substantive meaning (May, 1961). The meaning, is in accordance with their own writings, is a
personal responsibility and a duty. The meaning is what every one of us attaches to his life.
The important things, the meaningful relationships, values, ideals, dreams and hopes. The
signs pointing straight ahead and back in time. Coming from the past as invisible threads that
bind us to our ancestors. Myths and narratives of family history, ghosts and shadows, happy and
sad moments of distant and remote, through narratives, names, name of locality and maps,
formed into shapes and attitudes that give the person a sense of continuity and competence.
Sometimes, however, is some traumatic events in childhood, that cause rupture and
discontinuity, which spread to the four points of the soul, towards any notion of trust and
security.
"Nothing is as it was before. What would fill the existence with love and certainty is now an
intolerable source of pain, anxiety and abandonment
In sequence the desperate attempt to survive follows the child. That necessarily will limit
the complexity of emotions to the basics that reach the primordial emotions of the body. An
attempt of integration on what is remained after the fragmentation and disintegration. The child
clams up so it will not strew in psychosis. Freezes internally to keep in check a bleeding wound.
And the void, the absence of internal objects (Matsa, 2008), hovering inside. The chasm which

swallows insatiable the meanings, the important and influential of life, do not find somewhere to
click and crumble endlessly. This is the cost for this unbelievable pain of memory not to be lived
again (Miller, 2003).
So slowly but surely the child stops feeling so he/ or she does not remember, causes pain
so as to feel, it seeks upon destruction to pretend that that she/he exists, she/he uses consolations
to warm up, he/she tries to kill himself or herself to remember (and to remind!) that only the
living have such an option.
The vast majority of children hospitalized in have a traumatic childhood and teenaged
years. Sexual abuse in particular, is causing a number of negative impacts on children.
Permanently it injures the body and soul and leaves persistent scars in time and treatment.
Particularly the sexual abuse that is performed within the family brings the maximum negative
impact, to the extent that undermines the destruction in sense of security and confidence, basic
characteristics for healthy relationships. The child to cope with the pain and confusion builds
cognitive schemes that describe itself with the darkest colors of obsolescence, of self-blame, of
shame and anger:
Dad is good, for him to do what he did to me, it is my fault.
I'm not worthy to be loved
Relationships hurt
If I trust, I would get exploited
These shapes are, descendants of the bipolar childhood thinking but also of the need for
survival in a harsh environment, get conditioned as they follow the path to adulthood. All sorts of
relationships (friendly, erotic, professional) get crowded within this narrow- emotionless -mold.
Pervasive eroticism, seduction, manipulative maneuvers, dramatization, obsolescence and
idealization, all in service of a single emergency, to confirm the basic shapes of the selfworthlessness.

The interactions is not a matter of choice in this case. The child will connect in the only
way he/she learned in the abusive environment that he/she grew in. This convinces him or her
that he/she is unworthy, diabolical, that has a dark and cunning piece that lives to punish. He/she
is now certain that came to life to destroy and be destroyed. With the above behavior he/she will
be properly adjusted so that, as a self-fulfilling prophecy, sooner or later will cause the maximum
fear. Loneliness and abandonment.
In this way, the other person is not invited in the child's life as a companion, friend or
classmate, but as a spectator to the tragedy of fragmented existence. He/she does not become a
helper and a companion, but a sea wall of emotions, grief, envy, object of lust, of worship, of
hatred, of idealization and of devaluation. Every so often the nursing group becomes the object
of these archaic associations. Sometimes as an idealized mother, and sometimes as a deadly
Medusa, as partial symbol and as a Chimerian figure of an internal world separated into two. Just
the way the primary object was split.
Relations are treated, often in terms of endurance and distance. How much will you last
next to me? If you're near me I'm in pain and if go away I'm afraid! As a result the deep
existential pain of rejection continuously gets ignited by the weakness for relationships with
emotional attachment and substance. In the deep pain of abuse is added and the daily pain of the
lack of meaning. And a drop, a large or small from the daily routine is needed for the glass to
overflow. Then the pain becomes unbearable as he/she explodes with violence against the
unworthy self (Gustafson, 1986). Self-injuries, risky behaviors, suicide attempts. And death still
seems not so obnoxious, at least not more than an abiotic life (Linehan, 1999). Treatment at this
stage, is not given verbally. It's more treated by:
I'm here for you and I am able to bear your own pain and my fear of liability.
I do not judge, behind what you are doing (which is understandable under the circumstances)
there is a wounded soul who needs care. The words and the technicalities-can wait.
In this critical phase the care of the nursing team is priceless. The warmth of a hug, care
and grooming, the mirroring of emotions, the containment. The containment is defined as
placing a limit around an experience or feeling. The experience or feeling is subject to

management or refusal, it could be maintained or passed on, and it could be experienced or

avoided, so that their results could be alleviated or strengthened. Bion (1970), describes the
relationship between the content and the container, indicating that the container could act as
either a filter or a sponge, to manage difficult feelings, or it could become a rigid frame that
prevents or limits thus making the content which may be experienced as a threat or as
salvation.
The Nursing team has the heavy load of becoming the object of teenage impulsions, often
acting as a lightning rod for the overwhelming negative feelings. The good enough mother,
according to Winnicott (1960), is able and willing to endure in her "hug" (holding) the whole
destructiveness and hatred towards the child's primary object (symbolically the female breast). In
this way the nursing team is the metabolite of painful feelings by preventing the onset of the
acting out.
With the above processes hospitalization becomes for the teenagers, a significant
restorative experience, meeting with the other person and identifying with better standards. The
ultimate goal of nursing intervention is to help adolescents to become competent for real
meaningful relationships, through the practical assurance that they deserve love and acceptance.
As aptly phrased by Paris (2008), People can't find a love that lasts, or a good person until they
feel that they deserve to be loved ".

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