Tips and techniques for engaging and managing the reluctant, resistant or hostile young person

Louise K McCutcheon, Andrew M Chanen, Richard J Fraser, Lorelle Drew and Warrick Brewer
Med J Aust 2007; 187 (7): S64. || doi: 10.5694/j.1326-5377.2007.tb01341.x
Published online: 1 October 2007

Assessment of most mental health problems in primary care is undertaken opportunistically.1 Here, we discuss some of the challenges to engaging and treating young people, and suggest strategies to manage difficulties in the doctor–patient relationship.


Normal adolescent development is characterised by significant increases in novelty-seeking, risk-taking and peer-directed social interactions, which foster the development of adult independence.2 However, these changes occur more rapidly than the development of executive and regulatory skills, leading to a developmentally normal mismatch between fundamental drives and self-regulatory skills.3 This might manifest as behavioural problems, or as difficulties expressing thoughts and feelings, taking another’s point of view or anticipating the consequences of one’s actions.

From this perspective, most young people are usually doing the best that they can to manage and are not deliberately trying to be difficult, manipulative, or challenging to assess and treat. Adopting this non-blaming approach allows the clinician to keep an open mind about the young person’s reasons for presenting, assume a cooperative stance, and avoid being controlling, authoritarian or punitive (Box 1). Young people usually want to be treated as if they are able to make decisions for themselves, but some struggle with asking for assistance, or reject help when it is offered, even when a situation feels wildly out of control.

Potential threats to engagement
Family involvement

A young person’s relationship with his or her family will vary considerably with age, living arrangements, cultural expectations, and the degree of autonomy and closeness within the family. The extent of involvement of family and important others in a patient’s care should reflect individual circumstances and wishes. While involving parents is clearly important and desirable, evidence for any benefit from mandatory parental involvement is lacking.6 The law recognises the rights of “mature minors” to make decisions about their medical treatment and to receive confidential health care.6 Treating a young person without parental involvement might become necessary when family members are opposed to the patient’s wishes or are likely to undermine effective treatments (to which the young person is able to give informed consent). Moreover, mental health problems (in the young person and/or his or her parent[s]) might affect the presentation and engagement of young people or family members.

Try to establish early in the course of treatment what the young person prefers and whether there are specific reasons for not wanting family involvement, such as stigma, shame, or previous adverse clinical experiences. It is often helpful to describe the pitfalls of not involving the family, such as lack of support or the likelihood of poor medication adherence if a young person needs to conceal his or her medication. In such cases, clearly document your assessment of the young person’s capacity to give informed consent. Family involvement might vary over time, and initial refusal to include family members might be revised at a later date, especially when issues of stigma or shame have been addressed.


Sanci and colleagues1,6 have comprehensively discussed confidentiality in relation to young people, including its application to mental health problems. In practice, confidentiality needs to be discussed at the outset of any consultation. If family or carers are involved, this should be done (or reiterated) in their presence. This should also include an explanation of the limits to confidentiality, and family members or carers should be reassured that ensuring the patient’s safety will always be paramount. Patients can also be reassured that only sufficient information to ensure their safety or that of others would ever be shared with specific others, rather than wholesale disclosure of all personal information.

The challenging patient
Actual or threatened deliberate self-harm

Deliberate self-harm (DSH; for example, self-cutting, deliberate overdose of licit or illicit substances), which is common among young people in Australia,7 is strongly associated with mental health problems8 and, when associated with the intent to die, it is the single most potent risk factor for completed youth suicide.9 It should therefore be taken seriously and a thorough risk assessment should always be performed.

Apart from the intent to die, DSH might also serve functions such as the regulation of negative affect, communication of distress, expression of emotions, or coping with dissociative states.10 The reasons for a particular incident are not always clear to the observer or even to the young person.

Young people who engage in DSH, especially repeated DSH, are often described as “attention-seeking” or “manipulative”. In fact, they are usually very ineffective manipulators, and it is the coarseness and transparency of their actions that makes them so poor at getting what they want and need. It is more helpful to consider that the young person uses such self-destructive coping strategies because they have not yet learned more appropriate and effective ones. Adopting this approach allows the clinician to empathise with the young person’s distress and to avoid feeling victimised or exploited by the patient, which only increases the likelihood of provoking a dismissive or even punitive reaction.

If DSH is assessed to be a coping strategy, treatment should assist the young person to assess the costs and benefits of this strategy and to try new ones that might be more effective or cause less harm. It is important to understand that repeated DSH is usually experienced by the young person as successful in some way. This often seems counterintuitive to clinicians, but patients can usually tell you that “it works”, at least in the short-term. It is unrewarding for clinicians to argue against this or respond in a punitive way. Patients should feel able to disclose their behaviour without feeling judged. Cost–benefit analysis or motivational interviewing4 can sometimes help to model tolerance, while exploring reasons (eg, distraction or regulation of affect) for behaviour such as DSH without condoning its use and the consequences of such strategies.

Although DSH might initially also prompt care from others, if repeated it can soon begin to elicit frustration or rejection from others and shame in the self-harmer. Sometimes, the realisation of this can prove a potent motivator for change in the patient. It is sensible to be clear about your concern for the young person’s wellbeing, and that your aim is to help the young person work towards reducing this behaviour and developing more appropriate and effective coping strategies. Provision of psychoeducation, especially about risks (eg, wound infection, potential lethality of paracetamol), is important but should not instruct patients how to harm themselves more effectively.

In general, the chronic self-harmer is unlikely to change his or her behaviour quickly. In attempting to consider how much chronic risk is acceptable, it is important to understand how the usual level of risk might have changed. Any new life event, a recent onset of a mental health problem (eg, depression), or a sudden elevation of risk or potential lethality should be taken seriously and followed by an appropriate clinical response.

1 Tips for fostering engagement with young people

  • Louise K McCutcheon1,2
  • Andrew M Chanen1,2
  • Richard J Fraser1
  • Lorelle Drew1
  • Warrick Brewer2

  • 1 ORYGEN Youth Health, Melbourne, VIC.
  • 2 ORYGEN Research Centre, University of Melbourne, Melbourne, VIC.


Competing interests:

None identified.

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  • 6. Sanci LA, Sawyer SM, Kang MS, et al. Confidential health care for adolescents: reconciling clinical evidence with family values. Med J Aust 2005; 183: 410-414. <MJA full text>
  • 7. De Leo D, Heller TS. Who are the kids who self-harm? An Australian self-report school survey. Med J Aust 2004; 181: 140-144. <MJA full text>
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  • 10. Paris J. Understanding self-mutilation in borderline personality disorder. Harv Rev Psychiatry 2005; 13: 179-185.


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