Adolescent dysphoria, sexual behavior and spirituality.

Adolescent behavior and mental health have increasingly become matters of public concern. While the biologic aspects of depression were recently emphasized, the etiology of affective disorder in adolescence remains multifactorial. Most models suggest that depressive states develop when a (genetically) vulnerable individual encounters a social stressor (eg, an abusive relationship). (1)

The relationship between adolescent sexual behavior and affective states is receiving increased attention in the literature. For some time, clinicians have recognized that dysphoric youth engage in high risk behaviors, specifically substance abuse and early sexual activity. In some youth, these behaviors seem to ward off unpleasant affects. However, a growing body of research is suggesting a contrasting view: early sexual behavior may predispose youth to depression. (2) An analysis of these complex relationships is beyond the scope of this paper. It is clear, however, that a clinical presentation of adolescent depression necessitates a review of the adolescent's sexual behavior.

In addition, since the family is the primary context for all development, adolescent depression requires a careful assessment of family functioning. Current literature focuses on the attachment of parent to child and, particularly in adolescence, to the adolescent's emerging independence. (3)

Therefore, a clinician assessing a dysphoric adolescent must consider both sexuality and family. Children learn from parents about sexuality either directly through instruction or indirectly through observation of parental interaction. Parents' spiritual perspective or worldview clearly influences attitudes toward sexuality. (4)

With respect to sexual behavior associated with adolescent depression, spirituality may serve as either a protective factor or as a risk factor. Early sexual behavior is universally seen as a risk factor in adolescent health. (5) Spiritual and religious involvement of the adolescent and the family are associated with delaying sexual intercourse. (6,7) Research has found a positive correlation between spirituality/religiousness and a family environment with a high degree of marital commitment and stability, seen as conferring mental health benefits to children and adolescents. (8) Spirituality can also model forgiveness for sexual and other transgressions, a component in healing that is increasingly recognized in secular settings. (9)

Religious and spiritual perspectives can also serve as a risk factor when developmentally normal adolescent sexual urges are not respected and openly discussed. Spiritually based codes of sexual behavior may cease to provide a healthy structure and become harsh and rigid when implemented by an emotionally distant family.

The following two cases illustrate both the presence and the absence of spirituality as a clinical risk factor.

Patient 1

Amanda, a 16-year-old, tenth grade student and an only child, was admitted to a psychiatric hospital after an ingestion of eight pills of the antidepressant sertraline. After stabilization, she was referred for outpatient treatment, including psychotherapy. Her depressive symptoms had begun several months earlier, with decreased school performance and mild insomnia as the primary symptoms. Her hospitalization was triggered when her mother found a note from her boyfriend, Colin, which made reference to increasingly intimate behavior between the two. Amanda's religiously devout parents were significantly distressed when they confronted her. They restricted her from seeing the boy and, as one way to monitor her behavior, her mother began to surreptitiously read her daily diary.

Therapy was intense and involved numerous early interchanges during which trust was a constant theme. Her parents were convinced that she had had sexual intercourse with Colin, something Amanda vehemently denied. Over a several year course of therapy, Amanda resisted the family's religiously based conservatism, which included a subservient view of women that angered Amanda. Her parents attempted to control Amanda's friendships with those who did not share their own religious beliefs. Over time, they reached compromises. Amanda told her parents that she believed in God but primarily had problems with organized religions. The family allowed her to attend another church, comfortable that "at least she was going." Amanda became more respectful of her parents. She continued to try to see Colin and was angered at her father's hypocrisy: when she wanted to invite Colin to church, and her father did not allow her to do so, she wondered, "Isn't that what the church is for--to reach out to people?"

In this case, the family's religious rigidity appeared to provoke a negative reaction against organized religion. The spirituality that her parents represented seemed to worsen her depression, to the point of desperation and attempted suicide. The therapist had to carefully monitor the influence of spirituality in treating Amanda's depression.

Patient 2

Derek, a 16-year-old, tenth grade student, the second of four children, was referred by his pediatrician to a child and adolescent psychiatrist for evaluation of anger, depression and impulsivity. He had no previous psychiatric history, apart from being treated for attention difficulties as a young boy. He was sexually intimate with his girlfriend, although they had not had intercourse. Derek described her as someone whom he "could never live without."

In the first several sessions, Derek related a troubled relationship with his father. As he described the father's constant criticism, he shared his rage toward his father for having an ongoing affair with a woman for whom his sister was employed as a babysitter. While his parents remained together, his father remained unrepentant for his behavior. At the time of initial evaluation, Derek described routinely calling his father to inquire regarding his whereabouts if he did not arrive home at an expected time. He related to the therapist that from the ages of 9 years to 11 years, he had harbored the secret of the affair and painfully related the burden of anxiety that accompanied this knowledge. Derek shared with the therapist that he would not tolerate his father ever hurting his mother again. As a concomitant, he acknowledged that it was difficult for him to trust his girlfriend and her fidelity to him.

This nominally religious family had no prior psychiatric history. Derek's anger and dysphoria seemed powerfully influenced by his knowledge that his father had never asked his mother for forgiveness. He was also plagued with insecurity in his own dating relationship, seemingly influenced by his parents' troubled marriage. In addition to relationship dynamics, Derek seemed deeply troubled by his father's lack of reconciliation toward his mother. In this instance, the absence of a religious/spiritual source of coping, such as reconciliation and forgiveness, seemed most troubling to Derek.

In Amanda's case, her parents' religiously mediated impulse to provide a safe structure for the modulation of her adolescent sexuality became overly rigid and provoked her depression and resistance to change. In Derek's case, his depression seemed powerfully influenced by parental sexual behavior which subsequently influenced his dating relationship. The protective functions of spirituality, such as living by a higher standard, acknowledging one's moral failures and seeking forgiveness, were absent.

What are the implications for the busy clinician? By asking relevant questions, the physician underscores the importance of the spiritual component of care. This indicates to the patient and to the family that open dialogue about problematic aspects of spirituality is possible and suggests the potential for utilizing spiritual resources.

Adolescent depressive symptoms necessitate inquiry regarding sexual behavior and family relationships. This inevitably leads to a consideration of the family's spiritual perspective, or worldview. This perspective may be part of the problem, as in Amanda's case, or a needed resource as in Derek's case. While confidentiality of the adolescent must be respected, the clinician should promote needed dialogue with parents about sexual behaviors which have the potential for life-changing consequences (eg, pregnancy, sexually transmitted disease). The therapist's own religious or antireligious attitudes must not prevent such interaction between parents and adolescent.

In Amanda's case, the clinician could allow her to express concerns about parental restrictions while supporting her parents' adherence to their own worldview and expectations for Amanda's sexual behavior. A brief exploration of the reasons for mutual mistrust would also be helpful, since they seem to reflect differing perspectives on how the parents should fairly and respectfully address concerns rather than differences over core spiritual beliefs.

A clinician treating Derek would want to openly acknowledge his demoralization and longing for integrity in his father. The clinician would also want to help Derek to consider his models for living, and how he might better relate to women: "Has he seen examples of behavior that he admires?" "Where does he hope to find ideals that he can live by?" These are questions that require spiritual answers. Although the clinician needs to respect the confidentiality of this adolescent patient, he also should consider encouraging Derek to express his wish that his father be a role model for his family. If interest is expressed, the clinician even could offer to help the father with this challenge.

Both of these cases were appropriately referred for mental health treatment because of their complex family dynamics and significant parental emotional needs. Mental health clinicians in such cases should address spiritual issues as they arise, and consult with clergy if unsure how to best help patients meet their clinically important spiritual needs. (10)

References

1. Shaffer D, Waslick BD. The Many Faces of Depression in Children and Adolescents. Washington, DC, American Psychiatric Publishing, 2002.

2. Hallfors D, Waller M, Bauer D, et al. Which comes first in adolescence-sex and drugs or depression? Am J Prev Med 2005;29:163-170.

3. Sexson SB, Glanville DN, Kaslow NJ. Attachment and depression. Implications for family therapy. Child Adolesc Psychiatr Clin N Am 2001;10:465-486.

4. Josephson AM, Peteet JR (eds). Handbook of Spirituality and Worldview in Clinical Practice. Washington, DC, American Psychiatric Publishing, 2004.

5. Albert B, Brown S, Flanigan C: Fourteen and Younger: The Sexual Behavior of Young Adolescents. Washington, DC, National Campaign to Prevent Teen Pregnancy, 2003.

6. Weaver AJ, Samford JA, Morgan V, et al. Research on religious variables in five major adolescent research journals: 1992 to 1996. J Nerv Ment Dis 2000;188:36-44.

7. Mabe PA, Josephson AM. Child and adolescent psychopathology: spiritual and religious perspectives. Child Adolesc Psychiatr Clin N Am 2004;13:111-125.

8. Murstein BI, Mercy T. Sex, drugs, relationships, contraception, and fears of disease on a college campus over 17 years. Adolescence 1994;29:303-322.

9. McCullough ME, Pargament KI, Thoresen CE. Forgiveness: Theory, Research, and Practice. New York, Guilford Press, 2000.

10. Peteet JR. Approaching spiritual problems in psychotherapy: A conceptual framework. J Psychother Pract Res 1994;3:237-245.

Allan M. Josephson, MD, Christopher K. Peters, MD, and Mary Lynn Dell, MD, MTS, ThM

From the Division of Child and Adolescent Psychiatry, Department of Psychiatry and Behavioral Sciences, University of Louisville, Louisville, KY and the Department of Psychiatry, Emory University, Atlanta, GA.

Reprint requests to Allan M. Josephson, MD, University of Louisville School of Medicine, 200 E. Chestnut Street, Louisville, KY. Email: [e-mail]