PROFILES IN COURAGE

Helping very troubled teens to cope with their problems is perhaps the toughest challenge for any therapist, but Californian New Zealander Ron Phillips has a story with many happy endings. BY PAUL LITTLE.

There are five boys assembled for the therapy session at Middlemore Hospital's Campbell Lodge in Manukau City. Three brown, two white and only a single baseball cap between them. All but one are in some form of residential care.

They attempt to sink into their chairs – a posture not exclusive to dysfunctional adolescents – as Ron Phillips, their therapist, asks them one by one how their week has been. "Nothing special" appears to be the consensus. "Pretty bad," says one.

For several weeks, Phillips has been telling these teenagers a story about a boy on a mythical journey through the Land of Confusion. In this week's episode, Regal the eagle flies the boy to the castle Splendora, where he meets Hugh, part human, part dog, part bird, and the source of all good decisions. Hugh tells him that he will soon meet Worm, the source of all bad decisions, and gives him the word "courage". The crowd in the castle, meanwhile, chant, "Create alternatives." Worm is disappointed in the boy, who has given up the angry, negative behaviour he showed early in the story. "I loved it when you did those things," Worm tells him. The boy says he won't swerve from the path to his goal.

At the start of the story, one boy's arms are folded tightly, one's head is flung back to stare at the ceiling, another's chin must be wearing a groove in his chest. During the telling, arms relax, bodies lean forward, chins are lifted. Phillips finishes the story and turns to one of the boys.

"What was the word the boy got?" A shrug.
He turns to another.
" What was the word?"
" Courage."
" How can moving your behaviour in line with your goal, and courage be the map to success?"
Another shrug. Phillips turns to another boy. "Do you have a goal?"
" Get home for Christmas."

This boy came to town from the country and quickly ended up living on the streets with a drug problem. He is in the care of Child, Youth and Family. When told that the best thing he could do for himself was spend half an hour a week talking about a story, he said, "F--- that. There isn't anything that can help me."Why don't you come once and prove me wrong, then?" challenged his counsellor six weeks ago.

"What are four things you can do to reach that goal of getting home for Christmas... one or two things?"
" Finish school."
" What if you didn't feel like it?"
" I'll just do it."

Phillips ceases to be elliptical and spells it out. "That's where courage comes in. That's moving your behaviour in line with your goal."

As the session draws to a close, Phillips says to the group, "When you're asked to do something you don't feel like, is your response predictable? I ask you to create some alternatives, because your crap behaviour will never get you where you want to go."

It's the first week of December, and Phillips asks the boys if they want to break now for Christmas or try to squeeze in one more session. They vote for one more session.

Chances are these boys will end up like many of the hundreds of children who have gone through Phillips's groups. The 12-year-old dying of anorexia who is now on a surfing tour of the world. The self mutilating Goth who is currently at law school. The glue-sniffing teen prostitute who will finish school next year. The survivor of multiple suicide attempts who is at teachers college.

Ron Phillips is close to every New Zealander's stereotyped image of a Californian. He's a big, handsome man in his early 50s, whose vowels go on forever and whose speech is peppered with "right ons" and "cosmics" guaranteed to trigger every Kiwi's innate mistrust of ebullience. Kids – and many of their parents love him.

Phillips is the originator of the cumbersomely named Therapeutic Storytelling Intervention (TSI), a form of therapy for teenagers that is achieving remarkable results with severely troubled adolescents at Campbell Lodge, in the heart of an area that has no shortage of troubled adolescents.

"Campbell Lodge is a tertiary crisis centre," says Phillips. "That means we work with the highest level of disturbance. If we can't help you, there's no place after this."

There was no eureka moment for TSI. It evolved. After "a wonderful upbringing" in San Francisco, Phillips became a teacher. Wanting to work in special education, he and his teacher wife Mary found jobs at a residential treatment facility. To his dismay, Phillips found that it was a "school for scoundrels. Kids came in and became sophisticated in deviance. We couldn't tolerate the graft and corruption, so we moved to the centre of California in 1975 and started Creative Alternatives."

This was also a residential programme for troubled teens, but its core principle was puffing kids into families. It continues to this day, with Phillips's brother in law as executive director, and currently has about 240 kids in care.

"At Creative Alternatives, we were spending an astronomical amount on outside clinicians," explains Phillips, "so the board sent me to the University of San Francisco so we could do counselling in the facility." He gained a masters in counselling and guidance and his Californian child and family counsellor licence.

"I was using the latest in group-therapy processes, but nothing was working. These kids had had multiple hospitalisations; multiple foster homes, multiple placements, and they were tumbling towards institutionalisation. I had to have staff all around [the group sessions] just to keep the kids contained. I started telling stories for survival. And when I told stories, they'd listen. I'd tell the same story to several groups a week, so when I finished, it was a good story."

The story became a book called Gem of the First Water, a sort of Pilgrim's Progress in which a troubled boy journeys through the Land of Confusion encountering characters representing the issues that all teens face, from accepting responsibility to resisting temptation to learning that they can find creative alternatives to their bad behaviour.

Phillips packed into his story as many issues as I could think of. "Once I discovered I could talk to the kids, I started throwing in the kitchen sink. I took concepts of rejection, denial, the defence mechanism, and created archetypes so we could talk about them."

The reason that it works is simple by making the discussion about the fictional boy rather than the kids in the groups, individuals don't feel singled out. Their defence mechanisms are bypassed as they think about the boy's situation and apply the conclusions to their own lives, effectively doing all the work themselves. Nor do you have to be a whacked-out attempted suicide survivor to benefit. Adolescents with merely the standard level of confusion will gain from these lessons.

"We're from the generation of 'you should', 'you must', 'if you don't'," says Phillips. "These kids have been told these things a zillion times and they've closed down. This journey gives a blueprint for how to get on through life – it's pretty explicit and shows you what you should and can do if you choose to try."

Gem of the First Water isn't Tolstoy, and it's not even Tolkien, but teens invariably get caught up in the story, because it's about them.

"In one group," recalls Phillips, "two kids were having an all-out fight. We had to separate them with massive amounts of staff. One had a split lip that later required stitches, the other had a black eye. But both of them got ice and insisted they wanted to hear the next segment of the story before they were seen to, so they sat there listening while their faces swelled up."

The process works as well in New Zealand as it did in California, because "they're issues of life, not of gender, or economics or race. The boy is every boy, red or yellow, black or white, rich or poor.

TSI came to New Zealand with Phillips in 1991. After 13 years at Creative Alternatives, he and Mary were burning out and the strain was also starting to show on their three daughters.

"We wanted a year's working holiday and decided on New Zealand because it was clean, green and everyone spoke English. We moved to Kerikeri. We didn't know a soul and we were only coming for a year. I got a job with the Special Education Service as a psychologist. We just loved it and decided to stay."

Phillips began again at the beginning. "I'd go to the local principals and say, 'Here's what I do, do you have any kids you think are at risk?' And they were open to it."

The Northland police became interested in his work, and in the ensuing decade it has spread slowly but erratically around the country. Phillips went to Campbell Lodge as a family therapist and TSI consultant in 1996.

"The DARE [Drug Abuse Resistance Education] people have 600 to 800 trained facilitators using it nationally," he says. "Safer Streets have put it in 150 year-nine classrooms." The Nelson and Marlborough child and adolescent mental health services have also adopted it.

But Phillips is frustrated that it is not being used even more extensively. He attributes this largely to the fact that in his industry, "if someone's doing something wonderful, other people don't want to know, because the inference is they're doing something wrong."

As for the Ministry of Health "The Ministry of Health is not routinely informed about specific clinical interventions undertaken by child and youth mental-health services," says spokesman Todd Krieble. "However, we are aware of the work being done at Campbell Lodge with troubled young people, and we're very interested to hear that this particular model of working that has evolved in New Zealand has attracted international attention. We will be interested to see what any resulting research shows.

"It must be noted, though, that it is not the Ministry's role to promote specific therapies, other than those that have been internationally proven to be effective for specific problems."

Phillips must be one of the few US nationals to know what it feels like to be on the receiving end of the cultural change.

The major difficulty with wider acceptance of TSI appears to be the lack of rigorous research, here or anywhere else, into its effectiveness. However, Middlemore clinical psychologist Sarah Fortune has been studying it, in a "rough and ready" way.

"I think the major breakthrough is that kids are bad at coming to any kind of service," says Fortune. "We get a lot of kids who have a lot of life problems and TSI is something you can do alongside that. So, even if you're not going to school regularly and you're getting stoned and you have a lot of fights with Mum and Dad, you can still benefit. Lots of groups are run for one type of problem girls who are sex-abuse survivors, for instance but most kids who live in South Auckland don't have the luxury of just having one problem. Over a year, we've looked at about 1100 kids and asked them and their parents to rate behaviour, mood, suicidality. Overall, mums and dads rate behaviour as a lot better. Kids rate their perceptions of themselves as a lot less negative. They have a much-reduced expectation they'll harm themselves, and they perceive a vast improvement in their relationships with their families. All in statistically significant numbers."

And these are the kids for whom Campbell Lodge was the last stop.

The next step is to perform the sort of rigorous international research that will satisfy the ministry. One such study is being undertaken at the University of San Francisco's Center for Child and Family Development, which places counsellors in that city's schools to identify and work with at risk children and their families.

"We haven't used TSI here yet." says Brian Gerrard, executive director of the centre. "But Ron did a workshop here last fall which had a very good response. We're hoping he will teach it here next summer as an adjunct professor." In the meantime, the university will conduct the first randomised clinical trial of TSI.

"We'll take 30 schools and randomly divide them into two groups one that receives TSI and one that doesn't. We're also going to compare it to cognitive behaviour therapy, which is a very popular therapy for young people. We'll measure the before and after looking at grades, class attendance, at-home behaviour and some self-reported measures of depression." Gerrard points out that when assessing any therapy, caution is crucial. "They can become popular and faddish with very little evidence" and that 10 to 20 years is standard for a new technique to become established. However, he believes that his centres study will go a long way to legitimising and accelerating the use of TSI.

Hugh Clarkson, clinical head of child and adolescent mental-health services at Middlemore, is also keen to conduct research to complement the Californian study. A plan is in place, but funding this is a health story, after all is a problem.

"In mental-health care," explains Clarkson, "you use treatments with a research base and for which there's good evidence. Universities have the monopoly on running that kind of research. Or drug companies, and no drug company will be interested in TSI. But once your research is published in a refereed journal, then it becomes kosher."

Gem of the First Water has been criticised for lacking humour (most forms of therapy are so funny, after all), being too American. ("Some of the nicest redwoods I've ever seen were at Rotorua." says Phillips), and on gender grounds because it's about a boy. ("If it's a group of girls or mainly girls, you can just change it to a girl," he says, sighing.) But it hasn't been criticised for being ineffective.

"It's been out there in the industry and no one has said it doesn't work," he continues. "Because it does work. You can't deny the testimony of people who say their lives have been changed."

"No one I know of is opposed to it," adds Clarkson. "Some people wonder how much it's Ron who is the real therapeutic ingredient. Ron doesn't think it's that crucial, but he's got a great feel for teenagers. I think you have to like storytelling and teens to be able to practise the therapy. I don't know that's been entirely answered."

But as Gerrard points out. "A lot of people don't like to work with adolescents. They're not attractive. They have rings in their noses and bellies. It's a phase adults put up with. I think we prefer to work with adults, and Ron has shown courage working with this population."

The real difficulty maybe. Clarkson says, that "it's a general approach and it doesn't quite belong to anyone. If you're treating autism, you get interest from the autism association and the researchers at university researching autism.

"But the people who are interested in reaching teenagers are all of us and none. People are enthusiastic about early intervention in theory, but it's hard to get people in a public health clinic to free themselves from more serious work to do that."

Clarkson's financial hopes rest on the next NRC funding round. "It'll possibly be two years until we can publish. Realistically."

Until then, Ron Phillips and the facilitators around the country who have been through his training will continue to tell his story, and at least a few kids who otherwise might not live to see it will get home for Christmas.