Adolescent Therapy that Really Works

Janet Sasson Edgette

Overview – Excerpt – Table of Contents

Chapter 1. Nothing Matters Until You Matter

There have always been a few clinical populations that especially stump the mental health professionals in their service – substance abusers, antisocial personalities, and people experiencing some of the other character disorders. Adolescents could be considered another one, although many clinicians (and parents) would shriek in outrage at these youngsters being included in such a notorious group of individuals. Not all clinicians have difficulties counseling teenagers, but many do, and those that do often struggle mightily. At best, they muddle along through awkward or silent or testy sessions that they later share with colleagues in a spirit of bemused tolerance. At worst, they find themselves saying or doing things they’d never want to be saying or doing, and wind up blaming the adolescent him- or herself for why the “treatment” hasn’t been successful.

It’s easy to blame the lack of clinical success with adolescents on the teenagers themselves. After all, they are “teenagers,” with all that this concept conveys culturally, historically, and sociologically: irascible, defiant, coy, pseudo-independent, imprudent, puckish, argumentative, and thrilling. They think they’re invincible and infallible. What do they want with a therapist? Even the ones in pain can’t comfortably accept the benevolent overtures of a kind adult, whose assistance reminds them too much of their own vulnerability and need for grown-up comfort and support.

Or can they?

The Need for a Teen-Sensitive Approach

Sure, these kids can accept adult comfort and support, and they’d probably do it more easily and more frequently if approached by the clinical community in ways different from those commonly practiced. These adolescents – part kid, part young adult – are often approached by their therapists as if they themselves had initiated the therapeutic process and actually wanted to be there working on their problems. They didn’t, and they don’t. Many adolescents who do want to resolve their problems can’t make that known directly and choose instead to absorb the benefits of therapy on the sly; they make the first changes outside of session time, out of the therapist’s or parent’s eye, without public acknowledgement, without direct comment. It’s their way of saving face, and we need to let them do it that way.

Therapists who have trouble working with teenagers don’t let them do it that way. They instead demand direct, verbal responses that are already apparent in the teenagers’ body language and expression. I’ve already told you the answer, thinks the adolescent boy. I’ve already said okay. Don’t make me say it out loud.

Most therapists who have difficulty working successfully with teenaged therapy clients get in trouble by trying too hard.

Therapists who struggle with adolescents may ask the teenager to review what changes he or she has made toward articulated goals in the past week. Those were (and still are) your goals, not mine, thinks the teen. I never consented, I just stopped fighting. whatever made you think I was on board?

Therapists may be tempted to fan adolescents with accolades and congratulatory remarks when they finally do make some kind of change in their landscape of behavior or attitude. Some kids like that, but some don’t. The ones who don’t may think, The more you congratulate me the more it makes me feel as if you’re thinking that I finally “came over to your way of thinking.” I can’t do this if it means you think I’m saying that you were right and I was wrong. It’s important to know which of these two types each kid is.

Competent therapists unfamiliar with adolescent therapy are thrown a curve when their “safe” clinical environments, which invite disclosure and self-observation in their adult clients, are experienced as claustrophobic and unshapen by their younger clients. Adolescents don’t want to be shielded from opinion or judgement; they instead seek safety from injunctions to change, from condescension, from adult gratuitousness, and from oversolicitation. Most therapists who have difficulty working successfully with teenaged therapy clients get in trouble by trying too hard.

A Tough(er) Customer

These are good reasons why competent therapists find themselves uncommonly baffled when working with adolescent clients. As winsome as they may be at times, teenagers present clinicians with challenges that adult clients don’t.

First, adolescents are largely an involuntary clientele. They are in your office because someone – a parent, teacher, school counselor, or grandparent – has thought it necessary that they be there. They often see their difficulties as not of their making, and would much prefer to assign blame to family members, school personnel, others’ misguided thinking, and the wind and tides rather than assume accountability for their problems with friends, parents, grades, alcohol, self-image, mood, and so on. Adult clients don’t as often or as stridently begrudge a therapist’s speculation that their way of handling the people and events in their lives might have something to do with their discontent. With an adult client, the therapist has more of a partner in the process of therapy.

This is not usually the case for the therapist of angry, depressed, or acting-out adolescents. This therapist has no apparent partner, even though a partner is usually or potentially there. The therapist has to find that partner, without giving chase. The funny thing is that adolescent clients can continue to be as “involuntary” as they wish – no problem there – as long as they allow themselves to be “porous” to the therapist’s influence, even if that porous nature is camouflaged by recalcitrance and miserly conversation.

Second, the symptoms with which reactive, angry, acting-out adolescents present can be very intimidating. They storm out of rooms, punch holes in walls, cut their arms with blades, drink and drive, refuse to go to class, provoke arguments, and the like. If they’re really mad, they show it by locking themselves in their room, threatening suicide, or running away. Sometimes they attempt suicide. Sometimes they don’t eat enough for their bodies to function. Sometimes they refuse to say anything at all but instead cry a river of tears. Therapists feel enormous pressures to make the scary symptoms stop. Right away.

Third, teenagers – especially those who do not want to be in a therapist’s office – don’t necessarily adhere to common social protocols that grease the sticky interactions that occasionally occur in first meetings between people. These clients don’t care if you are more uncomfortable than they are in getting a conversation going. Therefore, they don’t try to absorb the awkwardness through self-adjustment, as adults (often very conscientious in pleasing professionals) will often try to do. Adolescent clients may not way to make favorable impressions, or care if you like them (some would prefer you didn’t), or be interested in what you have to say. This is in marked contrast to the encounters that mental health professionals typically have with their more accommodating adult clients, and it especially blindsides the therapists who historically have banked on influencing clients through the authority bestowed on them by age, status, title, or university degree.

There Is No Influence Without a Relationship

Fifteen-year-old Julie was ushered into my office by her unstrung parents. It was our first meeting.

“We need you to talk to Julie about her smoking. She started smoking cigarettes this summer and she won’t listen to us. She also needs to have a better attitude toward school this year,” Julie’s mother implored.

“Why is she going to listen to me any more than she would you?” I asked.

“Because you’re a therapist.”

“I’m a therapist who’s still a stranger. Besides, she already knows all the fact about smoking and school anyway.”

“Well, what’d we come here for then?” Julie’s dad asked.

I ushered the family into my office and offered to explain how I thought I could help. I told Julie’s parents that I wouldn’t be effective with their daughter were I to try and muscle a point across. I told them that I saw my job as engendering some measure of curiosity within Julie for what I might say, and that I wasn’t even sure what that was yet because I didn’t know what things made it easier or harder for her to change her habits and attitudes. Without knowing that, I could only deliver the same old lecture she’d been hearing from everyone else. Julie’s parents listened and understood. Julie listened too, although she pretended not to.

“If I can find some way to matter to your daughter through understanding her differently, then what I say to her can matter.”

The assumption (or hope) that a therapist can influence genuine change within a reluctant teenaged client in the absence of a meaningful relationship is a problem that rests behind may disappointing interactions between therapist and client. The therapist either acts as if the teenager were interested in the encounter, or sustains an unwarranted belief in the power of rationality or common sense to transform the youngster’s thoughts and feelings: This time she’ll see how she’s messing up her life. I’m making it so obvious.

But is it really that obvious to her? And even if it were, what is there about it to induce the adolescent to change? It’s still the same old message in a new presentation – the well-meaning therapist reduced to no more than a hired gun.

This means that as a community of clinicians we can focus on proferring a different and more influential message to our adolescent clients, or that we can focus on building a more compelling relationship between them and us. Or both.

A Different Message

A different message could be something the adolescent hasn’t been told about herself before. It could be something she has heard, but never in a way that affected her and made her want to know more. maybe it’s some remark or question or physical expression that invites the adolescent’s participation in a way she never experienced before. It won’t be an interpretation of her motives or behaviors, which usually interests the therapist but no the teenager, nor will a summation of data or potential consequences have the desired effect. It appears to me that the further the therapist’s overture or comment strays from directly relating to the relationship, and the more it approximates an injunction to change, the less it facilitates the teenager’s engagement in therapy. The unexpected absence of manipulation, and presence of commitment to the working alliance in formation, both serve to create an atmosphere in which young clients – so sensitive by now to the efforts of adults to get them to change – unwittingly allow themselves to “use” the therapist’s comment in a therapeutic way.

“I wish I knew how to convince you to give to give this another try without sounding like a salesperson,” I say to a reluctant new client with a history of negative therapy experiences. That statement is about my experience of the teen in the moment. It does not ask her to do anything different; it speaks to my wish that I could do something different. It is very different from saying to the teenager that I really think she should give the therapy a try. That I do is implicit, but not called for. It’s a decision the client must make for herself, and the way I speak lets her know I understand this.

“Eric, you’re so bent on being right that I don’t think you’d consider a better alternative even if you thought of it yourself!” I remark to a likeable but utterly self-righteous 17-year-old who thinks he has the world all figured out. I’m not asking him to reflect on his self-righteousness nor discern its origins. I’m not even asking him to become less self-righteous. Instead, I’m showing him where it limits him. Whether he does anything about it is up to him, and the lovely irony of it all is that because my comment respects that the choice of changing is so thoroughly and exclusively his, the boy remains (or becomes) psychologically liberated to do so.

But there’s something else happening here as well. When the therapist’s remark is stripped of any frank injunction to change, the teenager not only tolerates – but also becomes interested in – listening to things about his person, without defensiveness or protest. He becomes genuinely curious about how a benevolent, nondemanding other sees him. This opens the door for the therapist to accomplish a real clinical feat, that of making the indisputable (about the teenager) acceptable (to the teenager).

The Power of Permission in Psychotherapy

My first lesson in the paradoxical power of giving permission came to me when I was 10 years old. Invited to sleep over at my best friend’s house, but suffering from the malady of childhood homesickness, I wrestled with whether or not to go and risk facing once again the shame of needing my mother to be called at 11:00 at night to retrieve me. But the Shetland pony in Kathy’s backyard and the prospect of meeting her adorable older brother won me over, and I marshaled up the courage to try again.

I walked up to Kathy’s front door with my mom in tow on that Friday afternoon, and waited for what always happened. I waited for my friend’s mom to tell me how much fun I was going to have that evening, and for the pressure of the mom’s promise to me that I’d never get homesick at their home. I’d invariably disappoint.

But Kathy’s mother did something different. She ushered me in through the doorway, turned to my mother, and calmly said “Goodbye for now, Mrs. Sasson, I’ll probably be seeing you later on!” And I stared up at this brilliant woman who had become the first person ever to give me permission to be homesick. And because I walked around all afternoon and evening thinking to myself that I could get homesick any old time I felt like it, and that it would be okay and even expected, I never once felt it come on. My mom stayed home for the first time.

Permitting someone ownership of his or her beliefs, impulses, and defenses and of their consequences in your presence, without applying any pressure on the person to change, is a powerful phenomenon for encouraging the very change never asked for. It’s a concept close to Carl Rogers’s (1979) unconditional regard, but more active in its appreciation of people’s (felt) needs to stay as they are even when negative consequences are apparent or severe. never manipulative, never designed specifically for change nor offered up in the spirit of paradoxical injunction, the act of respecting individuals’ propriety and control over their being and the choices they make serves naturally to liberate them from the need to defend, promulgate, or otherwise impose these choices. In the absence of threat, an individual is freer to evaluate what is working and what isn’t, and make changes pleasurably experienced as autonomous.

True Change Agents in Adolescent Therapy

It’s typically not the mandate, the insight, nor the therapist’s compelling common sense that induces change in most adolescent clients. Often the threat of meaningful consequences imposed by newly empowered parents can do the job, and sometimes the parents need to let that be good enough; too many want attitude change when they need to settle for behavioral change, at least in the beginning. But occasionally it’s something else that moves teenaged clients enough emotionally so that they genuinely want to do things or become willing to see things differently.

One of the things that can accomplish this is creating a therapeutic relationship and interpersonal atmosphere where the therapist finds that he or she has received “permission” from the teenager to say things to her that others in her life have never been permitted to say. This kind of permission has little to do with whether or not the teenager wants to hear something, only that she will allow herself to be constructively affected by it, without refutation, without defensiveness, without bracing. She accepts the therapist’s benevolence as well as the therapist’s expertise and takes the message home. The client may pretend, for the moment, that the comment was insignificant, but stops short of dismissing it out of hand.

What kind of things? Things that others, mainly adults, have felt they couldn’t say for fear of reprisal, or have not known how to say, or haven’t known that they need saying. They are things that concern the adolescent’s personality, relations, sensitivities, vulnerabilities, or hidden strengths. They are things that affect profoundly what is or is not happening in the young person’s life. They are the things that everyone has been thinking but no one has dared to speak about.

Creating environments where the teenager will listen to what he’s never let anyone tell him before is an important piece of this therapy.

That’s rarely the whole therapy; usually the process is complemented by instilling the necessary behavioral controls, restructuring the family system, authorizing the parents to act as parents or getting them to be less dogmatic and authoritarian, managing depression or anxiety or impulsivity, supporting school-based interventions, engendering a greater sense of compassion within family members for all of their struggles, illuminating and resolving power struggles, enhancing communication, and similar interventions, depending on what is relevant for each particular family. But creating environments where the teenaged client will listen to what he’s never let anyone tell him before is also important, and is a critical aspect of the therapy’s having heart. The therapist leads the way in helping the teenager, with or without his family, experience a degree of candor, compassion, and commitment to honorable behavior that encourages a more positive way for that person to present himself and relate to others in his world.

A Different Relationship

Here’s how I heard the story that family therapist Carl Whitaker was said to have told.

A man is found by his townspeople at the top of a bridge. he is threatening to jump off to his death. The police commissioner arrives, takes his bullhorn in hand, and orders the man to come down.

“No!” responds the man.

“C’mon, you’re making a mistake. You’ve got family, friends who love you,” tries the commissioner.

The man on the bridge ignores him and takes a step toward the edge of the bridge.

“Don’t do this. Think of your wife!” the commissioner screams out.

“I’m a lousy husband. She’ll be better off without me.”

“Think of your kids!”

“I’m a lousy father, too.”

“Get down you son of a bitch or I’ll shoot!” the commissioner, in desperate exasperation, shouts. The man on the bridge looks down at the police commissioner, and comes down.

Being real works. When people disguise their true feelings and reactions of the moment, they lose emotional contact with those around them. And when the contact, goes, so does the ability to influence. When people are what they feel – which is different from acting on how they feel – they can affect those around them profoundly. That man on the bridge, without having to think about it, knew when the police commissioner’s relating to him switched from official to genuine. He only responded in kind.

This is one reason why adolescents frequently get so angry with their therapists and counselors and parents. When these adults are all so busy trying to keep things “calmed down” or under control, or keep the adolescent levelheaded, the kid goes ballistic. The adults find it hard to meld their role of the rational, wise helper with their reactivity to what is going on in the moments. They feel anxious or frightened or angry, but believe they can’t show it. They want to shout, “I feel like I’m losing any ability to influence you and it scares the daylights out of me,” or, “I’m so angry at you that I can hardly stand to talk, but you’re too important to me not to,” but they believe that parents and counselors and therapists don’t say those kinds of things. these adults try to stay calm themselves, and wind up instead with heartburn or headaches or anxiety attacks. The teenager wants only the authentication and contact; in its illusory absence, she reacts in the only way she feels she can – dramatically.

Years ago, I worked in a residential treatment center for emotionally disturbed adolescents. I walked down the hall one day and knocked on the door of a colleague’s office. I had wanted to invite her to lunch. Nell opened the door a crack and whispered to me that she had someone in session with her. I said fine, and that if she were free in the next little while to give me a knock and we could go to lunch. Behind Nell in the background was a young boy of 13 or so, sitting solemnly and stiffly in a chair. Nell looked terribly self-conscious and swiftly closed the door. I realized during my stroll back to my office that I had become, to Nell, the “contaminant” to her “treatment” that she was always on guard against. I thought back to some of our conversations about therapy, in which I would talk about prompting these young clients to reconsider choices made or about laughing with them about a funny story from school, and she would talk about parameters and neutrality. No wonder she felt blindsided by my lunch invitation during her session. Nell apparently considered that her client learning her lunchtime habits and the company she kept had compromised her holding environment. But how easily will that kind of clinical atmosphere facilitate such a boy’s comfort with, and utilization of, therapy.

In another instance, my supervisee came to me describing the withholding, sullen, silence of a 15-year-old boy brought in for therapy by his parents because of declining grades, depression, and pot smoking. The kid came alive only, and barely, when Rich discussed music, vacations, sports, and the like. But their conversations went nowhere, with Rich trying hard to make something happen, and Billy trying at nothing at all. Rich wanted to know what else he could try to get the kid to talk. I responded, “Tell him you feel like a salesman on commission selling a conversation. Tell him that you don’t want to be reduced to talking about cars in order to get a smidgen of interest out of him, but that you’re stuck and you don’t want to stare at the walls for a half-hour every week. Ask him what he really wants out of this, or if he wants anything at all.”

“What if he says he wants nothing at all?” Rich asked.

“Then at least you know where you stand and the two of you don’t have to fake it anymore. It’s not that asking him is going to cause him to feel that way. It’s better that it be out in the open. Then, either your client has to find a way to make your time together more useful to him or you bring the parents in. I’m sure they’ll have plenty of ideas for what to do with the time. but don’t start feeling as though you need to work so hard to get his interest that you start dreading his sessions. It is his therapy, after all.”

“I feel like I should be giving him advice or something,” Rich replied.

“He doesn’t want your advice. If you give it, he’ll see that you don’t understand him or his communication to you. Deal with his communication first – which is I don’t want to be here and have no use for this or you – and then you have a crack at something real happening. The therapy can only come out of that real contact, even if it’s about not wanting therapy. Learning about relating genuinely is the therapy here.”

That seems to be the difference between psychotherapy and teaching. Therapy changes people through an experience, whereas teaching does so through imparting knowledge or skills. When a therapist offers unsolicited, unwelcome advice to a client, he declares a loss of faith in his ability to influence his client. The setting then changes, and the therapeutic contact is reduced to one between dispenser of information and unwilling learner. The process grind to an uneasy, paralytic halt.

The Importance of Saving Face

Adolescents need help from therapists in finding exit strategies from their problems that keep intact their sense of dignity.

Many of the more challenging adolescents who wind up in our offices would truly like things to be different in their lives, despite reluctant, aloof, or irascible presentations. They want less conflict, less anger, less sadness, less confusion, and less alienation from their brothers and sisters and parents. One common problem is that they haven’t yet discovered how to do this on their own; another common problem is that they haven’t been provided with ways to do it that respect their dire need to save face while making changes in their lives. It’s easy to forget that these kids have probably spent months, maybe a year or more, justifying and defending their way of viewing the world and their own role (or lack thereof) in their life’s successes and failures. They need an exit strategy that keeps intact their fragile sense of dignity and autonomy so that they can move away from their defunct ideology and toward something they may only be able to acknowledge privately as being more advantageous.

A good therapy helps the adolescent find this. The surprise and relief on the adolescent’s face is spectacular when she realizes that the therapist understands this need of hers and can help her both find a way to resolve her problems – be they familial, social, habit related, school based, or otherwise – and do it in a way that preserves her self-esteem. There are few better ways of making oneself matter than to really understand another’s unarticulated, largely unrecognized emotional needs, and constructively address them without making the person uncomfortable for having had them in the first place. Accepting and accommodating to this particular need in the teenager works to release the young client from her predicament; somber examination with the intent of dissolution makes it rise up like an angry pimple.

I’d been seeing Maggie for a few months before we bumped up against this issue. She had been brought to me for therapy by her parents, who were rightfully concerned about her moribund manner, darkly sarcastic humor, and social isolation. Maggie disdained anything bright and positive, anyone friendly and fashion conscious. She reserved the greatest disdain for the “in” crowd at school, calling the girls “perky populars” and dismissing them out of hand, by definition, as unintelligent. How would she ever be able to let herself lighten up if she associated that with looking stupid?

This would be her dilemma, I predicted to Maggie: finding a way, when she did feel better, to comfortably adopt an easier-going state of mind and be more social without feeling as though she had compromised the stump speech she’d delivered to me in earlier sessions. It was only through a respectful acknowledgement of her platform and the obstacle it posed to her that I could ever hope to subsequently influence her rigid tenets about sociability and intelligence, and deal productively with her depression. I was never even convinced that she fully believed them all anyway, but that was for her and not me to say. It didn’t really matter anyway; in her sad, morose, and prickly way, Maggie needed some excuse for why didn’t want (have) friends.

Not everyone worries so much about saving face. I would have handled this differently with a client who was more related and livelier and happy to upgrade his points of view. I would have challenged his premise at the outset: “No way!” I’d have said, “You mean the same person can never be happy and smart at the same time? If you had to pick one, which would it be?” And he’d tell me his pick and I’d tell him mine, and I’d have an opportunity to learn about how he came to believe this and where the psychological sites of plasticity were that it could be changed.

Lily was another client of mine, a little older. I never forgot her reticence to change because she was worried about how humiliated she’d feel when everyone realized that she had “finally come around.” As depressed as Maggie but far more related and disclosing, Lily struggled against her mother’s admonitions to be cheery at all costs lest she lose the affections of those around her. She grew up with nothing but scorn for this piece of Pollyanna advice, and so resented her mother’s thinly veiled threat of her own withdrawn affections that she remained wedded to her depressive and solitary demeanor partly out of spite. How could she ever bring herself to show a lighter side and not feel as if it were the same cheery face her mom had been waiting for all these years?

Poor Lily. She never could figure that out. She understood what held her back and recognized that she could define her own relief from depression without paying homage to her mother’s counsel, but she never was able to rise above what she felt would be a self-inflicted assault on her dignity, and chose instead to stay where she was.

These are the stories of therapy I tell from the various clients I’ve worked with. Another therapist would probably tell a different story, even from the same client. we all see things differently, and choose facets of the interpersonal experience that call most loudly for our attention. In the pages to follow, the reader can hear more about what has called out to me in my work with teenagers like these. I like best the ones who balk at first, because they seem to be the ones who travel the farthest in their recognition of the emotional charge and lift that comes from genuinely knowing oneself, letting oneself be known by another, and enjoying the companionship of that moment.

ISBN: 0-393-70500-5
Paperback, 320 pages