Furthermore, in the spirit of establishing rapport with the reluctant or resistant adolescent client, therapists will sometimes set the scale more heavily in favor of empathy and support than accountability, to avoid difficult topics and not alienate the young client. They might excuse behaviors like extreme rudeness, profanity, and direct insults or refrain from commenting on the client's inappropriate activities like getting stoned and having semianonymous sex or a propensity for shoplifting that scream out for a genuine response. This reticence can convey to the teen client not that these therapists genuinely care, but that they're willing to sacrifice a measure of self-respect in order to appease the client.
However, when we sacrifice our personal boundaries or pretend not to notice things taking place in session in order to keep the peace, we lose the credibility we need to be able to do our job. Balancing the demonstration of our understanding and compassion with our ability and willingness to hold everybody in the room accountable for their actions (including ourselves) is one of the most critical challenges therapists face with clients, particularly troubled teens.
If there were a universal icon for adolescent therapy, it would have to be the stony face of a silent teen sitting in front of an oh-so-gently probing therapist. The act of speaking becomes so loaded with meaning that it threatens to overshadow the therapy itself and slow it to a halt. Because we've allowed the act of speaking to matter more to us than to our clients, we've inadvertently played up the value of words as currency, giving our clients the power of the purse, so to speak, forcing us to beg for every cent. As a result, adolescent clients who resent being sent to therapy or who are simply self-conscious about talking to someone they hardly know can sit and watch the entertaining show of the tap-dancing we do to get a response from them.
As long as we approach the problem of helping teenagers by asking, "How do I get this kid to talk?" therapists will carry the burden of energizing the therapy--not a great clinical strategy. What follows are three case studies in which some of the principles that I've discussed above--or their absence--played important roles. The three girls I've written about are very different personalities, with differing degrees of interest in therapy. As a result, my approach and configuration of their respective therapies is different in each case. Other than a few minor modifications in tone or pacing, I'd approach boys with the same set of principles with which I approached these girls.
The Gentle Art of Not Taking the Bait
Rachel, who was 15, was referred by her family physician when her mother discovered she'd been cutting herself. She offered no resistance to therapy and came to her sessions eagerly. Dressed in gray and black, and often wearing a hoodie pulled down low to cover much of her face, she was funny, warm, kindhearted, likable--and brimming with self-contempt. Sophisticated and circumspect in my office, she was, I learned from what she told me, quite different among her friends. With boys, she flaunted her sexuality--wearing tight clothes and a good deal of makeup, flirting strenuously--to make up for what she believed to be her subpar looks and personality. Partly because she was by nature empathetic to other people's pain (being only too aware of her own) and partly to compensate for her own feelings of inferiority, she became the go-to person for all her friends who wanted to discuss their problems. She was content to absorb their pain in exchange for feeling valued and tended to say yes and agree to do things even when she really didn't want to. At the same time, she had a reputation for being someone her peers wouldn't want to cross, sometimes lashing out when frustrated or when she learned about some injustice suffered by a third party. Over all this lay an unmovable mass of depression and anxiety like a heavy cloud that she'd been under for years.
Rachel was also very reckless and self-destructive in a willful, intentional kind of way. In the beginning, she told me the kind of things she did--something guaranteed to raise a therapist's anxiety level. She burned her arm at night with a heated safety pin or cut herself with a knife in order to focus her thoughts away from her problems, so that she could fall asleep. Though she'd never engaged in sexual intercourse, she mused out loud about when she would, with whom she would, and how many partners she'd have should she start having sex. She frequently drank too much and had experimented with drugs. I think some of what she told me was a test. So many adults, from teachers to parents and school counselors, had reacted with such urgency and insistence to what she was doing--in itself kind of gratifying reaction--that she'd never had the chance to stop and consider whether she wanted to continue doing it. Would I respond as every other adult had? I began to understand that one key to working effectively with this girl was in not reacting with obvious alarm, even though everything about the situation and her clear anguish seemed to clamor for it.
"She's much prettier than I am anyway," Rachel said to me one day, by way of summarizing why her boyfriend had dumped her for another girl in their grade. "So I really can't blame him." She clearly meant it, and her sad, revealing comment simply hung in the air between us.
This is the kind of statement that would make many therapists want to give Rachel a pat little speech: being pretty isn't everything; if that's how her ex-boyfriend appraises girlfriends, then maybe he's not such good boyfriend material after all; you're pretty, too. Besides the fact that most teenage girls who've been dumped wouldn't believe these sentiments, had I given this kind of response, it would have made the exchange all about me and what I wanted her to believe, instead of about what she thought and felt. I'd be showing her that I was less interested in understanding the values in her world than I was in trying to utilize her disclosure to "raise her consciousness" and make it align with values I thought were important.
Instead, I asked her, "Are there differences between boys who pick their girlfriends based on how pretty they are and those who base their decisions on a whole bunch of different things?" After we'd discussed her male friends' criteria for selecting girlfriends for a while, I asked, "Hey, how come when you tell me about the boys in your school, it always sounds like they're in the driver's seat?" These questions, with their gentle counterpoints to Rachel's pliant manner around boys, served to nibble at the edges of her way of thinking about boys, girls, and their relationships with each other. They helped keep the conversation open and move it forward a little. I was seeding the idea that she could ask for more; that she deserved more. Because of Rachel's deliberate but reserved nature, my choice of tone in therapy was--decidedly--understatement.
There were other interventions I mulled over, looking for the right place to introduce them. For example, I wanted to affirm Rachel's essentially benevolent nature and generosity, but I had to do it in a way she wouldn't find patronizing or gratuitous. She'd always made it hard for others to compliment her, mainly because she was uncomfortable when evaluated more favorably than the self-image she held--as a kind of unattractive loser--which she consciously projected. I think praise made her uneasy, seeming to make her beholden to a standard that she felt pressured to keep up and afraid she couldn't. In other words, while her low self-image maintained her depression, it also felt safer than risking the failure and disappointment of not being able to live up to the good opinion and high expectations of others. Once she told me that she didn't at all mind the low points of her depressive cycles, because she knew that from there, it could only get better.
So, instead of openly pointing out to Rachel what I regarded as her instinctive kindness, I just said that I'd been moved by the stories she'd told me about caring tenderly for her two younger brothers when her mother was away and about getting two girls to stop teasing a third online. "You keep these two facets of your personality--your caring nature and high sense of justice--under such wraps though; nobody sees this part of you." I said this simply as an observation and opinion--not implied advice--indicating no requirement for her to respond. But she did, with a shrug. "It's no big deal," she said.
"Rachel," I responded. "Why is it so important for you to present yourself as less than you are?"
"Because I don't care," she replied. She then added, "Actually, I think I just really hate myself."
It would have been tempting to ask, in deeply concerned tones, "But why? You have no reason to hate yourself. You're such a lovely, kind, good person. You just aren't having a very good day." Such a response--essentially denying that she feels what she feels--could only inspire the client to clam up or just get up and walk out. Instead, we sat together quietly and easily for the remaining few minutes of the session.
Soon after Rachel's comment about realizing she hated herself, I started noticing changes in her demeanor and in the stories she brought to therapy. She looked more carefree, and one day said she was aware of "smiling a lot." She hadn't mentioned school in months, dwelling more on issues with friends and family. Now, she began talking about school, telling me that she'd been writing poems about "conscience," and "putting down the knife." Rachel was offended when her mother suggested she was cutting herself because of a boy, and even more offended when her mother asked if it was because of her. "These are my scars!" Rachel pronounced to me in session. "I don't do this because of a boy. That would be kind of pathetic, don't you think? And my mother just thinks everything is all about her!" At some point in a conversation around this time, I found the right opportunity to say to Rachel, "You know, you have a 'no' in you now." She nodded.
Shortly thereafter, Rachel's mother called me to say that her daughter had indicated she wanted to come in to therapy less often since she didn't have all that much to talk about anymore. In the last few weeks of therapy, Rachel described her new interest: serial killers. With insight and compassion, she talked about how they were often dehumanized by the media and even by the people who were studying them and trying to understand them. Interestingly, she added, "If you dehumanize them, then you can't understand them or catch them. It turns them into monsters, but they're human, too." For some therapists, this new interest in serial killers might itself sound alarm bells. I took it as a reflection of how Rachel had managed to rehumanize herself in her own eyes--an important first step in allowing others to see her that way, as well.