10 Ways to Improve Your Therapy with Adolescent Girls
by: Martha Straus
Lucy begins talking before she even makes it into the office. By the time she takes her seat, I'm hearing the details of her day. She floods me with vivid descriptions of friends and enemies in her school, and, without prompting, I learn about the fight at dinner the previous night with her elderly grandparents, who are now, somewhat unwillingly, her guardians.
I draw a sociogram as she speaks, frantically trying to make sense of what she's pouring out, and also trying, in vain, to slow her down as I scribble a schematic who's who of her world. My arrows and jagged lines illustrating relationships in all directions resemble a web built by a spider on hallucinogens--a chaotic mess.
When she's done, she exhales sharply, studies my drawing for accuracy, grabs my pen to embellish one big conflict, and glances up at me triumphantly. Yes, that's everyone--that's her life. My intake questions, the usual provisos about confidentiality and scheduling, are all postponed as I follow her compelling agenda.
All the while, Lucy has been sorting out the contents of her large purse. She spreads them on my couch as if they were science specimens: four notes passed to her from class, folded in carefully-tucked triangles; three other odd little pieces of paper with doodles and phone numbers on them; a pack of Marlboros; a fistful of loose change; a small, pink, bulging wallet; a guitar pick; an accordion of photos held together by a frayed rubber band; crumpled class assignments; a jumble of makeup tubes, brushes, and compacts; aspirin; a few receipts from places in town; a movie stub; and a sheath of detention slips.
I inquire about whether I can ask about the items she's organizing. Even though it seems obvious to me that she's handing me literal pieces of her story, I want to be respectful. Still, I'm curious: what's in those notes, that wallet, those detention slips? How does she apply so much makeup? Lucy is amused and, grinning for the first time, agrees to let me write down the inventory of her purse for future reference. She tells me the name of her lipstick, and the color of her nail polish, waiting patiently while I write. These details suddenly matter. And happily, she carefully brings the pocketbook in with all these items again the next week in case I've lost my list, adding two green condoms, and a CD of music from a girl band, "who aren't really lesbians, but pretend to be." She's off and running again and I'm back sucking wind trying to keep up.
What's she telling me, in this deluge of words and things, about her feelings, I wonder? About the dark places that include her mother's abandonment, the father she's never met, the depressing apartment with ailing grandparents, about the screaming matches in the halls at school, about how such a bright girl can be failing every subject, including gym? And when do I begin to ask my intake questions about her childhood milestones and illnesses, struggles in elementary school, special interests and talents, goals for treatment? I'm clear that all of this must wait. Lucy's pocketbook is wide open for me, and I'm going in.
And, anyway, this is what therapy is like with adolescent girls: an unpacking of metaphoric bags, some long locked up, some spilling over, some ripping at the seams, some like Lucy's, all out there. In my attention to the details of their baggage, I'm not just a therapist; I'm part valet, part archaeologist, and part synthesizer, too.
What's the Difference?
The popular assumption is that girls are easier therapy candidates because they've been encouraged to express their feelings, while boys have been stifled. Girls emote; boys stuff. Girls have a range of affect available to them; boys are only entitled to their anger. Boys just know how to grunt, hit walls, and shoot hoops, while girls are relational, processing events endlessly with their friends and raging at their mothers.
Some of this overgeneralization may even be true some of the time, though if you do therapy long enough, you'll meet more than your share of sensitive, articulate boys and incoherent girls. But would the work we do be different if our theories of change were specially designed for boys or girls? After all, research clearly shows that the divides of race and class are even greater than those between boys and girls on practically every measure of difference. And taken as a generational concern, we seem to be giving a pretty intractable cultural raw deal to all kids. As psychologist Ron Taffel suggests in his recent book Breaking Through to Teens, the compelling issues faced by boys and girls today are substantively the same: they're starving for passion in their lives and for authentic and enduring relationships with compassionate adults.
Still, for me, working with girls is what I do with the greatest interest and passion. Like many female therapists who have this specialty, I had my own tough times as a teenager. I have wells of empathy to draw on, and can stay attuned with them more easily than with males, or females of other ages. Our bond is implicit, and by being as fully authentic, connected, and present as I know how, I help them make it explicit.
I really was curious about the contents of Lucy's pocketbook; it was fun to explore them together. Like Lucy, other girls seem to carry around pieces of a coherent personal story with them, and there's something particularly compelling about being able to help them identify the pieces and then put them together. I know the fundamentals of good therapy help boys, too, but I have to work harder with their "otherness."
Thus the thoughts that follow are largely informed by my 20-odd years of experience treating adolescent girls and their families. They synthesize what's helped me forge alliances with them quickly and inspire change.
Lessons for Working with Adolescent Girls
1. Make and Keep Promises
Adolescent girls often come to therapy without much experience with real adults. One bright 15-year-old contending with the relentless narcissism of her divorcing and dating parents observed to me recently that I was "the only grown-up" she'd ever met. It was an exaggeration, I think, but not much of one. Because therapy isn't usually a daily event, we have an opportunity to build trust more quickly when we find ways to make promises to girls, and then deliver the next week. I may ask them to bring in music, for example, so I'll promise to provide the CD player. Or when I go to the Networker Symposium, I'll promise to send a postcard of the Capitol. If we're doing a crafts or collage project, I'll promise to bring supplies we need and have them ready when a girl returns to my office. I promise to go to school meetings, to say certain things in family sessions, to remain hopeful, to keep confidentiality. And then I deliver on all these promises.
Being consistent by doing what we say we will is important for adolescent girls because they experience so little predictability, internally or externally, in their lives. Kept promises give girls rapid feedback that they're important to you, even when they are not in front of you. This sort of object constancy sets a tone of trust and safety that may otherwise be harder to establish. And it sets you apart in a landscape marked by self-involved and forgetful adults who may not promise much nor keep the promises they do make.
For example, 13-year-old Hilary had grown up in the foster-care system, and knew precious little about adult follow-through. Developmentally, she was a young teen, still into horses and puzzles. Early on in our work, I suggested that I might get a horse jigsaw puzzle for us to do together. She seemed mildly interested, so the following week, when she returned, I had it for her. Looking astonished, she said, "You got this for me?!" We took it out and spread the pieces on a table in the corner of my office to work on from week to week. When we'd completed the puzzle, we covered it in jigsaw glue, and the next week, she took it home--a symbol of me and our time together. This may sound like a fairly small example of promise keeping, but, for Hilary, it provided some vital glue for the pieces of our relationship.
2. Admit Your Mistakes and Apologize
Most adolescents have precious little experience with adults apologizing to them. But like anyone else, young girls appreciate it when we admit that we've made a mistake. It helps level the playing field and demonstrates a level of respect that adults seldom feel like offering. It builds empathic attunement and gives them the chance to forgive us. I've found, when I've apologized for messing up, that adolescent girls can be surprisingly forgiving, even if often not of themselves. This fact can also help therapy along. They'll forgive you readily for a mistake you made and later, when they're being relentlessly hard on themselves, you can compare their sterner self-judgments with their kindness to you when you goofed up.
Some of my greatest therapy moments have come out of screw-ups. A couple of years ago, I gave appointments to two girls named Jessica at the same time. The moment I opened my office door, I realized my stupidity. Jessica One reached into her back pocket and flashed her appointment card, as though it were a front-row ticket to a concert. "It's my time, and I can prove it," she laughed. I asked her to hold on for a moment, and met sheepishly with Jessica Two, to touch base and reschedule. I apologized profusely, and when we met later that day, I apologized some more.
My work with Jessica One had a little spike of energy that day (she was the youngest of five sisters and enjoyed the sweet waiting-room victory for a few giddy minutes), but Jessica Two and I made a connection after I made a mistake, admitted it, and apologized to her. That subsequent hour of therapy with Jessica Two was the turning point for us, maybe because the playing field had suddenly leveled, and maybe because I was working hard to make repairs to this rupture. It's common wisdom that greater intimacy follows from a repair to a relationship. This isn't to suggest that I advocate wearing mismatched socks or showing up late on purpose. But these mistakes and missteps inevitably happen. And when they do, we get to say we're sorry, and figure out what we'll do differently the next time.
3. Hold Hope
Somewhere between their Cinderella-like rescue fantasies and the hard truths of their lives, many girls get lost in hopelessness and despair. They live so much in the present and in their feelings about what's going on now that they don't know how to feel confident about the future, to plan for it, or to envision it as a reality. This envisioning problem compounds their damaged sense of personal efficacy.
When I'm with a girl who's floundering, seeming desperately lost and unable to take hold, I often intervene with a bold hopefulness. For these girls, I feel one of my most important jobs is to be a holder of hope for the future. I've come to understand that my confidence in my young clients and in their ability to heal is central to their developing the ability to believe in themselves.
Seventeen-year-old Marianne was in tremendous distress when we first met. She'd been at boarding school and had repeatedly gone to the infirmary to have her hearing checked and then her eyes, feeling she was hearing and seeing the wrong things. She felt tormented by horrible voices, and was afraid to go to sleep.
She called her parents one day in the middle of the fall term almost incoherent with fear, and they brought her home, not knowing what was wrong, but perceiving she was at the breaking point. I met with Marianne and her parents that day. I soon determined that she needed to be hospitalized for her safety and to get stabilized on medication. Before she left my office, I told her, "It won't always hurt like this. You'll feel better. I know you're not hopeful right now, so I'll hold the hope for you. Tell me when you can share in it with me. Until then, I'll be our holder of hope."
Marianne made rapid gains as an inpatient, and returned for several months of work with me afterward. When we were terminating and looking back on our work together, she recalled that she'd used my hope to get through the nightmare of being hospitalized and having to conquer the voices inside her head. She said, "I always remembered that you said you were hopeful that it would get better. That made a difference when I didn't know if I could keep going on."
4. Trust the Process
With adolescent girls, our impatience to do something to make a change in someone's life--to be transformative in a big way--can come across as criticism and disrespect. After all, if their problems were so easy to solve, they'd have done it already. And sometimes girls interpret our agenda-setting ideas as power moves; we're then like other adults in their lives who think they know best and tell them what to do.
It's often a benign intention, wanting so much to be helpful, that can get both novice and seasoned clinicians in trouble. Before we rush to intervene, we need to breathe deeply and attend closely to less conscious and intentional matters in the therapy room--what it feels like to be there (for both of us), what else is happening beneath the surface--to get into that limbic resonance that connects us, and deeper still. It's fundamentally important to trust the process, and to find a way to stay connected to girls during the hours that we're with them. The course of therapy can't be reduced to a series of plans and goals; it also takes place in tiny moments and crevices of a relationship. The "process" is happening even when (or maybe especially when) we're doing nothing at all.
Attending to the process is an idea that's become almost my mantra in my clinical supervision of graduate students. In this age of presto-chango technique and managed care, the process is too often a casualty of the pressure to make therapy as brief and problem-focused as possible. We forget that there's meaning everywhere, if we have the pluck and luck to discover it, and that it often flows out more freely when we're patient, honoring a girl's agenda over our own, sitting a while longer with our own uncertainty and discomfort. Regardless of whether adolescent girls are oppositional and challenging or sweetly contented with us, we are too often tempted to take over and act rather than allowing the flow of the session to dictate what we'll do next.
One day just a few weeks into our meetings, Lucy and I were sitting together companionably. She was doodling on a big pad perched on her lap, not saying much to me, just occasional idle chatter accompanying her curlicues and the three-dimensional rendering of the word "Matt," a boy she was madly pursuing. I was beginning to squirm, and my personal demons were telling me that I ought to be "doing real therapy" with her now that we'd "established a relationship."
So I began to speak, quietly wondering about how I could be helpful to her, about whether we might now talk about some goals, about some problem-solving strategies she might like to learn. When I was done, Lucy looked up at me horrified, her lip quivering. For the first time since I'd known her, she silently began to cry. She regained her voice after a couple of interminable minutes and said, "This is the only place I have that I can just be me. Why do you have to fix that?"
I backpedaled fast, supporting her determination to be herself in other situations, too. I breathed deeply and leaned forward into the space between us. I reached for a colored pencil, and asked if I could color in a letter of Matt's name. As the sound of pencils scratching on paper filled the room, I realized anew that Lucy's healing depended in good part on my ability to trust our unique (if at times slow and seemingly dull) process in the therapy room. I don't always know what is, strictly speaking, "therapeutic"; sometimes all it takes is just being present. And sometimes just being present is harder than providing big-time interventions.
5. Identify Choices, Ask for Choices, Take Joy in Choices
Many teens feel that they have precious little say in their lives--it feels to them that someone is always telling them to go to school, do chores, eat dinner, do their homework, turn down the music, and get off the internet. They're told to go to therapy, too--something else they didn't choose. Yet, self-control, which comes from the ability to make and follow through on our own choices, is the scaffolding that holds up so much of our lives.
With a sense of self-control, girls can develop self-esteem, have safe and intimate relationships, figure out how to succeed in school and work, and learn how to negotiate with their parents more effectively. Adolescent girls need to see themselves as capable of making choices, and caring adults need to help them choose and notice when they do.
Donna was 18, drinking too much, and cutting herself. She was doing poorly in her first year of college and was feeling increasingly desperate about whether she'd ever be successful. She'd come into therapy and tell me about all the regrettable things she'd done the preceding week. It was quite evident in the narrative that she didn't see herself as proactive in any sphere in her life; the only control she believed she had involved choosing self-harm.
So I framed all the events she reported as choices. I asked, over and over again: Is this what you want? Is this how you want to show up in the world? What happens when you do? What happens when you don't? How true are you being to yourself in making this choice? How does it help you get the love and care you need and deserve? When she drank less, I congratulated her for making a good choice, and asked her how she was able to do it. These questions stemmed from my heartfelt belief that Donna had more control over her life than she thought she had. They steered her in the direction of finding the strong voice that she could identify and distinguish as her own.
6. When She's at a Loss for Words, Guess and Guess Again
Even though girls are supposed to be verbal and emotional, they're often surprisingly lost when describing their internal lives. Many girls, well into adolescence, remain concrete in their reasoning and have a limited vocabulary for describing their feelings. Cut off from anger, impelled by culture and family to present a smiling facade, they often really don't know how they feel. Therapists are often frustrated when they get the usual responses to the inevitable inquiry about how a teenage girl feels about something: "Fine," "I don't know," or strained silence.
At this juncture, I no longer think girls are being defensive or withholding when I receive one of these responses. Instead, I plunge ahead and guess. I frame my musings in general language: "Some girls I know might feel pretty angry about something like that." "I think I'd be pretty frustrated if I had to deal with this." "I know a girl who said she felt like crying an ocean when that happened to her." "I wonder if you might feel a little confused by this." Such reflective dialogue about deeper feelings and what they might mean helps girls. They see me trying and when I guess right, they feel felt. They also begin to learn to draw meanings from feelings themselves. Guessing is a kind of foray into helping girls develop their own emotional intelligence and "mindsight," so they become increasingly able to know what they think and feel.
7. Base Expectations on Developmental Level, not Chronological Age
If girls develop at different rates along so many concurrent lines in their physical, emotional, social, and cognitive paths, how do we know what are reasonable expectations and where to set the bar? One of the great challenges of work with adolescent girls is that they often enter treatment for adult-sized problems that they've attempted to solve with child-sized strategies. I believe that I'm treating an increasing number of anxiety disorders because our expectations for girls exceed what they're capable of delivering.
This issue is particularly compelling when safety is concerned. We have hugely unrealistic cultural and societal aspirations for adolescent girls--wanting them to function independently and wisely long before they have the tools to do so. By the time a girl is 11 or 12, we may expect her to be able to be alone for many hours a day, organize her school work, get dinner started, and manage herself in public with poise and maturity. Adults may become annoyed by a girl's "ditziness" or emotionality, express shock or dismay at her poor choices and judgment, or take her irritability as a personal affront. Because girls look like young adults, and can sound like them, too, we're too apt to forget that they're frequently overwhelmed by expectations that they can't consistently meet.
A few weeks ago, I met Margaret for the first time. She's an angry, unhappy, 13-year-old girl, who came to therapy with her father, her 9-year-old half-sister, Izzy, and her stepmother. Her family members had a long list of changes they wanted Margaret to make--to lie and argue less, be more respectful, do her chores, stop blaming Izzy for everything, and stop stealing from her stepmother. When I asked Margaret the "miracle" question about how she'd know her own problems had gone away, her answer surprised me: "I wouldn't have to pick up Izzy at the bus stop after school and watch her every day until 6:00, so I could maybe do karate again. And I'd only have to get dinner ready a couple of nights a week." I realized then that the family expected Margaret to function as an adult and parent; they didn't see how these high expectations were causing this young, confused child to feel overwhelmed and frustrated.
When I meet an adolescent girl for the first time, I assess her cognitive, social, emotional, and physical development, and consider what level of independence and responsibility--for herself and others--she can handle. I set the bar a little low at first, to be sure she's safe and competent to get over it. I educate the parents, who see an almost-grown woman before them, about the fact that this girl is still just a child. Girls benefit from the temporary "loan" of an adult's executive functioning while their own brains are still undergoing major renovation--and so much of their behavior is controlled more by emotion than by reason. Even when girls say they're capable of behaving more independently, or deny wanting such support, adults should not take these statements at face value. The fact remains that evolution has given young humans a long period of dependence and that this simply can't be rushed, no matter how much adults may need girls to grow up faster.
8. Build Teams
In today's America, the nuclear-family model is inadequate for raising adolescents. Parents are unable to function in all the roles needed by girls to develop safely into women or provide everything--supervision, nurturance, role-modeling, initiation into the adult world, education, and counsel--required to launch them into womanhood. With the powerful second family of pop and kid culture all around, girls need lots of adults to hold and support them--adults who can function as parents, friends, mentors, and elders. Clearly, a therapist who sees the girl for 50 minutes a week can't provide all the nonparental adult time she needs.
From the onset of treatment, I view myself as part of a team, adding adults as we go. One of my favorite team stories is about a funny and maddening 14-year-old named Megan. She was diabetic, learning disabled, truant, and recently adopted by her long-term foster family. Megan had adults scrambling in all directions to support her, and we added more when she was hospitalized for medical problems, and then still more when she attended a residential school.
One day a few months into treatment, she was bemoaning the fact that she had no one on her side, "Everyone is against me," Megan wailed. I glared at her, handed her my clipboard, and asked her to write down the names of people who'd tried to help her just in the past two weeks. We began with a truant officer, added the nurses on the inpatient unit, extended family, school personnel, her adoption worker, and myriad others. Megan counted happily to a team of 24 adults. She seemed quite pleased and laughed as I admonished her to carry this list with her at all times, so that she could never again say she was alone. Even in less complicated situations, girls need more adults in their lives, now that they so seldom have nearby extended families or a cohesive community to back them up.
9. Empathy, Empathy, Empathy
It isn't easy, when an adolescent girl aims a verbal bomb at us, to remain empathetic, but when we do, we run less of a risk of taking things too personally. Girls, even big, tough ones, have limited strategies for getting their needs met. They come to therapy following years of struggle and failure in relationships. We need to try not to be wounded or disappointed when they aren't good at the therapy relationship either.
Sally, a pistol of a girl, was 13. With hair she'd cut herself one afternoon, broad shoulders, and a fierce scowl, she was the terror of her suburban middle school. People, got out of her way when she walked down the hall. Teachers disliked her because she continually and relentlessly challenged their authority. She was sent to therapy after she swore at her English teacher one too many times and was suspended. The school hoped I could "help her be happier." I suspect they hoped I'd sedate her somehow, too.
Sally was a bright enough girl who had a couple of critical older brothers and parents who were overworked and exhausted. Her parents had trouble making it to therapy appointments together, but, separately, both expressed bewilderment and frustration about their angry kid.
Because I prefer a girl who has pizzazz, I immediately liked Sally, and told her so the first chance I got. I admired her determination to be true to herself and to have a voice. So even after she used that voice to let me know I was wearing the "ugliest-ass pair of shoes" she'd ever had to look at, I still liked her. And when she told me I was wasting her time and that her cat understood her better than I ever could, I still liked her. Ditto following the comment about feeling that she was talking to drywall one day when I wasn't immediately responsive; I told her no one had ever compared me to drywall before. Even after she put her muddy boots on my couch and told me to "just shut up for a change," I was in there with her, liking her. I scowled affectionately, and mutely waved her feet off the furniture. And then I asked another question about the "emo" music she had on her iPod and listened hard to her answer.
Sally's actions were, I believe, creative attempts to share with me how rotten she felt, and I held (clung, really) onto my empathic connection and didn't let her push me away. I've finally learned, after years of being hurt and worried in such situations, that what's transpiring isn't about me at all. My job with Sally, and other girls who use insults or verbal aggression as a way to get personal, is to reflect back a better way of staying connected.
Sally probably wanted a relationship with me more than most girls I've worked with. I had to keep remembering that her oppositional strategies were in the service of engagement. By doing that, I was able to tell her, "I love your spirit. When you talk like this, I know that there's someone in there worth fighting for. I admire that so much. The last thing I want to do is to send another shut-up woman out into the world. Promise me you'll fire me if I do that." Then, to try to engage her in the work of smoothing her rough edges so others would want to be there for her, I added, "But we need to do some work on your style and figure out together a way for you to develop a voice that people can hear. I can help you become a better Sally advocate."
Like many girls who aren't used to people responding as I did, Sally redoubled her rejection of me, just to be sure I was sufficiently indefatigable. For a few weeks, she became even more adamant she didn't need some "nosy shrink" in her business, and challenged me still some more. But over time, her comments became part of our way of being together: I'd I go to the waiting room and hear about my shoes, then wait patiently while she read a magazine, and she'd eventually wander in, sighing with ennui. Then she'd get down to work. Several months after I terminated with Sally, I got some high praise from her: she sent a friend to me for therapy (who told me she had instructions to check out my ugly-ass shoes).
10. Don't Underestimate Your Role
One of the biggest mistakes we can make is to devalue ourselves, or at least our importance, to the girls we treat. Maybe adults come to therapy to fix particular problems. Adolescent girls don't; they want to be seen and heard. They want to feel felt. They usually want a relationship with you, even (or especially) if they say they don't.
Fifteen-year-old Marissa was a "multidiagnosed" girl I saw just three or four times, before losing her back into the system in which she'd spent her entire life. She came to me drug-addicted, with years in and out of foster care, a police record, and suicidal ideation. Her current placement was unstable because she wouldn't follow even the most reasonable rules in the home. Her foster parents had just about given up.
I hospitalized her to keep her safe when her despair grew so acute that she seemed a danger to herself. During her stay in the hospital, I sent her a silly greeting card, telling her I'd really enjoyed meeting her, and noting her strength to endure. Then I lost touch with her. I know now that Marissa wound up in juvenile detention until she turned 18.
Three years later, I was summoned out to my waiting area to greet a smiling young woman, who claimed to know me. She introduced herself as Marissa, the kid I'd hospitalized a few years back. She told me she'd always planned to see me when she got out of detention, because she'd kept the card I had sent her and she wanted to let me know how important it had been for her.
I've learned these simple, vital lessons through the years, and I relearn a few of them every week. I'm still discovering who I am as a therapist for adolescent girls, honing that growing edge of attunement to myself and to the girls I treat. So when the loquacious Lucys of the world bring their volatile social connections and overstuffed pocketbooks to me--metaphoric and otherwise--I now know that my job is to show up with my most patient, empathic, creative adult self, and help them unpack them.
Martha Straus, Ph.D., is a professor in the Department of Clinical Psychology at Antioch New England Graduate School in Keene, New Hampshire, and adjunct instructor in psychiatry at Dartmouth Medical School. She's the author of No-Talk Therapy for Children and Adolescents . Contact firstname.lastname@example.org. Letters to the Editor about this feature may be sent to email@example.com.