Mistakes Therapists Should Avoid
By Janet Sasson Edgette
It’s probably fair to say that most teens loathe the very idea of therapy. Yet, with confused and troubled adolescents needing our help more than ever, the gap between our grad school training and what works in real-life practice continues to widen.
"How do I get her to talk about her feelings?" asks Jean, a counseling intern about to meet 13-year-old Hannah for an initial appointment. "I'm not sure what to say to her." Hannah will be the first client Jean has seen without a more experienced cotherapist at her side, and she's worried.
Oh boy, I wonder privately. Are they still teaching that good therapy means getting kids to pour out their feelings? I'm suddenly reminded of a teen client I'd seen years ago who, when I asked what hadn't worked in her prior therapy, began a mocking singsong of her therapist: "So, Cindy, how does that make you feel? How does that make you feel? How does that make you feel?" "Ugh," she continued, "enough already with my fucking feelings. It made me feel like I just wanted her to shut up! That's how it made me feel!"
"Don't worry about getting her to talk about her feelings," I say to Jean. "If you're doing anything close to what Hannah needs you to do, you won't have to. She'll show you what her feelings are."
It hadn't been all that long ago that I, too, had thought a client's feelings were the Holy Grail of therapy. But I've realized in the years since that direct questions about feelings are actually a source of irritation to kids. They'll talk about them, alright, but not in a discussion isolated from the conversation at hand, with a spotlight turned on it. Besides, the question itself is now so predictable, parodied even by the people it's supposed to serve.
Most teens are in therapy only because their parents, their teachers, the juvenile court judge, and/or some adult in authority somewhere has told them they must see a therapist. Consequently, they often find most standard, shrink-wrapped attempts to "engage" them infuriating. For example, to the therapeutic bromide, "We're not here to talk about me. We're here to talk about you," their (usually unspoken) response can only be, "You may be here to talk about me, but I'm not--I never wanted to talk to you in the first place." In short, they don't talk, don't want to answer questions, don't want to be in our offices, and don't intend to make it any easier for us, so we often resort to our stale therapeutic cliches because we don't know what else to do. It's probably fair to say that most teens, being highly protective of their emerging selfhood, loathe therapy sight unseen, and that too many hate it even more once they've had a taste. At a time when adolescents and preteens need our help in navigating the multiple challenges of family, academic, and social life more than ever, the gap between clinical theory as taught in graduate school and real-life practice continues to widen, unfortunately.
Most of us were never trained to talk to adolescents. I was taught psychotherapy by psychoanalysts, who worked hard to instill in me an understanding of the importance of unconscious conflict, character structure, object relations, interpersonal dynamics, and transference. It was great training and has proved highly valuable, but it was a beginning, not an ending. This hit me right between the eyes when I took my first job as staff psychologist at a residential treatment center for socially and emotionally disturbed boys and girls who didn't give a crap about their unconscious conflicts or anything else having to do with therapy. I'd ask them, "What are your treatment goals?" and they'd look at me as if to say, "Lady, is there anything on my face that says I have a treatment goal?" I'd make an interpretation of their behavior--"I wonder if you yell at your mother when she asks you where you're going because it feels invasive" or whatever--hoping to spark a little insight, and they'd stare blankly at me for a moment before getting up and leaving the session.
When I began treating adolescents in earnest, I realized that if I wanted to keep one of them sitting in my office for more than half a session, I'd have to change how I spoke with them. We needed language that was more natural, shared, mutually revealing than the questioning, interpreting, ritualized clinical language I'd been taught. I did learn this new tongue, but not by myself--I was taught by these angry, unhappy kids. They became my first postgraduate instructors as they began to respond to our more transparent and unaffected encounters. They showed me that successful treatment with them wasn't a matter of how I thought therapy "should" go, but of what would make them want to come back a second and third time.
I began to realize that the point of talking to them was to get them a little curious about what we might wind up chatting, joking, or arguing about in the current or following session. Another point of our talks was to get them to be less afraid of hope. So many of these kids had been let down so often by different adults, institutions, and circumstances that they'd learned to protect themselves by refusing to allow themselves to want anything they thought they might not get--lasting friendship, support from parents and teachers, good grades, a sense of self-worth, and certainly any real help from a therapist. So, I started to feel that if I could nudge them along to think that they might want to try just a little bit, with my help, to get something they wanted, it would be a great leap forward in treatment.
Over the years, I've developed an approach I call Natural Law Therapy, which simply means that I try to conduct therapy as much as possible according to the normal, natural way people talk to each other in different circumstances, without premeditated rules, protocols, or scripts. People who are perceived as not sounding natural or real or normal often are considered phony, duplicitous, and overbearing. Not surprisingly, they evoke in others a sense of distrust, anxiety, defensiveness, and anger. Of all clients, perhaps teenagers are the most protective of their vulnerable sense of dignity, and are particularly unforgiving of adults who seem to talk down to them, attempt to get some advantage over them, or assume a verbal one-up stance.
Some of my therapy principles have a counterintuitive element to them. For example, how can we demonstrate our trustworthiness to a teen who distrusts all adults? A standard rule for inducing trust in clients is promising confidentiality up front. But I've found that refraining from pointing out inconsistencies in their stories that they aren't yet ready to address is a better way to gain teens' trust than promising to keep their secrets. Rather than using the standard clinical technique of addressing these inconsistencies in the form of a mild confrontation, it's more respectful to protect their dignity by keeping mum. What makes a kid feel safe is knowing that if he says something he hasn't meant to say, or hasn't realized would invalidate his previous assertions, I'm not going embarrass him by pointing out his oversight.
For example, I once treated a 14-year-old girl who was adamant for the first three sessions that she had no problems at all. In the fourth session, I was commenting on her apparent lack of awareness of how her anger and irritability affected the rest of her family when she blurted out, "Why should I be worried about them when I'm the one with all the problems?!" To point out that she'd just contradicted what she'd been saying for weeks would have been unkind and unhelpful, demonstrating that I was far more eager to be right and make her see the truth as others saw it than to help her become more comfortable with saying what she really felt or thought.
I also began to rethink the meaning of the therapeutic alliance and establishing rapport. The usual process for connecting with clients is to spread empathy all over the place, to make careful, nonjudgmental responses to every word a client utters. But too-obvious attempts at therapeutic joining with teenagers before there's any real engagement just raises the "yuck" reaction in teen clients, and immediately compromises any relationship-building. Rapport isn't something that emerges directly from "rapport-building techniques"; it only grows organically from the mutual regard and respect that people develop for each other--something that requires genuine engagement over time. The idea that rapport leads to engagement is exactly backward. You engage and, if you like what you see in the other person, you connect. Then you have rapport.