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Measure for Measure - Page 2

Parents are likely to respond more positively when their tone and affect are accurately matched by the therapist who knows how to reciprocate the challenge. They feel strangely comforted by the therapist's anger and disappointment, having been matched, contained, and validated by the sharing of annoyance in the interchange. The emotional intensity in the interaction here is essential to the effectiveness of the intervention. The therapist has to learn to be comfortable with the strategic use of authentic anger and any other emotions that arise in clinical sessions.

The parents grow a bit softer and seem more reasonable about the rate of progress. "I guess we didn't know what to expect. Jason has always been so difficult. I guess we want him to be normal . . . well, more normal than he is now." Both then start cracking up, perhaps having realized that, for a 17-year-old, wanting to drive a luxury car and entertain his lady friends in a hot tub isn't all that abnormal. Now there's an opening for more traditional goal-setting and a team approach with the parents.

The therapist asks about what "more realistic expectations" about Jason's behavior would look like and how long he'd have to achieve them. Parents and therapist then collaborate on limits, privileges, opportunities, and responsibilities, discussing appropriate consequences to impose for his recent transgressions, such as suspension of his driving privileges and limiting use of the family house for entertaining his friends.

When Jason comes in for his appointment following this meeting, he's good and angry: "I thought you were on my side! I thought you were my shrink!"

Clearly, he's responding to the shift in family behavior facilitated by the therapist. His privileges are now tied concretely to his responsibilities, and he's mad.

"I am your shrink," the therapist responds. "And you're your parents' child. Given that you continue to behave like a spoiled little boy, I have to deal with your parents. Do you want me to treat you like a grown-up or a child? What's more respectful, that I treat you like a 17 year-old or a 5-year-old? You tell me."

Jason mutters something under his breath that doesn't sound entirely cordial, but is willing to engage in a constructive conversation about how to earn his privileges back. The therapist's Socratic questioning results in Jason's assuming a more mature position. After all, what teen would say "I'd rather be treated like I'm 5 years old."

Jason goes on to finish high school and enrolls in a trade school. While he continues to have occasional troubles with his parents, and engages in soft drug use, his overall behavior is more appropriate. Therapy is slowly reduced to twice a month, then once a month, and then is terminated. From time to time, the therapist hears through the grapevine that he's made a reasonably stable adjustment to young-adult life.

This model is employed most successfully with highly resistant, defiant teens and their families. With cooperative teens and families, a more traditional insight- and growth-oriented model is sufficient. Critical to the success of implementation is the therapist's comfort with using anger therapeutically. The approach can backfire if the therapist isn't skilled in accurate mirroring and joining.

The techniques must be used in a conscientious and strategic fashion, based upon an accurate reading of the therapist's feelings engendered by the client. This case study is but a brief synopsis of this approach. Ethically, as with any other treatment modality, the therapist needs to pursue appropriate training and supervision to use this technique.

Therapists receive little if any real training in using the anger that resistant teens provoke. We aren't taught that such anger is inevitable, and a critical part of treatment. Most often, we're taught that client change is only achieved by offering "reasonable" cognitive reframes and insight.

With hostile teens who are out of control, grandiose, and impulsive, we must be able to deftly counter their attacks with a matching level of emotional intensity. We can then create a safe twinship of shared emotion, leaving little for the teen to oppose. Engagement and the process of change begin here, because it's how teens can feel understood. Mirroring and joining techniques speak to a resistant teens' wish to be matched, contained, and challenged. This allows them to speak meaningfully about their chaotic lives—allowing them to be seen for who they know themselves to be at that moment in time.

Case Commentary

By Janet Sasson Edgette

So ingrained is the idea that therapists should meet clients where they are that we've forgotten the merits of asking them to come to us. What other profession works this hard just to get someone through the front door?

I agree with Victor Shklyarevsky and Kimball Magoni that responding effectively to teens' anger is essential to working successfully with this population. However, I'm not convinced that matching an affect is as compelling to a teen as the authors suggest. I think it could actually backfire, especially if the pitch of the therapist's response is seen as having been chosen for effect.

Adolescents are keen observers of the balance of power in relationships, and pick up quickly on adults who play to their favor. Matching angry teens' verbiage with some of their own really is just another way in which eager therapists try too hard, although at first blush it may appear not to be.

Shklyarevsky and Magoni do make a valuable contribution in pointing out the limitations of empathy and warmth in reaching angry kids who sit in your office only because they were told to. But engagement can happen through a variety of exchanges other than mirroring disrespect and fury. Besides, why would a therapist respond angrily to a new client anyway? Given that the teen's tirade has begun before any real contact was made, it can't be personal, so why respond as if it were? I can't take this seriously even if I wanted to, I'd think as the therapist, because we only just met. At least wait until I'm the one actually making you mad!

There are other ways to get angry teenagers' attention than to respond in kind. Warm wit or disarming candor can be far more effective clinical tools, as can a therapist's quiet, understated refusal to take at face value something meant not to communicate but to derail the process of connection. An advantage of that approach is that it allows therapists to demonstrate their ability to roll with what the teen offers up, and no one feels trumped. Just think of the therapist Judd Hirsch played in Ordinary People: unaffected, attentive, filled with understated compassion, and sharp as a tack. This was a man you knew could help! I can't be the only one who wishes I'd had a therapist like that when I was 16 years old.

Authors' Response

We appreciate Janet Sasson Edgette's comments, and certainly agree that a variety of approaches can be used to engage defiant teens. However, if Timothy Hutton's character in Ordinary People were to change from a warm, caring, hurt, and troubled youth into a furious, conduct-disordered, impulse-ridden, defiant teen, her suggestions might not apply. In fact, the warmth and candor she recommends are too often experienced by the kinds of clients we're talking about as disingenuous, pandering, and irrelevant.

Edgette objects to the therapist's starting out by being angry with a new client. That's not what we do. Our cardinal rule is always to follow the client's lead: a teen's defiance is matched with defiance; his or her cooperation is matched with cooperation. Moreover, our goal is always to match accurately—never to trump.

Of course, the proof is in the pudding. When a teen responds to such interventions with laughter and a knowing smile, we know that he or she feels understood, and that the alliance is on its way to being cemented. We suspect that, faced with our sort of client, Judd Hirsch's character would be thrilled to have the kind of skill set we're describing. It would certainly make for one hell of a movie!

Victor Shklyarevsky, Psy.D., is a clinical psychologist at the Center for Psychological Services in Paoli, Pennsylvania. He specializes in work with children, adolescents, and young adults. Contact: Kimball Magoni, Ph.D., is a licensed psychologist in the Philadelphia area who trained at the Philadelphia Child Guidance Clinic. He conducts individual therapy for children and young people, supervision, workshops, and parent coaching. Contact: kmagoni@;

Janet Sasson Edgette, Psy.D., is a clinical psychologist practicing in the suburbs of Philadelphia. She's the author of Adolescent Therapy That Works: Helping Kids Who Never Asked for Your Help in the First Place and Stop Negotiating with Your Teen: Strategies for Parenting Your Angry, Manipulative, Moody, or Depressed Adolescent. Contact:

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