This article first appeared in the September/October 1997 issue.
ANY THERAPIST WHO has ever tried to engage an anxious, sullen or confused adolescent who refuses to talk knows the meaning of frustration and futility. When the old standards of ‘joining” with clients active listening, supportive reframing, miracle questions provoke little more than furious silence, toneless monosyllables or dripping contempt, therapists need an entirely new clinical language that doesn’t depend on words. If teenagers won’t talk in family therapy or refuse to have therapy with their parents present, we need to find other ways to make systemic changes. “No-talk therapy,” which emphasizes individual connection, competence and creativity, goes beyond traditional approaches. It works when we give up on our obsessive need to dwell on problems and find, instead, something to cheer about.
There are times when not talking is the only form of communication available to an adolescent. The silence can have so many sources lack of skill; boredom; powerlessness; feeling trapped; alienation; shyness; control issues; even terror. These are all potent reasons not to talk. The seemingly barren therapy hours that follow can cause even the most seasoned therapist to feel like a first-year grad student. And, as our anxiety increases, so does the possibility for a head-on struggle in the therapy room. This kind of confrontation is even more likely in family therapy, as we juggle alliances between parents and kids. Before we know it, we’ve become another threatening, cajoling, nagging and pleading control agent in a teenager’s life. Teenagers rarely resort to silence as a first option. By the time they refuse to talk to therapists, adolescents usually have many other people in their lives reminding them of their ineptitude. Their wordless tenacity as parents, teachers, doctors and therapists command them to speak merits both empathy and respect. After a while, silent kids can usually learn to tolerate family therapy and more active problem-solving, but first they need something to be proud of and someone to feel close to.
Eliza Bennet is a fierce and wary 15-year-old girl with long, dusty dreadlocks, a pierced eyebrow and an attitude. Following a Tylenol overdose, she had been admitted to the mental health unit at the local hospital. Her 10 days there had been remarkably disruptive and unproductive. She had, by all accounts, turned the place upside down, staging sit-ins at the nurse’s station for more cigarette breaks and refusing to attend family meetings. Staff had to lock the unit after learning she had been organizing an escape of her fellow patients. She would not speak to adults about how she was feeling, but filled notebooks with raging diatribes about the assault on her dignity there. The referring social worker told me that Eliza had finally signed a contract that included participating in outpatient treatment and taking antidepressants. However, she had added a couple of conditions of her own: She would not “do” family therapy and she had to regain all the freedoms she had lost before the suicide attempt. But, with her insurance used up, there had been little time for prolonged negotiations.
I agreed to treat Eliza, although I insisted on beginning with the whole family; if Eliza did not want to talk while we discussed their concerns, that would be okay with me. I needed to hear what her parents had to say and wanted to see how she acted with them. Even if I ultimately decided to do mostly individual therapy with Eliza, I still wanted to establish a precedent for parent or family sessions early on, remaining flexible as the work progressed. My first assumption about Eliza was that her terms for therapy not talking, not wanting her parents present -were a last-ditch effort to preserve self-esteem. She knew that the focus would be on her failures she was smart to want to avoid that discussion.
Eliza came with her parents to our first meeting. When I went out to meet her, she was sprawled on a couch in the waiting room looking at People Weekly while her parents and other patients were squashed together in the remaining chairs. When I introduced myself, she glanced at me briefly from under piles of hair, her hazel eyes disarming-ly intense. She then returned to her magazine. Eliza’s father told her firmly to get up. I offered her a cup of coffee or tea. She poured herself some coffee, dumping six teaspoons of sugar into it while her mother silently grimaced, and sauntered down the hall into my room. Knees tucked under her chin, Eliza glowered at the floor as we discussed her parents’ concerns, the hospitalization and Eliza’s development over the years. True to her promise, she did not speak.
The Bennets shared a familiar litany of disappointment that typically precedes this level of alienation poor grades, acrimonious family relationships, probable drug involvement, marginal friends, few outside interests. The family had moved to town, against Eliza’s wishes, the previous fall, and her adjustment to the new life had been poor. She once had been a helpful oldest sibling, a good student and a nice kid, but had spent the year floundering. Her parents at first had been sympathetic to the difficulty of changing schools during sophomore year. Gradually, though, they became less willing to indulge Eliza’s griping and began to clamp down on her. Three younger siblings were all doing well. Her suicide attempt had followed being grounded for a failing report card. Starting off with all of this anger and pain can reinforce a teenager’s determination not to talk. In hindsight, I might have done better to have the family meeting later, or just hold the first session without Eliza.
I asked Eliza’s parents to leave and spent the remainder of the time with her alone. Concerned that she now thought I was “out to get her” like everyone else, I began by asking, “Why do you think I asked your parents for all that information?” She shrugged and replied, “I have no idea.” Like most furious teenagers, Eliza operated under the assumption that, as a group, adults act in cruel and senseless ways. The past six months of Eliza’s life had led her to feel she had no say over things that mattered to her; the hospital had left her feeling even more powerless, despite her wild protests. Given this recent history, my first priority was to set the record straight I was different. I told her I believed I could help her and that, while I admired her spirit, I thought we needed to work a bit on her style. This was her therapy and I was not going to take ownership for what happened here together we needed to come up with a plan. I also said that I hoped we could have fun and that I wanted to get to know her. I then sat back, telling myself to keep breathing.
After several geological epochs passed, Eliza sighed, wearily, “It’s all so pointless.” She stared at the clock and wedged her coffee cup between two puppets so it looked as if they were sharing it.
“That’s completely true, and you can still have some fun in the next 70 years,” I replied, unwilling to be diverted from a more positive opening chord. “What do you like doing?”
Eliza looked at me for perhaps the third time since we met and said she wanted to be lead singer in a band someday, even though she knew it wouldn’t happen. I wondered out loud why she wasn’t starting her own group right now; she had free time and friends who also played guitar. Eliza picked at her sneaker and said softly, “Maybe I will.” A few minutes later, she walked out without saying goodbye or indicating whether she would return the following week.
In no-talk therapy, there is, of course, some dialogue, if only now and then. The conversation seldom, however, concerns problems and their solutions. When kids don’t want to talk, they are typically both bored and degraded by the discussion of their problems. Rather, we talk about, and do, things that build a sense of competence, comfort in the therapy room and control over their own behavior. In that first session, my primary aim was to find out about one thing Eliza enjoyed and felt good about, and get her to do more of it. I did not ask about her depression, her family problems or her hatred of school.
This is not flashy work. Change in no-talk therapy is usually incremental; no presto, change-o here. It is, more than most therapies, about unseen and unspoken connections. A few weeks into the treatment, the relationship feels stronger. The adolescent who has kept tenuous control by remaining mute may at least be playing five-card stud or sharing a bowl of popcorn. She may even start talking. With the basic needs for competence and connection in place, change can follow quite steadily. In this therapy, kids are involved in finding out about those aspects of their lives they can control and the contributions they can make.
The next week, Eliza brought a People magazine into my office and asked if she could copy an article about a musician she particularly liked. I followed up with a couple of questions about the music, which she answered briefly, but without much irritation. Encouraged, I asked her to bring in a tape of the group so I could hear it. She did not respond. We then launched into silence. The no-talk dance is a two-step, with the adolescent always leading. In this, we are both clumsy; we approach and retreat not knowing where our feet are all the time.
A few minutes later, Eliza, glancing around the room, noticed her coffee cup still sitting on the puppet shelf. “Hey, is that mine!?”
I was embarrassed at the obvious chaos of my life. ‘Yes, I suppose it is. I guess I didn’t do such a good job cleaning my room.”
Eliza seemed delighted for the first time. “Cool,” she said, looking right at me. She gulped down her current coffee, then put the second cup inside the first. The seedling of a relationship began to grow at that moment. We fell silent again for several minutes, but this time something new was in the air. I couldn’t have planned this intervention, but had the sense to appreciate it. Each week for the next few months, the stack of cups grew alongside us.
Part of the early work with teenagers is aimed at making a connection at a safe developmental point perhaps before life gets so difficult. I willingly support regression; if kids don’t talk, they still can play. When I pulled out a deck of cards the next week, Eliza looked at me, surprised. I shuffled for a few minutes, engaging her slyly in a conversation about games she liked “as a kid.” We played cards in companionable silence for the next three weeks. She taught me several new card games, patiently going over the rules as necessary. I continued to avoid questions about her life outside the room. I did ask, during the early weeks, about suicidality, as I informed her I had to as part of my job. Her responses were monosyllabic, but reassuring. In no-talk therapy, teenagers may be able to tolerate an occasional foray into more typical inquiry, especially if it is brief.
From time to time, I also sent Eliza silly greeting cards in the mail to let her know I was thinking about her when she wasn’t with me. I have found that this small effort has tremendous significance to teenagers. One of the challenges of no-talk therapy is finding other ways to communicate. Writing notes works on many levels here, including providing constancy to someone whose world is in flux. I also encouraged Eliza to keep writing in her journal, and offered to write her back if she wanted to keep one to share with me. Other no-talk kids have written with me this way, and, at the very least, my offer told Eliza I was interested in what she had to say. Toward the end of treatment, she brought in some songs she had written, though she never took me up on my offer to read other writing.
At the end of the month, Eliza came in and announced she had signed up, along with four friends, to perform in the high school talent show, and she was going to be the lead singer. She excitedly described in great detail what she planned to wear. For a new kid in the school, and one very much on the social fringe, this was a huge and daring step. I was, naturally, very enthusiastic, though, looking back, I may have been expecting changes too quickly. Teenagers who have made such a huge mess of things seldom just snap out of it.
Eliza’s mother called a few days later and asked if she could attend a session to discuss the problems Eliza was still having at school and at home. She had been suspended for smoking in the parking lot during class time and had stayed out all night drinking at a friend’s house with several boys, some of whom had dropped out of school. Her grades were improving and she seemed much less depressed, but she was still making some bad choices. I agreed that we needed to meet, but this time I wanted to strategize with Eliza to see how to make it helpful to her.
“Your mom called. She wants to come in,” I opened the next session. “What should we do?” Eliza was not surprised; her mother had told her this already.
“I’m not coming.”
Here we go again, I thought, quickly running through how I felt about all of this. I could simply meet with her mother, but the prospect of discussing Eliza behind her back felt all wrong. If our goal was getting her more in control of her life, she’d have to be a part of this. On the other hand, if I aligned myself with her mother too much, I would lose the fragile connection I had worked so diligently to achieve.
“I want to hear about how you see all of this, but I hope you can also brainstorm with me about how we’ll handle it,” I said, making an effort to get on the same team.
She slowly responded, “I already got grounded for staying out. I don’t see the need to talk about this anymore. She wouldn’t have let me go if I had told her about it, so, of course, I lied. What would you have done?” Eliza was mad, but she was telling me about it. I let the silence simmer a minute. I was thinking to myself, “Spending the night with drunken, drop-out boys, are you nuts!?” But, I spoke cautiously. We’d been playing a lot of blackjack, so I described what I knew about her gambling style: ‘You’ve had a few good hands, now. You’re feeling better and doing better. People start expecting you to play for higher stakes when you’re doing well. But, sometimes you gamble way too much and lose most of your savings, you know?” Staying in the playful language enabled us to talk more safely. I let the image sit there, afraid, really, to say more. If I kept at it, we would have entered lecture mode before long. I’d be dishing out gratuitous advice like that Kenny Rogers song about knowing when to hold ’em and fold ’em, and Eliza would probably be entering her no-talk zone.
“I could still get a better hand, you know. You saw me do it.” Eliza was in the conversation. We still hadn’t resolved anything, but I was determined not to push her any further. Nonchalantly, I grabbed the deck of cards and started shuffling. I was ready to stop the discussion if she needed to back off here. She made no gesture toward the poker chips and did not seem to want to play. I kept shuffling. She scowled. Minutes passed. I put down the cards and breathed on.
“So,” I finally ventured, “She’ll come next time. And . . . .”
” I am doing better.” Eliza looked tearful. I hadn’t seen that face before.
“Okay, that’s right. I can tell her that. But how else will you get more chips? If you come, you can say this, too. Otherwise, we’ll be deciding it for you.” Again, I resisted the urge to solve this for Eliza. We were, briefly, into problem talk, and I didn’t want the discussion to replicate her past experiences.
“She treats me like the little kids. It is ridiculous to expect a 15-year-old to be home by 11:00 on the weekend. I’ll just stay at Sarah’s when I want to go out late; her parents don’t care when she comes in.” Eliza stared at me, challenging me. I decided to summarize what I thought we were saying. We expect bright and oppositional young adolescents to have abstract reasoning abilities and logical thoughts, but in my experience, they seldom do. Notably, refusing to talk does little for the development of negotiation skills. I saw little percentage in discussing curfews at this point. Eliza lacked the skills and confidence to advocate thoughtfully for herself; it would be an ugly scene. And, without a working relationship, I was in no position to impart negotiation techniques to her. So, I kept to a plan that incorporated no new issues and had a straightforward strategy.
“Okay, how about this, then? Your mom will talk about the stuff you’ve been doing. I’ll say I can see why she’d be worried, since I’m a mother, too. It’s in our job descriptions and we’re supposed to fret. If you come, you could then say that you have been doing better. I’ll completely underscore this. Since I’m such a big fan of yours, this will be easy for me to do. I’m going to ask her to describe some of the changes she’s seen. Do you think she’s so mad at you she won’t be able to do that?”
Eliza shook her head. “She liked my progress reports and she picked me up at rehearsal, so she’d better say that I’m doing more things. And, the contract I’m coming here and taking my happy pills.”
“Money in the bank. Are you in agreement?” Eliza shrugged, but seemed to concede she could handle it. I said, “I think you’re brave to do this. I know how you feel about family meetings.”
The following session went according to our strategy. Mrs. Bennet was able to be quite enthusiastic about Eliza, after confirming that I knew about what had been happening. Eliza knew I was going to be sympathetic to her mother, so didn’t have to worry about my taking her mother’s side. While not talkative, Eliza dutifully mumbled out her part about trying harder. I reiterated my sense of her efforts and told Mrs. Bennet she had a great kid. Clearly more worried than angry, Mrs. Bennet even bought Eliza’s proposal to stay at a friend’s house that weekend when the grounding ended.
After this session, our individual therapy resumed, though not exactly as before. Eliza was more willing to talk, particularly after the successful talent-show performance. We still played cards and drew pictures, but these were background activities to our talks. By the ninth session, three months into our work, we were able to begin to have some of the problem-solving and planning discussions that characterize more traditional therapy with adolescents. A family session with both parents was also quite upbeat. They had visited relatives over spring vacation, and Eliza had been her former, helpful self. She exhibited greater confidence, her grades were improving and she was staying out of major trouble at home (though mostly by being smart enough not to get caught). When, a few weeks later (and under pressure from managed care), I suggested we take a break from therapy, Eliza agreed that she was ready. I asked her what I should do with the 12 cups stacked neatly on the shelf. She said, “Keep them here. Put flowers in them.” She then looked straight at me and smiled.
by Ron Taffel
ALL TREATMENT WITH troubled teens should go this beautifully. Straus’s “no-talk” therapy skillfully combines a group of classic family therapy techniques -joining, refraining, structural reorganization, emphasis on competence and connection. Several aspects of her handling of the case stood out for me as representing the best of family therapy’s clinical tradition:
Starting the Relationship: At the beginning of treatment with untalkative teens, it is particularly important not to undermine the potential for connection by dwelling on problems. Family therapy has always emphasized what clients can do rather than focusing on what they can’t do well. True to this tradition, Straus refused to pathologize and instead gave Eliza “something to feel proud of and someone to feel close to.” The well-chosen words Straus used reflect the great works of Cloe Madanes, Mara Selvini Palazzoli and Michael White: she strategically put Eliza in charge of the therapy, paradoxically prescribed the presenting problem by telling Eliza it was fine not to talk and deftly reframed the focus of treatment from Eliza’s “irresponsibility” into helping her with her “style.”
Finding a Common Language: Once the basis for a relationship was established, Straus needed to create a mode of communication that would not itself become a power struggle. She turned to an approach we family therapists tend to keep at the bottom of our therapeutic bag of tricks avoiding the distractions of language, Straus played cards, shared popcorn, discussed music and encouraged journal writing. Developing a “space for play,” as child analyst D. W. Winnicott put it, is helpful to kids of all ages.
The Transformative Moment: With the structure of a good relationship in place, only one more therapy ingredient was necessary. Straus had to show Eliza, as psychiatrist Harry Stack Sullivan once said, “That we are all simply more human than otherwise.” Untalkative patients feel so belittled and compromised that such a discovery immediately levels the psychological playing field. Family therapists Nathan Ackennan and Carl Whitaker were pioneers in the art of transforming treatment into an
unpredictable exchange between imperfect beings. Straus joined this notable group of joiners with her wonderful self-revelation: “I didn’t do such a good job cleaning my room.” Eliza must have thought, “Ah, a nonhypocritical adult, a fellow traveler willing to admit that not everything about her is always right.”
Metaphor and a New Narrative: Triggered by Eliza’s acting out, Straus considered holding a family session. To handle Eliza’s discomfort, Straus dipped into the creative soul of family therapy: metaphor. Appealing to her client’s scoundrel self, she deftly chose the image of playing poker. Once drawn into this imagery, Eliza agreed to the family meeting. Straus artfully sided with the mother, strengthening and humanizing the parental subsystem. Salvador Minuchin or Jay Haley could not have done it better. Eliza now feels safe enough to continue reworking her life narrative from troubled revolutionary to a savvy poker player who is much more effectively involved in the game of school and remains the good-enough daughter.
Even reticent adolescents inadvertently reveal much about unspoken family legacies through their behavior. In the same vein, the techniques Straus used without a lot of fanfare wonderfully display our most treasured clinical heirlooms: tried-and-true interventions handed down by generations of therapists. This is an excellent teaching case precisely because it demonstrates how certain classic interventions and family therapy skills can still be used to connect with postmodern clients.
Martha Straus, PhD, a professor in the Department of Clinical Psychology at Antioch University New England, is the author of No-Talk Therapy for Children and Adolescents, Adolescent Girls in Crisis, and Treating Traumatized Adolescents: Development, Attachment, and the Therapeutic Relationship.
Ron Taffel, PhD, is Chair, Institute for Contemporary Psychotherapy in NYC, the author of eight books and over 100 articles on therapy and family life.