Q: In my practice, my work with many teen clients becomes a standoff. How can I better engage them?
A: Trying to get in the door with provocative, therapy-savvy adolescents can be a challenging task for even the most seasoned of therapists. Some adolescent clients are masters at putting up the invisible force field while pushing our buttons, or telling us what we want to hear and side-stepping responsibility. Through the years, I've developed several engagement strategies that I regularly use, singly or in combination, that have consistently helped me to establish a therapeutic alliance with even the toughest teen client.
1. Mirror the adolescent's nonverbal behaviors. One way to establish rapport with teens who refuse to talk is to mirror their body language and postures. This may include mimicking their facial expressions, sitting slouched or sprawled out on the chair, moving your legs in a nervous fashion, and tapping your hands on the chair arms. Inevitably, the adolescent will notice what you're doing and may even laugh, which can launch the rapport-building process.
I once worked with a 16-year-old named Sally who was diagnosed with borderline personality and bipolar disorder. She'd seen seven therapists before me and had been psychiatrically hospitalized three times for cutting and running away. In our first family session, Sally spoke little and wouldn't respond to my questions. However, what she really enjoyed doing was swiveling around in one of my office's swivel chairs. So I decided that I'd begin our next family session by meeting alone with her so we could swivel together as our warm-up before getting down to work. Sally smiled at me while we were sharing this activity together in silence. I recommended that we swivel counterclockwise four times and then four times clockwise at the beginning of each session. Not only did she agree to try out my idea, but she thought it was hilarious.
At this point in the session, she began to open up about some difficulties she was having with two peers who were spreading nasty rumors about her at school. Her desire to learn how to constructively manage this peer dilemma ended up becoming her initial treatment goal.
2. Honor and respect silence. The deep mistrust some adolescent clients feel toward therapists may grow out of negative previous experiences in therapy: perhaps their confidentiality was repeatedly violated, their parents' intolerable behaviors didn't change, or their situations actually worsened as a result of working with the therapists. These kids may already feel invalidated by their parents, teachers, and other adults in their lives.
It's important to remember that even with the most silent of adolescents the wheels are a turning in their minds as they size us up. As therapists, we need to be able to tolerate long silences, and still maintain our connection with the adolescent. By not giving up on the silent adolescent, we're conveying that we'll hang in until he or she is ready to talk. I usually say to them, "I just want you to know that I'm not going to tell you how or when to change—that's completely up to you to decide. But if and only if you decide you want to do something about your life, I'll help you out in the best way I know."
Another useful ice-breaking strategy is to say, "In order for me to get to know you better as a person, I'd like you to bring in some of your most favorite music." I've yet to have an adolescent not bring in music to our next session. I also like to compliment silent adolescents for showing up for our session, and for being respectful, reflective listeners.
3. Dance the two-step tango. This strategy is particularly useful for adolescents who are being forced to see us. The first step is to empathize with the adolescent about having to see you and the other consequences he or she has incurred as a result of alleged misbehavior. The second step is seeding the benefits of changing the behavior that led to the referral.
Candy, who was 17, was referred to me with her mother by the high school dean because a teacher had found her cutting herself with a razor blade in the girls' bathroom. Up to the time I met with Candy alone, she'd made it quite clear that she didn't have a problem and that therapy was a waste of her time.
I began by empathizing with her for being forced to see me by her dean, who'd "continue to hound" her if she didn't get counseling. She responded that he'd "threatened to call in the district psychiatrist" if she wasn't seen by a therapist. I said, "It's not uncommon for students who are caught cutting to be evaluated by their district psychiatrists or taken to the nearest emergency room of a hospital and subsequently psychiatrically hospitalized. That's a real drag!" Candy got a scared look on her face and asked, "You mean that could really happen to me?!" I said it happens a lot to students like her.
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Then I observed that cutting must be doing something good for her since it had been going on for some time. I asked her how it had benefited her. Looking surprised, she said, "When I get upset with my boyfriend or my friends, it gets rid of my bad feelings quickly." I said I could understand how difficult it would be to give up something that had worked so well for her, adding that continuing to see me would not only keep the dean off her back but keep her from being psychiatrically hospitalized needlessly. She acknowledged that the very last thing she wanted was to have to go into "the nut house!" By this point, Candy and I had connected and she agreed to come back and see me again.
4. Make the Adolescent an Expert Consultant. Challenging adolescents who've had extensive treatment histories can offer us valuable wisdom about how to best help other kids just like them. In addition, they make excellent systems consultants regarding what specific parental behaviors or family dynamics need to change first to help them improve their own behavior.
Cecilia, who was 16, had a long history of running away from home, prostitution, incarceration, abusing inhalants, and gang involvement. Former therapists had labeled her a borderline, sociopath, and resistant. Sensing that she had all of the power in the family, I decided to meet alone with her first before seeing the parents separately.
I asked her what her former therapists had tried with her and her family that she didn't like and was "a real drag for her," so that I wouldn't make the same mistakes again. Immediately she responded, "Siding up with my mom against me . . . that makes me mad!" From that point on, I began each family meeting by seeing Cecilia alone first, giving her sufficient time to strengthen our alliance, and regularly soliciting feedback about how our work together was going. She later told me she felt "respected" by me and felt like her "voice was heard for once in counseling."
5. Be an intergenerational relations arbitrator. One of the biggest challenges about work with teens is walking the tightrope between meeting the parents' needs, expectations, and goals and doing the same for the teen. Therapists have to be good intergenerational arbitrators to be able to develop "something for something" contracts.
When I first meet alone with adolescents, I ask them three questions: "How can I be helpful to you?" "What's the number-one thing your parents do that you'd like me to work on changing?" "Are there any specific privileges you'd like me to fight for with your parents?" Most of the challenging adolescents I've been referred haven't been asked such questions, but with the help of their expertise, you can quickly find out what they'd like to achieve in therapy, what their parents are doing that fuels their acting-out, and what's in it for them to keep coming to sessions.
Once adolescents begin to see their parents' behaviors change and they start getting privileges back and gaining new ones, our alliances with them will get stronger and they'll often commit to changing their problematic behaviors.
Matthew Selekman, MSW, LCSW, is the codirector of Partners for Collaborative Solutions in Evanston, Illinois. He's the author of Working with Self-Harming Adolescents: A Collaborative, Strengths-Based Therapy Approach and the second edition of Pathways to Change: Brief Therapy with Difficult Adolescents.
This blog is excerpted from "Mission Possible," by Matthew Selekman. The full version is available in the January/February 2008 issue, Looking In, Looking Out: Mindfulness as a Path to Relationship.
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