Anger is the normal reaction to teenage defiance, even for therapists, but clinicians typically receive little if any training in therapeutically using the anger that resistant teens provoke. However, a therapist's ability to tolerate and use his or her anger in clinical work can often be the most helpful tool for engaging these difficult clients.
When this understanding of therapeutic anger is employed in the treatment room, the old therapy term joining needs to be conceived in an entirely different, paradoxical way: it now means challenging and pushing back with equal force. With this approach, certain high-risk teen clients—who typically don't respond to softer, more empathic method—feel engaged and understood, since their unmetabolized anger is immediately acknowledged and addressed in the treatment process. The therapeutic use of anger has been a part of traditions as divergent as the "tough love" approach in substance abuse treatment and the well-established modern analytic approaches of Hyman Spotnitz and Robert Marshall.
Admittedly, the approach described in this case study challenges many of the principles of standard therapeutic etiquette. But we believe that "making nice" is doomed to failure when working with too many troubled teens who might otherwise be helped. From the very first moments of the initial session, our goal is to match the teens' negative intensity: to take what such rude and dismissive clients so readily dish out and give back the same. Instead of antagonizing these clients, this kind of mirroring allows them to feel safe and understood, enabling them to experience the therapist as someone who can meet them where they are emotionally. This initial joining can then set the stage for more sustained, long-term therapeutic work. The following case study shows this approach in action.
Jason is a tall, lanky, 17-year-old teen dressed in the mandatory XXXL T-shirt and jeans. Having been described by his parents as a "difficult child," he presents with a long history of problem behavior that includes polysubstance abuse, petty theft, drug dealing, and fighting. He's been brought to treatment by his father after being dismissed from yet another private school for a violation of its drug policy. Jason sits in the chair, looking at the floor, arms crossed in front of him, as if saying "I dare you to get me to talk." In the waiting room, within earshot of other clients, he'd loudly stated that he wasn't going to talk to some "faggot shrink."
Once alone with the therapist, Jason looks away angrily, and declares, "I don't need to be here. I don't know who the hell you are and what this is about, but I ain't saying shit and I don't need a shrink. You and my parents don't know anything."
The therapist meets Jason's initial stare with a big smile. "Let's get something straight," he begins. "I don't know who you are, and I don't know who you think I am. Here's how I see it. To me, you're just my 2:30 on Tuesday. I give even less a shit about you than you do about me. After you leave here, my life doesn't change at all. If it's not you, it's some other asshole in this chair at this time."
Admittedly, this approach is risky in that, in learning the techniques, the accurate "matching" is critical, so as not to overwhelm or unnecessarily provoke the client. In this case, Jason gives the therapist a look of genuine surprise, but also a small smile, suggesting he feels understood and "held" in a way more congruent with his personality than would be the case with a more traditional approach. His smile signals that he sees himself in the therapist.
As this example makes clear, in this model, therapeutic authenticity includes use of one's own anger. This isn't hard to do if you let yourself respond to what the teen is giving you. It's important to recognize that the therapist doesn't just react angrily, but strategically "doses" an angry response to match the teen's comments. The key here is to register the anger coming from the client, discern what it says about what the teen is feeling and communicating, and reflect it back in a similar tone, affect, language, and intensity. The therapist's "real self" has to include using the feelings that arise therapeutically in interactions with the client. All feelings count.
Having made the initial joining, there's an opportunity for the therapist to begin helping the teen to talk more openly about the reality of his life. The therapist continues, "Let's look at what's ahead for you right now. Your parents already wasted a whole lot of money on your school. Do you really think they're going to feel generous and get you a pony? I don't think so. I see tough love written all over them. Besides, you're 17, and soon the law says you're free to go. I know you think that's great—you can get laid and party all you want—but where are you going to get the money to live on?"
Subsequent to the initial confrontational joining, Jason becomes more engaged. He begins to protest in a more positive way. There's a little less cockiness now: "Well, I'm a hard worker. I'll work my ass off." Had Jason continued to challenge angrily, however, the therapist would have continued to challenge in equal fashion, creating a sense of sameness that makes a self-centered teen less defensive.
The therapist interrupts and rolls his eyes: "Doing what? Landscaping, serving fries, stacking shelves? What kind of car are you going to drive making seven bucks an hour? What kind of ladies are you going to attract? Let's see, seven bucks an hour, fourteen thou' a year. Oh yeah, Uncle Sam is going to want his, so now you're down to about a thou' a month. Here's what it's going to look like—no car, living in a crummy apartment with four or five of your dropout friends, and dating your right hand."
Jason's smile is now wider. He feels understood. All the major developmental struggles of young adulthood are right there—career goals, image, self-worth, and romance. Therapist and adolescent argue a little bit more, but the fight is gone.
In this case, the therapist has created a twinship of mutual challenge, distance, and angry affect that gave Jason the space and safety he needed to talk. Now the two talk about hobbies, ambitions, and aspirations. They jokingly agree that the therapist's job is "bullshit," that crazy parents pay him crazy money to make sure their kids go to college. They agree that the young man would be good at the therapist's job, provided he was willing to go to school for the next 10 or 15 years.
Over the next few months, Jason, having felt understood and matched, is able to talk more openly and put energy into problem-solving, as opposed to his customary defensiveness. When angry teens don't have to put their emotional energy into protecting themselves, they're freed up to explore their lives. In this model, when the teen can't elicit and sustain a battle with the therapist about the value of participating in sessions or whatever else, he's freed up to do the work of therapy.
Jason is now in public school, staying reasonably clean, and keeping on the right side of the law. He has a part-time job that has something to do with cars, his only identified area of interest. He's even talking about plans that include additional automotive training after he graduates from high school. This represents notable improvement after just a few months of therapy.
However, as Jason stabilizes, his parents decide to pull him out of treatment. The therapist requests a meeting with the parents to discuss both their decision and their general perception of their son's progress. They start off saying, "While we like you and appreciate what you're trying to do, we don't think this is working. Jason is still the same. Last weekend, he took our car out without permission, and when we came home from the club, he was in the hot tub with some girls." The tone of their voices then becomes louder and angrier. "When we confronted him, he told us to go to hell!"
The therapist responds with a challenge to their unrealistic expectations. "What did you expect? He's been a defiant jerk for the better part of his teenage life, and we've only met a dozen times. Of course he's going to abuse your generosity and resources. Be thankful that it wasn't your neighbors' car or their jailbait daughters. Frankly, I'm delighted that Jason isn't in jail. You want me to fix six years of insanity in six-hundred minutes of therapy? Is that what you were hoping for when we started? Why didn't you tell me that at the get-go? We could have saved each other a lot of time, money, and disappointment."
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.
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.
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.
This blog is excerpted from "How to Engage an Angry Teen," by Victor Shklyarevsky. The full version is available in the March/April 2008 issue, A Nation of Insomniacs: Reclaiming the Lost Art of Sleep.
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