Jerome Price and Judith Margerum
Most therapists agree that teenagers can be among the most difficult clients we see in our practice. They often refuse to attend sessions, refuse to speak when they do attend, swear at parents and therapists, and storm out of the room when they hear things they don't like. Difficult teenagers often argue head-to-head with adults, saying things like, "I'm not going to give them any respect if they don't give me respect," and "It's my life." At times such teenagers have thrown objects across the office. One particularly aggressive 12-year-old girl once threw her wooden-soled sandal directly at my face hollering, "I'm glad I'm not one of your kids!" Some teens are so direct that they come out and say, "There's nothing you (the therapist) or them (their parents) can do about me."
Any therapist treating domestic violence takes one look at a husband who is dominating and abusing his wife and recognizes that he exercises power over her. Yet, when a teenager threatens, dominates by shouting and imposing guilt and controls her parents by threatening to run away, too many therapists fail to realize that abuse is going on.
Adolescent and preadolescent behavior begins at younger ages as our culture educates them more rapidly. As psychologist David Elkind pointed out decades ago, children are growing up more quickly and losing their childhoods too early in our fast-moving society. As teenagers become adult-like at earlier ages, they see themselves as "equal" to the adults. Our society isn't teaching them that while they are valuable individuals, they don't have the same authority as adults. Teens are extremely vulnerable to believing that they can handle everything and don't need adults. They are struggling to take control of their lives at the same time parents are struggling to give them that control only when they're ready to handle it. There's a natural power struggle.
So, how does a therapist treat a struggle between a teenager and his or her parents? Does he ignore the power issues and treat everyone as equals or, understanding the need for order in a child's life, does he provide support and leadership? Therapies that advocate support without leadership fail, giving teenagers too much control. They begin to lag in school and get in trouble with the law. Emphasizing the clinical significance of leadership isn't new—Jay Haley, Cloe Madanes and Salvador Minuchin encouraged therapists 30 years ago to recognize the need for order and direction in a family's existence. The more stuck a case is, the more critical it is to take charge of the treatment.
There are four common errors that therapists make with teenagers. They are surprisingly simple to grasp, and they always make matters worse:
Mistake 1: Courting the Teenage Client. The seeds for the countertherapeutic courtship of teenage clients are generally laid in the initial phone call from a parent. The first words out of a parent's mouth often are something like, "The counselor at the school said we need to bring John in for family therapy, but John says we're the crazy ones and he won't come in. He said he wouldn't talk even if he did come in." This is the number one power tactic teenagers use to keep therapy from happening. When therapists tell parents there's nothing to be done if their child won't cooperate, we might as well say, "Sorry folks, but you better get used to your son's running your family."
At our clinic, our typical response when confronting this situation is to tell parents on the phone that we treat kids who "won't cooperate" all the time, and that they, the parents, must decide whether therapy is to happen. We suggest they tell their child that the session is scheduled and she's expected to be there, and if she is not, the grown-ups will meet anyway. We also coach the parents to point out that the adults will be talking about their child behind her back and making decisions about her life. Most kids come to the first session after hearing this. If they don't, we agree with the parents in the first session to change something major at home, and when their child gets angry about the change, to simply say, "Oh, we decided that at the therapy session." Teenagers almost always come to the second family session. As long as parents are reactive, and feel helpless and hopeless, the young person wields the power, dominates, controls, and simultaneously suffers.
Another way that many therapists court teenage clients and make matters worse is by according them the same treatment status as the adult clients. The prevailing belief—not supported by law—that teenagers are entitled to a confidential relationship with their therapists leaves a teenager who is drunk on power thumbing his or her nose at the parents.
We see teens alone at times, but almost never for a full session. We make it clear that we're closely involved with parents and we will use our judgment as to what we share with them. After all, what's the point of a teenager telling a therapist he's using drugs if the therapist can't help the teen discuss it with the parents and find a solution? We invite teens to withhold information from us until they decide we can be trusted. We find they share sensitive information with us even though we don't give them a guarantee of confidentiality.
Mistake 2: Telling Parents to Back Off. Teenagers almost always come into therapy complaining their parents are too strict and controlling. As a result, therapists who specialize in individual work with teens often get a misguided impression of what goes on at home and frequently advise the parents of teens to be more lenient--to relax their control. In fact, parents who yell and cajole are usually trying to avoid imposing a consequence on their teen. In that respect, they are actually protective and lenient.
Among the most harmful "back off" positions that therapists sometimes take with families is that young people have an inherent right to privacy outside the therapy room. Many parents we see report that previous therapists actually criticized them for nosy and intrusive actions. Consider the case of Mike, age 15.
Mike's parents brought him to therapy because he was failing in school, acting belligerent and, they suspected, using drugs. Mike spoke self-righteously as he explained his parents' shortcomings—they were too strict and overinvolved in "his business"—as though their strictness justified his drug use, blow-ups and refusal to work in school. The previous therapist, the parents said, had told them to back off and let Mike learn by his own mistakes.
When Mike and his parents came to the second session with us, he was met by a surprise. His mother handed me a small packet of cocaine and said that they had found it in Mike's desk. Caught red-handed, Mike was not the least bit contrite. He shouted, "What were you doing in my desk?"
In an instant, Mike's parents wilted and became apologetic. They went from a useful, proactive, parental posture to a defensive, reactive one. We affirmed that they had every right to gather information about their son's illegal and dangerous activities. With our support, they got tough with Mike and laid down the law. They told him he had to go into drug treatment and they took away the car keys. Furthermore, he was grounded until his grades went up and they unplugged his phone and computer. Finally, they told him they were considering sending him to military school. Once Mike realized he had to take care of business and change his behavior, the case progressed well. His parents then felt freer to be loving and supportive of Mike.
Mistake 3: Relying on Family Communication. The most pervasive idea in both individual and family therapy is that young people run amok because the family doesn't "communicate" well. Too many therapists focus on discussing what each member of the family feels without acknowledging any difference in status between children and parents. They seem to believe that children may comment on parents' sex life or spending habits as freely as parents would address the same subject with their child. But when a young person is out of control and drunk on power, this attention to open communication is like throwing gasoline on an open flame. I once told a 12-year-old client who was insulting her parents in a session to stop speaking that way. She leapt up, pointed at me and shouted, "You're a therapist. You have to let me say whatever I want as long as it's what I really feel!" I realized that this is what she had been taught by former therapists. Therapists commonly teach parents and children to speak in "I" messages, and when no power struggle is going on, this practice is perfectly reasonable. However, when adolescents are angry and explosive, there is typically a power struggle going on, and this level of communication inflames it by raising an out-of-control teenager's status to that of an equal partner with his or her parents.
Mistake 4: Succumbing to Tunnel Vision. Therapy is usually an individual or family process. But when treating explosive teenagers, we've found that it is necessary to look at an even bigger picture to find solutions. What's the school's role in maintaining this problem? Is the judicial system turning its back on a family in need? What about the extended family relationships? Could the therapy itself be keeping the problem going, rather than resolving it? In general, who else is involved in the problem and who else needs to be involved in the therapy? Without taking this extra step, many therapies of difficult teens will fail.
Almost all therapists who have worked with teenagers have found themselves stuck in a clinical impasse with an explosive teen and his or her family. Yet it's never too late to make a paradigm shift and help a family by using the clinical approach suggested here. But first, a therapist must become comfortable with the idea of dealing with power tactics rather than communication skills. Doing so also requires getting used to having teenage clients who don't like the therapist. The more aggressive a teenager is, the more certain it is that they'll try punishing the therapist. When they call me names I usually say, "You can't hurt my feelings because I don't love you. So I'll keep doing what needs to be done."
Therapists are mostly kindly helpers, so it's counterintuitive for a therapist who works toward nice outcomes to step toward the fire and heat things up. However, once a therapist has helped parents take charge and has seen the remarkable positive transformation in a formerly tormented teenager, it becomes easier to work this way. Parents start out saying, "It looks like my daughter's possessed." At the end of six or eight sessions, the same parent says, "My daughter's back. She isn't always sweet, but the girl I love is back."
This blog is excerpted from "The Four Most Common Mistakes in Treating Teens," by Jerome Price and Judith Margerum. The full version is available in the July/August 2000 issue, 24/7: When Does Work Become an Addiction.
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