Twenty-year-old Lara is sitting where she always sits, as am I. She’s comfortable here and surely knows how much I enjoy her. She has a new relationship and a new tattoo. Her dad knows about the former but not the latter. “He’d kill me,” she says. “After my first tattoo, he told me he wouldn’t help me pay for classes if I got another one.”
“Well then, you’re playing with fire,” I say.
“He won’t follow through. I can hide it from him anyway. And ohmygod I’m 20. It’s my body!”
Lara and I have spent many sessions dealing with her loving but anxious, overprotective father. And because I’ve known her since she was 12, her father was present for most of those sessions. I specialize in anxious children and teens, but I don’t see them alone. Anxiety is a family thing, and parents need coaching. Generational patterns aren’t broken by 10-year-olds sent back into an entrenched dynamic, armed with breathing exercises and reassurance. The rule in my practice: if you can drive to your appointment alone, you can come to your appointment alone.
Although we still have occasional family meetings, Lara now comes in on her own. We’re on the upside of a serious crisis that happened when she went away to college, almost two years ago. Given how capably she was managing her anxiety, I didn’t actually see her much during her junior year of high school and not at all her senior year. But after her first year in college, she was depressed, failing academically, cutting herself with razor blades, and filled with shame. Once home, she came straight to my office.
Lately, I’ve become aware of just how much of my practice is made up of young adults like Lara, whom I’ve known since they were little. In part, this is the natural result of having lived and practiced in the same town for almost 20 years: my teacher friends now have classes filled with their former students’ children; last week, I saw my son’s former babysitter pushing her baby in a stroller. But this pattern is also indicative of a generation of young people in trouble, stuck in the transition between childhood and adulthood. Unable to let go of one trapeze and trust that another is heading their way, they feel more scared and alone than ever.
Jane Brody, in her New York Times article “A Road Map Out of Loneliness,” writes of the high incidence of loneliness and isolation in 18- to 24-year-olds these days, and its unsurprising correlation to suicide. She adds that loneliness in this age group is far higher than in the elderly—as much as 50 percent! Jean Twenge’s recent article in The Atlantic, “Have Smartphones Destroyed a Generation?” describes teens spending less time with friends and feeling less connected to parents, despite spending more and more time under the same roof with them.
So what’s my role with my “long-term” clients in this age group who leave the nest for college but keep swinging back for therapy? Sometimes I wonder if there’s something contradictory about my practice. I describe myself as a brief therapist, who from the first session works to identify the therapeutic target and teach skills to address it. I bemoan unnecessarily prolonged multisession assessments and am adamant about offering parents and children concrete instruction immediately. Yet I’m starting to revel in the decades-long connections I have with certain clients, in the privilege of being there as they wade through the tween years, navigate adolescence, and venture into adulthood. I’ve come to realize that I can simultaneously be an important connection in the present, right here, and a conduit to the real world, out there.
Treatment with these clients usually begins when parents recognize that anxiety has taken over parts of their child’s life: school attendance is dropping, isolation or explosive behavior is increasing, or physical symptoms are dramatic. After they learn as a family how to recognize and manage the worry, long remissions are common. I rarely see them every week, or even every month. Rather, over the course of the years I know them, these families show up at predictable milestones, like the start of middle school or high school.
Some think preventively, returning to therapy in preparation for a transition. Others call when a crisis occurs and the anxiety grabs hold again: a divorce, the discovery of substance abuse, a broken heart, a diagnosed illness. With clients like Lara, the launch from home doesn’t go as planned. They return feeling lost, and tears come easily, but we’re always happy to see each other.
It’s common for symptoms to reemerge when life gets more complicated or changes course, so I honestly wasn’t surprised to see her. My job is often to revisit what my clients already know and then talk directly about the prevention in the future. I knew she had the strategies—we just needed to bolster them up, reactivate them. We talked about what she ignored or lost track of in herself, and asked important questions that this young adult needed to address: how will she know in the future to seek help? How and to whom will she communicate her feelings of being overwhelmed when they arrive? What are the signs she must recognize when she’s on her own?
Had I been meeting this distraught family for the first time, I can imagine being a bit overwhelmed with all that was happening. Most clinicians know exactly what it’s like to sit in those initial sessions with a person in crisis, when you hope you’re making the right moves, feeling both responsible for what happens and a newcomer to the party. But here’s where the years of connection made all the difference with Lara and her parents. In the midst of this crisis, I didn’t need to sort through their history, their relationships, their coping strategies. Like the small-town family doctor, I had access—not always the case with a young adult—to the bigger, fuller family portrait.
Perhaps most valuable during this tough phase was the trust that already existed among us all. Because of our connection, Lara’s parents trusted me enough to be direct, to ask me pointed questions, and to tolerate the discomfort of what we were discussing together. And I trusted them as parents. I’d seen their ability to follow through, to be loving and open, and to recognize when their own anxiety was perpetuating Lara’s or getting in the way of treatment.
Lara trusted that I could help her and, given her previous experience with my approach, knew I’d require her to do things that might be uncomfortable: communicating with her roommates at school about her plans to take a year off, returning to her part-time job at home, and exercising at least three times a week. She was self-conscious about being back home, and not sure how to respond to the normal questions people would ask her about her first year at college. Her anxiety magnified her fear of how others would react, the uncertainty of what they’d think about her. We knew her anxiety and depression would fully support avoidance, so she needed to do the opposite: step in, communicate, get out of the house, be active.
Our past success together created a positive expectancy that made the process move more smoothly. We could talk openly about the cutting she was doing at school and how she could share her thoughts, concerns, and feelings with her parents without such discussions turning into conflict and fueling feelings of isolation. We framed her panic, depression, and withdrawal during her second semester as a “bad breakup with her future plans”—she’d gone off to college certain of her career path (and with her parents’ enthusiastic endorsement), only to discover it wasn’t what she wanted.
She’s now spent this past year at home recovering from this breakup, being unsure of how the rest of her life will go, taking classes at the community college in town, and exploring what’s next. Her energy has returned, and she’s discovered a new career interest, quite by accident: working with an organization that trains service dogs. I’ve tracked a wonderfully normal push-pull with her parents as she’s bemoaned her father’s demand for a curfew and an equally normal sense of anxiety as she’s moved into a new intimate relationship and planned an adventure trip to Mexico with an old friend.
As we note each positive step forward, much of our time is spent talking about maintenance and prevention. In particular, we’re building a new pattern of seeking support and connection when the inevitable bumps of increasing autonomy and adult decisions leave her feeling unsure or even panicky.
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As a therapist, I don’t aim to be the main source of deep connection for these young adults. Quite the opposite. But my role as therapist is undeniable. Sometimes, at critical moments, I’m the lifeline, the hope, the constant. Sometimes, I get to be the cheerleader, the reality checker, the teacher who both models the new possibility and guides the skill-building that results in solid decisions and healthy relationships.
Therapy ends for all sorts of reasons. Plenty of families see me briefly. I often do one-time consultations. People get what they need and move on. But it seems that these young clients making the transition toward adulthood may be in more need than ever for ongoing connection and an open invitation to return as needed.
Is it the best strategy? Will it backfire? If we can use the connection to teach skills and normalize the uncertainty of transition, then I don’t believe so. Sometimes it feels like a replay of what toddlers do on the playground: venturing out and running back, just to check in, hand us a little treasure, receive a little encouragement, and then head out again. Twenty-nine years into my career as a therapist, as I witness these young adults move into the world, this type of connection and continuity feels more vital than ever.
Lynn Lyons, LICSW, specializes in treating anxious families. She’s the coauthor of Anxious Kids, Anxious Parents and Playing with Anxiety: Casey’s Guide for Teens and Kids, and the author of Using Hypnosis with Children: Creating and Delivering Effective Interventions.
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