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Creating a Therapeutic Alliance with the Troubled Teen

Matthew Selekman on How to Make Teen Therapy Engaging

Matthew Selekman

Building rapport with troubled teens in therapy can be a challenging task for even the most experienced therapist. A teen client can be a master 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 establish a therapeutic alliance with even the toughest teen client.

1. Mirror the teen’s nonverbal behaviors.

One way to build rapport with teens who refuse to talk is by using mirroring techniques, copying 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.

For example, 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 therapy 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.

At this point in the therapy 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 the first of several treatment goals.

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 turning in their minds as they size us up. By not giving up on silent adolescents, we’re conveying that we’ll hang in until they're 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.”

3. 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.”

4. 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.

This blog is excerpted from “Mission Possible: The Art of Engaging Tough Teens.” Read the full article here. >>

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Topic: Children/Adolescents

Tags: add | bipolar | bipolar disorder | borderline personality | counseling | cutting | family therapy | kids | mirroring | parents | SPECT | TED | teens | therapist | therapists

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