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Lessons from Therapy with Adolescent Girls

Four Tips for Strengthening the Therapeutic Alliance

Martha Straus

Lucy begins talking before she even makes it into the office. By the time she takes her seat, I'm hearing the details of her day. She floods me with vivid descriptions of friends and enemies in her school, and, without prompting, I learn about the fight at dinner the previous night with her elderly grandparents, who are now, somewhat unwillingly, her guardians.

I draw a sociogram as she speaks, frantically trying to make sense of what she's pouring out, and also trying, in vain, to slow her down as I scribble a schematic who's who of her world. My arrows and jagged lines illustrating relationships in all directions resemble a web built by a spider on hallucinogens—a chaotic mess.

When she's done, she exhales sharply, studies my drawing for accuracy, grabs my pen to embellish one big conflict, and glances up at me triumphantly. Yes, that's everyone—that's her life. My intake questions, the usual provisos about confidentiality and scheduling, are all postponed as I follow her compelling agenda. This is what therapy is like with adolescent girls: an unpacking of metaphoric bags, some long locked up, some spilling over, some ripping at the seams, some like Lucy's, all out there. In my attention to the details of their baggage, I'm not just a therapist; I'm part valet, part archaeologist, and part synthesizer, too.

For me, working with girls is what I do with the greatest interest and passion. Like many female therapists who have this specialty, I had my own tough times as a teenager. I have wells of empathy to draw on, and can stay attuned with them more easily than with males, or females of other ages. Our bond is implicit, and by being as fully authentic, connected, and present as I know how, I help them make it explicit.

Lessons for Working with Adolescent Girls

1. Make and Keep Promises. Adolescent girls often come to therapy without much experience with real adults. One bright 15-year-old contending with the relentless narcissism of her divorcing and dating parents observed to me recently that I was "the only grown-up" she'd ever met. We have an opportunity to build trust more quickly when we find ways to make promises to girls, and then deliver the next week. I may ask them to bring in music, for example, so I'll promise to provide the CD player. I promise to go to school meetings, to say certain things in family sessions, to remain hopeful, to keep confidentiality.

Being consistent by doing what we say we will is important for adolescent girls because they experience so little predictability, internally or externally, in their lives. Kept promises give girls rapid feedback that they're important to you, even when they are not in front of you.

2. Admit Your Mistakes and Apologize. Most adolescents have precious little experience with adults apologizing to them. But like anyone else, young girls appreciate it when we admit that we've made a mistake. It helps level the playing field and demonstrates a level of respect that adults seldom feel like offering. It builds empathic attunement and gives them the chance to forgive us. I've found, when I've apologized for messing up, that adolescent girls can be surprisingly forgiving, even if often not of themselves. This fact can also help therapy along. They'll forgive you readily for a mistake you made and later, when they're being relentlessly hard on themselves, you can compare their sterner self-judgments with their kindness to you when you goofed up.

3. Hold Hope. Somewhere between their Cinderella-like rescue fantasies and the hard truths of their lives, many girls get lost in hopelessness and despair. They live so much in the present and in their feelings about what's going on now that they don't know how to feel confident about the future, to plan for it, or to envision it as a reality. This envisioning problem compounds their damaged sense of personal efficacy.

When I'm with a girl who's floundering, seeming desperately lost and unable to take hold, I often intervene with a bold hopefulness. For these girls, I feel one of my most important jobs is to be a holder of hope for the future. I've come to understand that my confidence in my young clients and in their ability to heal is central to their developing the ability to believe in themselves.

4. Don't Underestimate Your Role. One of the biggest mistakes we can make is to devalue ourselves, or at least our importance, to the girls we treat. Maybe adults come to therapy to fix particular problems. Adolescent girls don't; they want to be seen and heard. They want to feel felt. They usually want a relationship with you, even (or especially) if they say they don't.

I've learned these simple, vital lessons through the years, and I relearn a few of them every week. I'm still discovering who I am as a therapist for adolescent girls, honing that growing edge of attunement to myself and to the girls I treat. So when the loquacious Lucys of the world bring their volatile social connections and overstuffed pocketbooks to me—metaphoric and otherwise—I now know that my job is to show up with my most patient, empathic, creative adult self, and help them unpack them.


This blog is excerpted from "Hungry for Connection" by Martha Straus. The full version is available in the July/August 2006 issue, 21st Century Teens: 2 Cool 2 B True?

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Topic: Children/Adolescents

Tags: ED | empathy | family | family sessions | girls | HEAL | Martha Straus | narcissism | parents | relationships | sex | SPECT | talking | TED | therapist | therapists | therapy | admitting mistakes | adolescent girls | girls in therapy | keeping promises | therapy for girls | therapy strategies

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1 Comment

Sunday, November 5, 2017 2:29:05 PM | posted by gabriela
thank you, i loved the article, it helps me a lot! I am working with an 16 year old with anorexia! very good insight!