What Works with Teen Clients

Forget Everything You Know About the Therapeutic Alliance

Janet Sasson Edgette

Most teens are in therapy only because their parents, their teachers, the juvenile court judge, and/or some adult in authority somewhere has told them they must see a therapist. Consequently, they often find most standard, shrink-wrapped attempts to "engage" them infuriating. In short, they don't talk, don't want to answer questions, don't want to be in our offices, and don't intend to make it any easier for us, so we often resort to our stale therapeutic clichés because we don't know what else to do.

Most of us were never trained to talk to adolescents. I was taught psychotherapy by psychoanalysts, who worked hard to instill in me an understanding of the importance of unconscious conflict, character structure, object relations, interpersonal dynamics, and transference. It was great training and has proved highly valuable, but it was a beginning, not an ending. This hit me right between the eyes when I took my first job as staff psychologist at a residential treatment center for socially and emotionally disturbed boys and girls who didn't give a crap about their unconscious conflicts or anything else having to do with therapy. I'd ask them, "What are your treatment goals?" and they'd look at me as if to say, "Lady, is there anything on my face that says I have a treatment goal?"

When I began treating adolescents in earnest, I realized that if I wanted to keep one of them sitting in my office for more than half a session, I'd have to change how I spoke with them. We needed language that was more natural, shared, mutually revealing than the questioning, interpreting, ritualized clinical language I'd been taught. I did learn this new tongue, but not by myself--I was taught by these angry, unhappy kids.

Over the years, I've developed an approach I call Natural Law Therapy, which simply means that I try to conduct therapy as much as possible according to the normal, natural way people talk to each other in different circumstances, without premeditated rules, protocols, or scripts. People who are perceived as not sounding natural or real or normal often are considered phony, duplicitous, and overbearing. Not surprisingly, they evoke in others a sense of distrust, anxiety, defensiveness, and anger. Of all clients, perhaps teenagers are the most protective of their vulnerable sense of dignity, and are particularly unforgiving of adults who seem to talk down to them, attempt to get some advantage over them, or assume a verbal one-up stance.

I also began to rethink the meaning of the therapeutic alliance and establishing rapport. The usual process for connecting with clients is to spread empathy all over the place, to make careful, nonjudgmental responses to every word a client utters. But too-obvious attempts at therapeutic joining with teenagers before there's any real engagement just raises the "yuck" reaction in teen clients, and immediately compromises any relationship-building. Rapport isn't something that emerges directly from "rapport-building techniques"; it only grows organically from the mutual regard and respect that people develop for each other.

Furthermore, in the spirit of establishing rapport with the reluctant or resistant adolescent client, therapists will sometimes set the scale more heavily in favor of empathy and support than accountability, to avoid difficult topics and not alienate the young client. They might excuse behaviors like extreme rudeness, profanity, and direct insults or refrain from commenting on the client's inappropriate activities like getting stoned and having semianonymous sex or a propensity for shoplifting that scream out for a genuine response. This reticence can convey to the teen client not that these therapists genuinely care, but that they're willing to sacrifice a measure of self-respect in order to appease the client.

However, when we sacrifice our personal boundaries or pretend not to notice things taking place in session in order to keep the peace, we lose the credibility we need to be able to do our job. Balancing the demonstration of our understanding and compassion with our ability and willingness to hold everybody in the room accountable for their actions (including ourselves) is one of the most critical challenges therapists face with clients, particularly troubled teens.

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The Gentle Art of Not Taking the Bait

Rachel, who was 15, was referred by her family physician when her mother discovered she'd been cutting herself. She offered no resistance to therapy and came to her sessions eagerly. Dressed in gray and black, and often wearing a hoodie pulled down low to cover much of her face, she was funny, warm, kindhearted, likable—and brimming with self-contempt. Sophisticated and circumspect in my office, she was, I learned from what she told me, quite different among her friends. With boys, she flaunted her sexuality—wearing tight clothes and a good deal of makeup, flirting strenuously--to make up for what she believed to be her subpar looks and personality.

Though she'd never engaged in sexual intercourse, Rachel mused out loud about when she would, with whom she would, and how many partners she'd have should she start having sex. She frequently drank too much and had experimented with drugs. Would I respond as every other adult had? I began to understand that one key to working effectively with this girl was in not reacting with obvious alarm, even though everything about the situation and her clear anguish seemed to clamor for it.

"She's much prettier than I am anyway," Rachel said to me one day, by way of summarizing why her boyfriend had dumped her for another girl in their grade. "So I really can't blame him." She clearly meant it, and her sad, revealing comment simply hung in the air between us.

This is the kind of statement that would make many therapists want to give Rachel a pat little speech: being pretty isn't everything; if that's how her ex-boyfriend appraises girlfriends, then maybe he's not such good boyfriend material after all; you're pretty, too.

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Instead, I asked her, "Are there differences between boys who pick their girlfriends based on how pretty they are and those who base their decisions on a whole bunch of different things?" After we'd discussed her male friends' criteria for selecting girlfriends for a while, I asked, "Hey, how come when you tell me about the boys in your school, it always sounds like they're in the driver's seat?" These questions, with their gentle counterpoints to Rachel's pliant manner around boys, served to nibble at the edges of her way of thinking about boys, girls, and their relationships with each other. They helped keep the conversation open and move it forward a little. I was seeding the idea that she could ask for more; that she deserved more. Because of Rachel's deliberate but reserved nature, my choice of tone in therapy was—decidedly—understatement.

The Paradox of Breaking Eggshells

Thirteen-year-old Danielle arrived in my office—courtesy of her mom—and was stinking mad about it. She didn't agree with anything her mom had to say: that Danielle had become more and more angry over the past few months, that she didn't seem to care about school anymore, that she was rude and disrespectful at home. All that was wrong in Danielle's world, according to Danielle, was that her mother wouldn't let her live with her dad.

That Danielle was going to be a challenge was obvious. She was dodgy (would totally ignore a question or comment), provocative, and outrageous. Early on she commented, "In school the other day, my friend and I yelled down the hallways, 'Babies in blenders! Babies in blenders!' It was so funny!" She wore the chainsaw earrings her father had given her for Christmas, as well as a perpetually insolent expression on her face, to make people a little nervous about whom they were dealing with. Danielle would have eaten a newbie therapist alive.

Here she is talking to me about her mother, for whom she feels utter disdain and no shame in showing it. "I can't stand my mom's boyfriend," Danielle spits. "He's such a pussy. He actually gets nervous when he tries to talk to me. And he's, like, what, 50 years old or something? He keeps buying my brother and me all these things just so we'll like him, but it's such bullshit." She laughs an unkind laugh, expecting me to appease her with a grin of my own.

Instead I say, "I feel sorry for the guy." Danielle looks up at me, hard.

What? I ask her with my face.

"You would feel sorry for him," she says, with disgust. "Forget it." She reaches into her backpack and takes out some homework to do, presumably for the remainder of the session.

"How come I always have to have the answer you want me to have in order to keep the conversation going?" I ask.

Danielle looks up at me, and with her questioning sneer and slight shake of the head mumbles, "You're so lost."

I keep on. "Yes, I do feel sorry for the guy. I feel sorry for anyone who wants to get to know you because you make them feel stupid for having tried. And I feel sorry for your mom, too, because she seems to really like this guy, but also wants your approval so she can feel that she's doing the right thing. But you see them struggling with all this, and yet you don't help them out. Instead you laugh."

"Why would I want to help them?" Danielle looks genuinely puzzled.

"Wow," is all I manage to say, suddenly very still.

Danielle looks up, disarmed and unsettled by my response. She stares at me for a moment and then turns away.

And there was the therapy—in that brief collision of our two different phenomenological worlds. In hers, being cavalier and mean is OK and even cool, but in my world it isn't. For a few moments, Danielle felt what it was like to be herself in my world, where the rules are different, and it made her uncomfortable. I don't think she'd ever had reason to consider just how dependent she was on having an accommodating context to make her lifestyle work.

So, what was the therapy, exactly, in that brief collision of worlds? Danielle is like the emperor whose lack of clothing nobody dares point out. In this exchange, without telling her she should change anything about the way she conducts her life, I was able to get the things I thought she needed to hear out into the room:

I don't agree with you.

I'm going to feel sorry for your mother's boyfriend, even if you don't.

Not everyone associates compassion with being a loser.

You control conversations by punishing people for responding in a way you don't like.

You're controlling with your mom, and she tolerates it because you mean so much to her and she's afraid of losing you.

That's not very nice.

Meeting Clients Where They Are

Because teenage clients are legally underage, we tend to treat them as if they weren't fully capable of making their own decisions. But no matter what we want for them or can see in them, the choice of whether to accept our help is always theirs—just as it is for adult clients we treat. Unless we honor that choice, creating a therapeutic climate in which they feel respected and able to accept our help is impossible.

We already know some of the things teens don't respond well to in therapy—excessive questioning, standardized treatment protocols, enforced between-session homework—so let's stop using them. They do respond well to active, authentic, and respectful relating, direct feedback, and advice. If these were to become a standard part of clinical training and treatment, we'd be taking a great step toward providing services to teens that they'd be as interested in getting as we've been in offering.

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Janet Sasson Edgette, PsyD, is the author of Adolescent Therapy That Really Works and Stop Negotiating with Your Teen. Her latest book is The Last Boys Picked: Helping Boys Who Don’t Play Sports Survive Bullies and Boyhood.

This blog is excerpted from "Why Teens Hate Therapy" by Janet Edgette. The full version is available in the September/October 2012 issue, The Craft of Conversation: Kindling the Spark of Therapeutic Change.

Photo © Lauren Bates

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Topic: Challenging Clients & Treatment Populations | Children/Adolescents

Tags: angry teenager | challenging clients | counseling teenagers | counseling teens | engaging teens in therapy | kids | Parenting | parenting issues | rapport | teen therapy | teenage counseling | teenagers | teens | therapeutic alliance | therapy for teens

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2 Comments

Wednesday, March 27, 2019 11:27:52 PM | posted by Elizabeth
This article was exactly what I was looking for. Part of my vocation is as director of an after school program for high school students. I have a long way to go, but this article helped me realize I am on the right path. Thank you!

Friday, August 26, 2016 7:15:47 AM | posted by ADas
Thanks a lot for sharing this lovely article. I really appreciate the hard work you put in it.