Danielle kept coming back for her sessions week after week. They were always made up of a lively mix of storytelling, debate, humor, confrontation, rages on her part, and the two of us visually appraising each other. Sometimes I met with Danielle's mom, and tried to help her play a less ingratiating role to her daughter's imperial manner and stand her ground more often, even if it meant being "punished" over the next few days by Danielle's snarky comments and noncompliance around the house. Two months into the therapy, Danielle insisted that I join her in excoriating her mother for not being willing to pay a deposit on an apartment rental for her dad, who'd just been booted out of his current one for nonpayment of rent. I declined to do this and she decided to end therapy. "How come my not backing you on this means we don't meet anymore?" I asked her before the end of what, in fact, turned out to be the last session. She looked at me and said nothing. "It's OK," I said. "When you feel it's safe to make room in your world for people who don't always agree with you, come back and we'll pick up where we left off." Danielle turned her face away from mine so I wouldn't see her begin to cry. I never did see her again.
This was not an ideal end to therapy. That would have been that a chastened, more insightful Danielle saw the error of her ways and became a kinder, gentler, more compassionate young person, who started working harder and getting better grades in school. But, whatever we like to pretend, relatively few therapy cases actually end with complete resolution, grateful tears, and the launching of a happy new life. Particularly when dealing with spiky, touchy adolescents who are in therapy only because they've been dragged in, we're lucky to make any impression whatsoever. I like to think that the therapy left Danielle with a reference experience of having genuinely, if briefly and despite herself, connected with someone whose values are antithetical to her own. Maybe in my office, she was imbued with that glint of curiosity, of vagrant hope--a tiny light at the end of her tunnel vision--that would draw her back at some point in the future to be open to some kind of therapeutic experience again.
Meeting Clients Where They Are
Elise, who was 16, was having a difficult day at school. Depressed, picked on by classmates, and unable to get sufficient attention from her few friends, she'd gone down to talk with her guidance counselor, a supervisee of mine. Early in their conversation, Elise emphatically announced that she hated everybody. "And I mean everybody!"
"No, you don't hate everybody," her counselor responded. "You don't hate me. You don't hate your mom. You don't hate your therapist." That was the end of that. Elise got up and walked back to class. What's the point in expressing how you feel if someone's right there to tell you you're wrong?
I asked Elise's counselor what it was she didn't like about Elise's statement that she hated everybody. "It's just so negative," she replied. "I wanted her to realize that there were all these people trying to help her, and that she didn't really hate them."
Elise's counselor was trying for too much too soon. I also didn't think it was the right approach for Elise, whose aloof demeanor and critical manner made it hard for anyone to make much of an impression on her. Without the traction of a relationship in which the counselor or therapist mattered to her, Elise would have no interest in hearing about anything other than what she wanted to hear at that moment--words of comfort or a remark that she could morph into something that validated her jaded outlook.
What was the difference between Elise's counselor's efforts to champion an alternative perspective and my similar efforts with Danielle? It was their personalities and interpersonal relationship styles. Elise was impenetrable and remote. She considered little of what others said or did. By contrast, Danielle took in everything around her, and then would spit it out on the floor in front of you. But for all her pugnaciousness, Danielle engaged with the people in her world, and each moment of engagement held open the possibility for someone--a therapist, teacher, parent--to leave something of him- or herself behind.
Latent power struggles in therapy make their way to the surface whenever our clients begin to see us as a threat to a point of view or sense of injustice they're not yet ready to relinquish. Elise wasn't ready to give up her negativity, which helped her keep people at bay and control interactions with adults, who predictably tried to get her to abandon her negativity in favor of something more hopeful. The conversation was the same each time: "Everything sucks." "No it doesn't! C'mon, look on the bright side." Just as predictably, their response confirmed Elise in her negativity.
Kids will let go when they want to. The work of therapy isn't getting them to do it, but helping them want to. More important, though, is to know that they don't have to let go in order for you to take the therapy forward. Elise could hate everybody and have a gigantic blind spot for the liabilities of being a lone wolf, while still being titillated by the notion, for instance, that letting others align with her could actually help her feel bigger, not smaller.
I suggested to Elise's therapist that instead of trying to "do therapy" right out of the gate, she give her students more room just to make the comments they wanted to make at the beginning. In the case of Elise, I suggested she might respond with something like, "Yeah, I think I have days when I hate everybody, too" or "What was your day like that you ended up feeling like you hate everybody?" or "How long does your 'I hate everybody' mood usually last?" all asked sincerely, not somberly as if trying to ferret out an underlying pathology. These questions would assist the counselor in joining Elise by normalizing what she felt instead of turning it into something "bad" or abnormal. Moreover, such responses would prevent conversational shutdown by communicating, "Yes, I understand how you can feel that you hate everyone in the world, and maybe today--or every day--you do. But nothing about that keeps us from talking about ways to help you make it through the school day."
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.
"The customer is always right" is increasingly the mantra for adults in therapy, but not yet for teenagers. If they don't talk enough or follow our recommendations, they're likely to be labeled "resistant," even "oppositional." The question of why they don't like therapy is rarely reviewed beyond the hermetic perspective of therapists. But paying attention to their complaints could benefit both us and them.
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.
Janet Sasson Edgette, Psy.D., is the author of Adolescent Therapy That Really Works: Helping Kids Who Never Asked for Your Help in the First Place and Stop Negotiating with Your Teen: Strategies for Parenting Your Angry, Manipulative, Moody, or Depressed Adolescent. Her latest book is The Last Boys Picked: Helping Boys Who Don't Like Sports Survive Bullying and Boyhood. Contact: firstname.lastname@example.org. Tell us what you think about this article by e-mail at email@example.com, or at www.psychotherapynetworker.org. Log in and you'll find the comment section on every page of the online Magazine.