Discover why many teenagers are resistant to therapy and how you can more actively engage them.

Teen Therapy: Common Mistakes to Avoid
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Dear Colleague,

When a counseling intern asked me how she should get a 13-year-old client to talk about her feelings, my immediate dismayed thought was Are they still teaching that good teen therapy means getting kids to pour out their feelings?

“Don’t worry about getting her to talk about her feelings,” I said. “If you’re doing anything close to what she needs you to do, you won’t have to. She’ll show you what her feelings are.”

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 for any number of reasons, such as acting out in school, violent behavior, rapid changes in demeanor, and teenage depression. Consequently, they often find most standard, shrink-wrapped attempts to “engage” them infuriating. They’ll talk about their feelings, but not in a discussion isolated from the conversation at hand.

Unfortunately, at a time when adolescents and preteens need our help more than ever to navigate the multiple challenges of family, academic, and social life, the gap between clinical theory as taught in graduate school and real-life practice continues to widen.

Most of us were never trained to talk to adolescents or given any specifics about teen therapy. I was taught the importance of unconscious conflict, character structure, object relations, interpersonal dynamics, and transference. It was great training, but it was a beginning, not an ending.

When I began treating adolescents, 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. I needed language that was more natural, shared, and mutually revealing than the questioning, interpreting, and ritualized clinical language I’d been taught.

I did learn a new tongue, but not by myself—I was taught by these unhappy, angry, negative teenagers. They showed me that successful treatment with them wasn’t a matter of how I thought teen therapy “should” go, but of what would make them want to come back a second and third time.

So many of these kids have been let down so often by different adults, institutions, and circumstances that they’d learned to protect themselves by refusing to allow themselves to want anything they thought they might not get—lasting friendship, support from parents and teachers, good grades, a sense of self-worth, and certainly any real help from teen therapy. I started to feel that if I could nudge them along to think they might want to try to get something they wanted, it would be a great leap forward in treatment.

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 one another. 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.

But how can we demonstrate our trustworthiness to an angry teenager who distrusts all adults? A standard rule for inducing trust in clients is promising confidentiality up front. But I’ve found that refraining from pointing out inconsistencies in their stories that they aren’t yet ready to address is a better way to gain teens’ trust than promising to keep their secrets. It’s more respectful to protect their dignity by keeping mum.

I’ve also rethought the meaning of the therapeutic alliance and establishing rapport. Overly obvious attempts at therapeutic joining with teenagers before there’s any real engagement just raises the “yuck” reaction in teen therapy.

The idea that rapport leads to engagement is exactly backward. You engage and, if you like what you see in the other person, you connect. Then you have rapport.

Therapists will sometimes set the scale more heavily in favor of empathy and support than accountability in order to avoid difficult topics and not alienate the young client. 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 to appease the client.

However, when we sacrifice our personal boundaries or pretend not to notice things taking place in the 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 is one of the most critical challenges therapists face with clients, particularly in teen therapy.

As long as we approach the problem of helping teenagers by asking, “How do I get this kid to talk?” therapists practicing teen therapy will carry the burden of energizing the therapy, which is not a great clinical strategy.

Because teenage clients are legally underage, we tend to treat them as if they weren’t fully capable of making their own decisions. But the choice of whether to accept our help is always theirs—just as it is for the adult clients we treat.

We already know some of the things teens don’t respond well to in teen therapy, so let’s stop using them.

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