Helping Teens

Foundation

What’s necessary to Build a Helping Relationship with Teens

Without rules there’s chaos. I need easy times—pizza, watching a video, hanging out together. They don’t listen enough to stuff that matters to me! Get them to show their feelings – without bossing me.
–What 250 kids told me they need more of from parents and other adults

Adolescents in the 21st century do not often have in-depth experiences with adults, yet the success of treatment rests squarely on the relationships you are able to create. Building this relationship with modern teens, however, must differ from narrowly conceptualized treatment paradigms.
First, working with adolescents in the ways I suggest is the most dramatic, edge-of-your-seat experience a therapist can have. In play therapy with younger children, for example, the therapist maintains a soothing tone and a comfortable, warm distance. The therapist observes and participates, often lulled into an almost trance-like state of fantasy engineered by the child. The purpose of this quiet acceptance is to help a child express his or her inner world as safely as possible.
In psychodynamic psychotherapy with adults, regardless of orientation, therapists maintain a variation of Freud’s “evenly hovering attention,” a process of letting one’s experience float along with the patient’s. Inquiry, reflection and interpretation are essential aspects of the work-which hopefully create an expansion of awareness, healthier ego functioning, and a relative balance in one’s psychic life.
In self psychology, the therapist is “a mirroring self-object,” which is multifaceted effort to understand the patient as fully possible. Treatment creates an empathic relationship that was previously missing in the individual’s life. The inevitable “repair” of a fragile empathic connection is based on a sense of respectful attunement and is central to the work of building more resilient self-esteem.

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Unlike these inherently modulated approaches, the school of thinking that is most useful with 21st-century teens is the “relational” approach, derived from a synthesis of interpersonal and object relations schools. As I discuss later, a highly modified relational frame is particularly helpful with teens – the emphasis is on highly modified.
What the interpersonal-relational writer Darlene Ehrenberg calls “the intimate edge of relatedness” is a most helpful concept with adolescents (though Ehrenberg writes primarily about adults; The Intimate Edge: Extending the Reach of Psychoanalytic Interaction, 1992). By this term Ehrenberg means the ways the two participants in the room actually feel each other, the place where they touch each other consciously and unconsciously. The quality of this “edge of relatedness” is what differentiates relationships, because the edge varies so distinctly in feel and action from one person to the next.
Nowhere in clinical practice (except, perhaps, with certain affective disorders and borderline clients) is the edge as vital and demanding as it is with adolescents. Because of roller-coaster developmental changes, ordinary high-risk decisions, intense cultural pressures, and the chaos of teen living, adolescents demand a level of responsiveness that makes most of the approaches described earlier seem stodgy. They are, to use a favorite adolescent term, “old.”
The relationship necessary is profoundly different from the quiet acceptance of play therapy, from the evenly hovering attention of analysis, from the inquiry of interpersonal psychoanalysis and from the empathic mirroring of self psychology. It is certainly different in its centrality from contemporary techniques, such as PTSD protocols, eye movement desensitization and reprocessing, coaching and cognitive-behavioral therapy, to name just a few.
Your active participation in building a three-dimensional relationship is essential for teens to feel. They need to “get” that you are right there, in the room, fully engaged and responsive. No wonder therapists report that, when working with adolescents, you must always be on. The edge of relatedness needs to be focused, flexible, heartfelt, and multidimensional. Nothing less can create a relationship substantial enough to cross the teen-adult divide, to contain the volatile nature of 21st-century teen life.
And, in order to build such a vital relationship, a number of surprisingly basic conditions are necessary.

Rules

“I’m sorry I’m late. Everyone was talking after school, I lost track of time…” “The bus broke down and I wasn’t near a phone, so I couldn’t call…” “We went to the pizza place and just hung out…” “I thought insurance was paying you directly…” “There’s a big reading test tomorrow and I have to stay home and study…” “You mean I have to pay even though he had fever last night…”
These are just a few of the stories we hear from kids and parents about their therapy obligations. How do we respond? Not well. For various reasons, most child professionals are progressive and antiauthoritarian. In fact, when many of us began doing this work, we believed our young clients’ anxieties often resulted from too many rules and too much rigid authority. Our training taught us that a warm, fuzzy embrace was a godsend for children. At the same time, many of us are again sensitized to constricting rules, feeling over controlled by managed care, the Health Insurance Portability and Accountability Act (HIPPA), and our own agency’s bureaucracy.
Put it all together, and we are uncomfortable being rule enforcers. But today’s kids are in trouble partly because in their world there are few rules that actually matter. We need to recognize that despite our discomfort, a laissez-faire relationship is indistinguishable from the everyday chaos many of our young clients now experience.
Establishing clear rules creates the secure frame that teens and parents need to begin managing disorder in their lives. Addressing the concrete issues of commitment, setting priorities, and seriousness about the process brings to the surface issues that might otherwise undermine the relationship. Instead of skipping appointments or prematurely terminating, families held accountable start talking about financial concerns or other fears that are threatening to devastate the home. When professionals challenge a family’s casual attitude about showing up on time, parents may begin to discuss the everyday chaos that can be so frightening to children. In addition, almost without fail, when a preteen or teen is late to therapy, the missed appointment time is used for the very problem that the adolescent has trouble with – substance use, after-school acting out, and so forth.

LATENESS, NO-SHOWS, CANCELLATIONS

When kids toy with the edges – lateness to sessions, missing a meeting –one traditionally thinks, “It’s grist for the mill” –what teens are expected to do anyway. Exactly the opposite is true. I’ve discovered, to my surprise, that kids are pretty much on time, often more so than adults. For the most part, they like to come to sessions. When that is not the case, our failure to address the issue almost always comes back to haunt us in serious ways.
If an adolescent who is usually on time is late for a session, I ask about it, reminding him or her of the rules: “How come you’re late? It’s not part of our bargain…So, what was going on?” Rather than letting kids off the hook, I’ve learned to regard lateness as is a signal that something is being held back. Invariably, I discover that these few missed minutes of our session were the exact moments he or she was smoking up with friends, doing a quick drug deal, vandalizing property, or having sex for the first time. More often than we realize, kids arrive a little late and a little high – but not so much so that they can’t carry off the meeting brilliantly. Again, this is the tip of the iceberg, a sign worth noting and discussing. Playing with the edges of treatment is often a way to tell us something extremely important is going on just out of sight.
When kids miss sessions, it is critical to address the issue – not just because of what it might mean in terms of resistance or an unconscious process. Sophisticated teens even use unconscious process in their own defense: “Didn’t you learn in school that people forget stuff sometimes? Everybody forgets, it’s just a Freudian slip. Go ahead – ask questions about my deep, dark unconscious!” Despite such bravado, chances are something was going on that caused him or her to skip a session. And, that something is often the exact reason the client is with you in the first place.
One boy, Marv, came in on a Friday afternoon saying he had to cut the session short and leave early to meet his parents for a family get-together. Instead of holding him to our time, I was the understanding therapist and said, “Okay, we’ll end a little early.” Next week I learned from Marv that he had arranged to meet several of his friends in the afternoon to go out and drink. They wanted to get a buzz in preparation for a concert that evening, where they planned to get totally trashed. The short session was a telling indication of his extracurricular life – if I had paid attention. Friday afternoon? Meeting parents, not his friends? And what about that huge concert in the park just about everyone in town had heard about?
Treatment parameters need to be discussed and processed. During moments of dialogue around specifics, kids start to open up about what’s really going on. Ten minutes addressing lateness leads to a discussion that opens doors behind the façade.
(there were more similar stories here that I left out)
Concrete rules and your willingness to stand by them run counter to incessant contemporary messages about instant gratification. Rules protect the frame and provide reassurance that the relationship will not simply melt into thin air.