On TreatingvAdolescents

On Treating Adolescents

Although I had a great deal of training and a broad range of clinical experience, it was not until I began working at high schools that I really understood adolescents. General principles and therapeutic guidelines remain constant regardless of the age group treated, yet adolescents rruly do represent “a tribe apart.”  They approach therapy with a sense of cynicism, skepticism, and caution unique to their emerging sense of self.  I recognized their distrust of someone my age. My grandchildren were not much younger than some of them,  my hair was grey, my hearing was failing, and I sometimes used expressions they had never heard before and did not understand.  I found I needed to make myself credible to them.  I sometimes had to break the rules. After about ten years of working with teens, individually and in groups,I can categorize the parameters of what I have been doing into five dichotomies:

1. Acceptance v. denial

There is a need for the teen referred for therapy to  acknowledge that things are not asthey should be.  While they may continue to attribute blame on parents, teachers, or peers, they must recognize that the bottom line is themselves.  Whatever the precipitating conditions, it is their problem, their issues, and their responsibility to get help and make changes.  If this is denied there is no basis for therapy.  

2.  Entry v. exclusion (trust)

Once acceptance is gained there is still a  need to gain entry into the adolescent world. the teen is being asked to reveal personal information, secrets, wishes, and hurts that he or she may have never revealed to their parents.  Some teens have confided this information to a best friend--one who may have shared in the experiences involved.  But the therapist is initially a stranger and revealing here is not without risk. When group therapy is involved the teen needs to trust, not only the therapist, but also the other members of the group. It is essential at the onset to make it clear that anything revealed is strictly confidential. Itell group members, “What is said in group stays in group, with three exceptions.  If I learn they are in danger, are placing someone else in danger, or are being abused, I am mandated by law to reveal it.”

Recently I attended an ethics training session for school psychologists.  The issue of confidentiality was being addressed. We were divided in group, each to discuss a real situation that had occurred and was explained to us.

A fourteen year old girl developed genital herpes. When her mother learned that she was being sexually active she became hysterical, screaming at the gir.  The girl replied “Dr. F. is much more understanding than you.”  Now the mother was furious.  “Dr. F. had no right not to tell me about this.”

There were five members of our group, including me.  I was the only person who said the mother needn’t be told, although the girl should be encouraged to reveal it to her parents and seek medical help.  When the small group reported their opinions to the general session, most of the larger audience also supported revealing.  I explained my opinion.  I I would reveal every instance of sexual activity, cutting, drinking and smoking pot  I would need to report the majority of students I see.  Furthermore, it would destroy my credibility and students would no longer trust or reveal these things to me. The presenter supported my position.   

3.  Independence v. dependence

High school is a hard transition for many students.  In the middle school teachers are more prone to spoon feed students having difficulty.  The school is smaller; classes are smaller.for students.  Professionals advocate for them at meetings with administrators, parents, disciplinarians.here is a tendency for counselors and psychologists to try to solve every problem

Classes are changed, students are provided passes to miss class, skip gym, eat lunch in the Guidance Office.  Sometimes such interventions are justified; sometimes we overdo it.  On occasion I have intervened in  strained relationships, bringing both parties into my office to “talk it out.”  This is usually a mistake.  There are situations that students need to solve themselves and counselors should stay out of it.  We need to build resilience and discourage dependence and fragility.

4.  Limits v. freedom

Therapists are taught to maintain a certain degree of distance in the therapeutic relationship.  Freud sat behind a reclining patient on the analytic couch.  Because the relationship is probably the most powerful determinant of therapeutic success (what Freud labeled transference) it is essential that certain boundaries be erected and maintained.  Therapists violating these boundaries probably represents the most frequent type of ethics violation and ,loss of license to practice.  This is an especially dangerous area with adolescents who are not above being seductive with therapists.  Nevertheless, a certain degree of bonding and a strong degree of trust needs to established.  I allow teens to address me by my first name.

I call them by their first name and I want to convey a high degree of respect for them if I expect it back in return.  I also do not react to cursing, obscenity, sexual content.  I don’t always like it but when I suggest that they are crossing the line they are quick to point out that this is therapy and they should be allowed to express their feelings.  Generally they are well behaved in individual therapy but groups often beco,me loud raucous, and obscene.  Girls appear worse than guys in this respect and often have no filter between feelings and mouth.     

5.  Structure v .chaos

Another type of limit is imposed when I attempt to structure the sessions. Most psychologists today adhere to a cognitive behavioral theoretical model. Following the writings of therapists such as Albert Ellis and Aaron Beck, they believe that mediating between environmental triggers and action or emotion are thoughts (cognitions).  These interpretations of the triggers may be irrational or illogical but well learned.  Therapeutic interventions are designed to help the client challenge his or her cognitions and learn more effective cognitions.  Such approaches are supported by objective, controlled research investigations supporting their

effectiveness in changing behavior.  Since psychologists are mandated to utilize empirically support treatment strategies, this approach  has become widely accepted.  Of course there are  always iconoclasts who believe that theories are useful.only to reassure the therapist  that he is doing something scientific.

No matter what I believe, students seen individually usually allow me to structure.  Those in groups do not.  What began as anxiety reducing groups became renamed resilience groups and then anything I want to talk about groups.  Unfortunately the things teenaged girls want to talk about are relationships with guys. They love group therapy; sometimes I do not.