by Bronagh Starrs
Therapy is about making contact; and adolescent therapy requires a specific repertoire of contact skills, often looking and feeling very different than therapy with adult clients. Coupled with the ability to make rich contact with the teenager, it is also essential that the therapist has a solid understanding of adolescent development and of how to support its unfolding in a therapeutic context. Psychotherapeutic work with adolescents must address both the interior and interpersonal dimensions of development if it is to adequately support the adolescent in adopting a more self-directed and integrated style of engaging in the world. Attending to the figural work of self-exploration, expanding awareness, problem solving, behaviour change etc. as well as assessing family context are key components of the work. It is the relational experience which carries and supports this work: contact with the adolescent, contact with his parents, and contact with self.
Rarely is an adolescent male client willingly referred for therapy – (“I‘m talking to no f**king shrink, that’s a bunch of bullshit!”). Mostly a situation with heightened drama has unfolded, with a teenager playing centre-stage, who is dragged reluctantly to my office. Adolescent energy is powerful, chaotic and messy and it is easy to get entangled in the confusion – particularly given that we all have our fair share of residual adolescent energy which can be easily activated. The therapist is constantly challenged to honest self-appraisal in order to support the situation with grounded awareness. The following is a description of one of those familiar clinical situations and my therapeutic response:
John was 15 and actively suicidal: he had attempted to hang himself the previous Saturday night and this was not his first attempt to take his life. His mother’s referral call was a desperate last-ditched attempt to save her son. She cried a lot during the brief telephone conversation. Could I see him as soon as possible?
So much happened for me, as the helping professional, in those initial few minutes speaking with John’s mother – thoughts, feelings, body responses, assumptions and judgments made, clinical decisions taken etc. And whilst the work lasted for a total of 14 sessions, really by the end of the 2nd session, the core of the work had been undertaken. So, what exactly happened for me in this therapeutic encounter?
I consciously do three things during a telephone call like this: (1) I breathe. (2) I remember I have a body and I stay in it. (3) I remember I have support. For me, doing this means the difference between holding and losing my ground as a therapist – for if I lose my ground, we’re all on the slippery slope. My initial response is always a body response. It goes something like this: I hear the anxiety in this distraught woman’s voice and I match her anxiety intuitively – adrenal glands active, buckling sensation in my knees, not breathing, a scream of agony too loud to ever be heard and understood by another human being stirring in my held breath. BREATH! I’m not breathing. Breathe. Soles of the feet. Breathe. Legs. Breathe. Map of the body. Breathe. Ok. Stand back. We have a situation here, remember what you know. This woman needs support and ground. Give her support and ground.
First major clinical intervention has happened: I have identified and separated my own personal agony from this woman’s. My buttons have been pushed for sure. Suicide and I have met before – both personally and professionally. And so my “Therapist-Messiah Complex” quickly kicks in: I have to rescue this kid. This live reaction will be my work-in-progress during any subsequent therapeutic contact. It will require heightened self-reflection, support from my personal therapist and vitally the support of my clinical supervisor. Mostly it will require me to breathe; remember I have a body and stay in it; and remember I have support.
Right now, this woman is in a panic, this is too much for her and she is overwhelmed. I communicate that I know this must be a nightmare for her so I might say something like, “I can’t imagine what this must be like for you, his mother.” Simple, though effective; my statement informs her that I’m trying to imagine it – which means I care, or at least I want to care. It opens the connection sufficiently for her to tell me a little of how she is feeling. At every opportunity I am trying to inject support and calm into the dialogue and I am trying to get this woman to trust that I know what I’m doing. This is literally a matter of life or death for her. It has been my experience, working in a post-conflict era in the north of Ireland, that very often adolescent boys are not brought to me for ‘therapy’, they are brought with a direct request from parents to keep them alive.
I make my first clinical assessment as soon as I hear John’s age. I decide to meet initially with John and his parents, then do some individual work with John. I tell his mother this is what I want to do – she hears this sure direction as some kind of competence. I hear the usual “I don’t think my husband will come”. My response is always the same: “It’s important that he comes.” They nearly always do.
Joint Parent-Adolescent Meeting
My decision to meet with both John and his parents for an initial assessment comes principally from a guess that disembedding is still an ongoing issue. I am mindful too, that this is an Irish male adolescent in desperate pain: I’m not sure how willing or able he will be to present facts and concerns to me in a reasonably objective manner. This situation which has unfolded is a ‘field situation’ and requires a ‘field response’. By this I mean that it is not only this 15 year old who is affected by what is going on – his parents will certainly be finding it difficult to cope with this situation also. It is likely that his parents are feeling very shamed – that they somehow have failed their son. They will all be in need of support initially. Meeting with parents also affords me a direct experience of family contact styles; of how capable these parents are of supporting their son etc. and I get a sense of how I might be able to influence the adolescent-parent field dynamics. By inviting his parents into the process, there is the potential to harness considerable support for this young teenager – if it works, how much more effective will this be than 50 minutes of therapy with me once a week? I also, of course, am presented with a multi-lens story of how John has found life so incredibly unbearable. The picture forming has more depth and clarity. I remember Mark McConville’s description of working with the adolescent in isolation as “sheer clinical folly”. I have come to see how this is so.
The adolescent in the first encounter is particularly vulnerable, and frequently enters the session armed and guarded for the criticism that seems certain to come. Remaining interested and centred, while seeming to need no more from the client than is available at that moment, goes a long way toward establishing a field where contact can develop. I let John know that he is under no duress to engage and I also watch for his cues, inviting him into the dialogue if I spot an opportunity.
It is likely there is going to be an intense opening to our joint meeting – this can generally be expected when trauma is so alive and evident in the encounter. For me the first ten minutes sometimes feels like ‘lancing the boil’. I remember my breath, my body, my support – when I do this I can be a solid support for this family. I make direct, respectful, non-shaming contact with each person. “I hear you and I want to support you” is what I hope they each experience from me. And so much comes from the lancing: John’s girlfriend was killed in a tragic accident almost a year ago; he has since been expelled from school and been in trouble with the police for violent, destructive behaviour; he is a gifted, passionate footballer who suddenly stopped playing; arguments with his father have recently ended in fist fights; he has been drinking heavily….
I note people’s feeling responses to one another during our dialogue and I share this with them, inviting them to respond. This directs the family to make richer contact with each other. It is very evident that these parents care deeply about their son. Part of my work is to try to make that support more explicit and expressive – translate it from the shaming focus on ‘bad behaviour’. So, for example, during the conversation about football, John’s father speaks about how proud he is of his son’s talent and potential to be a county-level player one day. I could see John’s face flinch and he looks angry. I stop his dad and check out with John how he is feeling. Angry indeed, John lets his dad know that the reason he stopped playing football was precisely because he felt he could do no good in his father’s eyes. He felt that his father was ashamed of him. When I invite John’s father to respond to his son, he begins to sob as he speaks. Through the tears he describes how immensely proud he is of his son, both on and off the pitch, of how much he loves him, of how unfair it is that his son is having to cope with such a difficult loss at this young age, of how useless he feels now because he cannot seem to help his son. John is now also tearful and they begin to speak directly and with love to one another. Something in everyone’s experience softens in this moment. John’s mother later in the session speaks of how touching it is for her to witness this tender moment between her husband and son; and how she had even been a little jealous of the closeness in their relationship until several years ago when John became a teenager. This becomes a perfect opportunity for John’s mother to tell her son how much he means to her also – another poignant moment in the contact between John and his parents. Towards the end of the session I invite John to return the following week to meet with me individually. I let the family know that an important part of the work will involve John’s parents from time to time. They all still believe it requires a miracle, though for now, some hope has stirred.
A Word On Working With Parents
When working with parents I pay attention to several things: 1) how tangled up is this adolescent’s development and presenting symptom issues in the family, i.e. to what extent is disembedding an ongoing issue? This is evident in all kinds of presenting profiles: teenagers battling with parental control; adolescents blaming parents for issues that they should/could be taking on as their own (like schoolwork), and so on. When there is an experience of trauma, as in John’s suicide attempts, I will always involve the parents.
2) Do I think I can influence the family’s workings? I rarely meet with a whole family, though I often meet together with an adolescent and parent(s) who are feuding; or alone with a parent whose behaviour I want to influence (like the dad I met with last week who regularly gets into mutually insult-spewing, shouting matches with his fifteen year old son). I met with the father alone because (a) I wanted to be fairly direct with him, and I didn’t want to risk shaming him in front of other family members; and (b) because their relationship is too volatile to try to do serious work with them in the same room. Often I find that I can influence a relationship more rapidly by meeting, at least initially, with the parties separately.
I also do a lot of pulling marginal fathers into my office for one or two visits. Fathers often feel estranged from, and suspicious of the entire therapy process, and for the adolescent, their father’s tacit embarrassment and disapproval of therapy can be a huge impediment. I will meet with these father’s once or twice, and attempt to establish some sort of loose “alliance” with them, just so that they will look at their son’s involvement with me in a more favourable light. These meetings also enable me to defuse some of the ambient, unspoken “Am I a bad parent?” shame that permeates the adolescent’s family field. I have learned never to underestimate the significance of the father-son relationship for teenage boys, whether a father is fully involved in or completely dislocated from his son’s life.
3) Do I need to experience the cast of characters in the adolescent’s life in order to have a deeper appreciation of what he is up against? Just being able to say to an adolescent, “you’re right, your mother’s a piece of work” can be very affirming. And on the other side of the coin, having met a difficult parent gives me credibility if I try to re-frame that parent’s behaviour, e.g. “…I don’t think that your dad’s disappointed in you; he impressed me as a man disappointed in himself..” etc. And it is often the case that an adolescent’s symptomatic behaviour is pointing to painful family issues e.g. parental addiction, domestic violence, etc. In these instances, it is always deeply telling for the therapist to sit with this adolescent and his parents – experiencing how frozen he is when they are in the room.
Individual meeting with John
John tells me I’m his third counsellor in less than a year. “The first one made me do stuff even though I didn’t want to. She’d say ‘do it, it’ll help you’ but it didn’t, it just made me worse. She made me cry all the time. The second one would say something and then there would be an uncomfortable silence for about half an hour, then she’d say something else and there would be another uncomfortable silence for another half an hour and then I’d go home.”
This is a scenario often described to me by adolescents: the counsellor is either intensely problem-focused, failing to meet the person behind the issue; or reveals herself as having participated in a psychotherapy training heavily oriented towards working with adult clients. Psychotherapeutic intervention with adolescents is a complex and challenging area of work and requires specialised, in-depth training. Certainly in my experience, learning about the dynamics of development and therapy with this age group has served my adolescent clients much better than relying on intuition, inadequate theoretical grounding and no conceptual framework to guide me through the frequently bewildering and directionless experience of therapy with a teenager.
Problem solving, conflict resolution, behaviour change etc., although important to address, are not defining themes of therapy with teenagers. The adolescent finds it more natural to describe his or her friends, siblings, parents, music tastes, football interests, school and so on, than to speak in terms of feelings and reflections. This is not avoidance; it is revelation. It is a self-defeating attitude to view the adolescent’s outward focus as simply defensive, concealing intrapsychic reality – rather than as a window into the adolescent’s world.
For me, therapy is about making contact with this adolescent and co-creating a human to human meaningful encounter where we are both of worth and we both have dignity and where there is nothing ‘wrong’ with either of us – contact which isn’t shaming. It’s about getting interested in who he or she is at the core, liking and appreciating that, and communicating that in some way to the adolescent. Once that contact has been established – we can get to work on the ‘problem’ in a way that is supporting and not shaming.
So I get interested in John’s world. I keep a glint in one eye: irreverence, humour, my own fiercely rebellious adolescent energy etc. I keep the other eye firmly fixed to this adolescent’s developmental journey, contextual field, level of internal and external support. So I make calls on a moment-to-moment basis about where our conversation is going and how much this adolescent can tolerate. He tells me how glad he is to have been expelled, it was a crap school anyway. I get interested in his definition of ‘crap’. Actually this is quite a prestigious grammar school and it turns out that John scraped a place in it by the skin of his teeth with a fairly average 11+ result. He never felt quite up to the mark, believing that he was the ‘stupidest’ in his year group. So, rather than be shamed about it, he didn’t study – excelling in non-academic subjects like sport and art. We will need to attend to this later in the work. We talk about the initial session – it was the first time he ever saw his dad cry. He didn’t think his dad cared; he thinks differently now – just a little differently.
He describes how he can’t stop thinking about his girlfriend who died. They were in love, were soul mates; he can’t live without her. Teenagers form extraordinarily magnetic, infatuating bonds with one another very quickly – they had been going out for four months. It is a grave mistake to dismiss the adolescent’s relationships as ‘puppy love’; we must take these connections seriously even though we may have very different ideas. When John tells me that they would regularly spend up to 8 hours on the phone with each other. That gives me an indication of how this young adolescent felt met in his relationship. Now I begin to appreciate the level of loss he is experiencing. As the first tentative giving of the self is experienced for an adolescent through the formation of a meaningful relationship, there can be a sense of great loss when this is terminated. This is even more poignantly felt when this ending is the result of trauma and tragedy as in John’s experience. John describes what his life has been like without his girlfriend – the loneliness, the emptiness, the pressure in his head when he thinks of how she would still be alive if he had not met her after school that day, the relief that comes when he punches something or gets drunk. Two things are apparent to me: he really misses this girl and he’s blaming himself for what happened. I offer these to him gently along with my hunch that teenage boys find it easier to translate their hurt into anger. He looks at me. I think I’m getting him. He thinks I’m getting him. We lighten it up after that, preparing to close the session. The irreverence kicks in and we banter about how Tyrone will win this year’s All-Ireland yet again. He thinks it’s Armagh’s turn this time round – I don’t fancy his chances!
The Following Sessions
As I said previously, by the end of the second session, the core of the work has been undertaken – a fairly clear picture has emerged of what life is like for John just now and importantly, this family feel met. I know that the quality of work with John would most certainly have been compromised had I chosen not to involve his parents. Later in the work I facilitated some important work between John and his father; I met with the parents alone – educating them about their role in the dynamics of the relationship and coaching them on how to support their son without nagging or shaming him. I also facilitated two more family meetings. Throughout the remaining 8 sessions John and I worked together in one-to-one sessions. John’s anger gave way to sadness which he was able to express through our conversations, his tears and some profound artwork; and he found new interest in and resources for living. He started playing football again. John and his father started fishing again, which they hadn’t done since John was 10 and which they both had missed. I prepared a report for his school (at his parents’ request and agreed to by John) which resulted in him being accepted back again. John began to feel surer of himself again.
This adolescent was lost in the world, overwhelmed by the loss of his girlfriend and the confusing task of growing up. His parents had lost faith in their parenting and lived in terror that their son would end his life. My task was to hold my ground and share it with them for a while until they each found theirs once more. The therapist’s capacity to stay grounded whilst tolerating intense anxiety and chaos which spills from the intrapsychic field into the whole family field; whilst having a solid grasp of adolescent development; whilst being able to draw up a broad therapeutic plan; whilst being aware of potential triggers in her personal process; whilst listening to this mother at the other end of the line describe her son’s failed attempt to hang himself the previous weekend depends, for me, on three things: (1) I breathe. (2) I remember I have a body and I stay in it. (3) I remember I have support.
Bronagh Starrs maintains a private practice in Omagh as a psychotherapist and trainer, specialising in working with children and adolescents. She is a founding member of Borealis, a support organisation for Humanistic and Integrative psychotherapists working in the north of Ireland. For details of upcoming training please contact Bronagh via email: firstname.lastname@example.org
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