A Gestalt Approach to Working with Adolescents

by Jennifer Foran

Does the body rule the mind, or does the mind rule the body?
I don’t know.
The Smiths

Introduction
Historically, adolescence has commonly been characterised as a period of ‘Sturm und Drang’ (storm and stress) but this way of thinking has been reconsidered. In Gestalt therapy the positive view of human nature, the relationship, contact processes, the importance of the field and the conceptualisation of development, can help guide the work with adolescents.

The word adolescence comes from the Latin ‘adolescere’, which means to ‘grow up’. This definition captures that adolescents are in the process of transition; they are neither children nor adults. ‘Growing up’ can be challenging and the developmental process can cause various degrees of stress for the adolescent and within the family system. “We might say that developing the capacity for contact (that is, for developing boundary conditions that support both joining and separating) is what adolescence is all about” (McConville, 1995: 5). It is through this process of boundary development that the adolescent is reorganising and defining themselves in relationship to their family, peers and their forming social world.

“Therapy is the careful, heartfelt, spontaneous management of contact process with someone who requires that contact in order to further her or his development and growth” (McConville, 1995: 256). Adolescent development is the development of contact. Connectedness and support can enhance the adolescent’s experience of psychological well-being and identity development. Support from the field is particularly important and adolescents who are supported in their environment are more likely to be adaptive, experience better peer relationships and are less likely to present in therapy, than those who lack support. In other words, without sufficient environmental support, adolescent development can go seriously awry.

Mark McConville states that “Adolescents who enter psychotherapy have become stuck in their developmental process” (1995: 124).

Gestalt therapists who work with adolescents inevitably encounter clients that present with complex interpersonal situations rather than symptoms. This approach of working at an interpersonal level helps me in the work to see the adolescent’s experience not so much as symptomatic of a diagnosable disorder, but as the manifestation of an under-supported developmental process. In addition, symptoms can be understood to be creative adjustments to the conditions of the field, and referring to how individuals creatively resolve the dilemmas that life presents to the best of their ability.

Adolescents can be understood only as part of the larger fields in which they live, and only when we see and appreciate their very personal, subjective struggles to renegotiate their status within those fields, find meaning and a place for themselves, and at the heart of that struggle, give birth to an existential self.

(McConville, 1995: xxiii)

Adolescent development takes place in a context (McConville, 1995) and it is important to meet the adolescent and the parents from the onset to gain an understanding of the adolescent’s life story and the relational dynamics.

A case example: Sara
A pseudonym has been used for this case example and details have been changed to protect the client’s identity.

Sara, 18 years old, experienced loss of vision suddenly. Following a thorough medical examination her consultant was unable to find a physical explanation for her symptom. There was a diagnosis of a Conversion Disorder with the recommendation of seeking psychotherapy. From the first telephone conversation with Sara’s mother it was clear that she was unwilling to attend or be a part of the process. Parents at times may be difficult to engage, especially if they are threatened or there is potential for shame. I pointed out the limitations of the lack of parental engagement in the therapeutic process and arranged to meet Sara alone with the notion of engaging the parents at a later date.

When I start working with an adolescent, an experimental attitude often works well. During the initial phase my main task is in building a relationship that fosters trust and safety. As the adolescent talks about the content or story of his or her life, my focus lies in the process – how are they engaging with me, how do I feel about them, etc. For me, adolescent therapy is first and foremost about making contact, it is about getting interested in who they are.

“Contact involves having the ability to be fully present in a particular situation with all of the aspects of the organism-senses, body, emotional expression, intellect-ready and available for use” (Oaklander, 2006: 22). In assessing the level of contact in the room I noted that Sara’s loss of vision resulted in her not being able to see me clearly and that her other senses would as a result be heightened.

My experience of Sara was that she eagerly took the space to talk about her experience inside and outside of the home. I took a detailed history, making sure to ask about her perception and experience of the problem. She described herself through the eyes of others, as a Goth. Her alternative identity made her stand out. It was her armour and her way to stand up to the world and make a statement. Books were her life and helped her sit with her deep emotional distress and alienation.

I was aware that the figural issue was the ongoing difficult relationship with her aggressive mother and her submissive father. For ten years, Sara had experienced verbal abuse and fighting at home. It is not unusual for an adolescent to arrive in therapy after an event that took place ten years earlier. She seemed to be deeply affected by her mother’s rage. Could Sara’s symptom be best understood as a retroflection of her feelings?

Sara was open to talking about her sight loss. Although Sara’s mother was resistant to the idea that the loss of sight was a result of a psychological problem, Sara was not. Sara spoke about her mother not accepting the diagnosis and requesting more and more tests, all of which she endured.

I learnt that life for Sara had been traumatic. At school she had been bullied from a very early age and the bullying more or less continued to the present day. At times the bullying was violent which resulted in Sara being taken to ‘A&E’ on more than one occasion. What also came to light was the presence of trauma in the family. When Sara was much younger, a traumatic incident led to her mother being unable to work. This traumatic incident seemed to have changed the family experience from happy and inclusive to walking on eggshells around the mother so as to not antagonise her. It seemed the experience at home mirrored her life outside of school, with the result of Sara having virtually no safe place.

Secondary school with its new beginning provided hope for Sara. She consciously tried to fit in and her strategy provided some reprieve from the relentless bullying. Interestingly her conscious effort to fit in coincided with the beginning of adolescence, a time where friendships take on a greater importance. It was short-lived and the bullying started again. Her fear of not being believed silenced Sara. It seemed from an early age that she was aware of the lack of support in the environment.

Adolescents are especially vulnerable to the effects of trauma, and trauma can have a significant impact on their development. Starrs (2014) in her clinical work with adolescents has identified two qualitatively different experiences of trauma:

1. Trauma without is an experience of trauma which is created from outside the family field, for example, death or an accident. The recent Paris attacks provide an example of trauma without. The overwhelming and traumatic events that some adolescents encountered that night will no doubt rupture their experience of contact boundary development.
2. Trauma within is the experience of trauma which emerges from the ground of family experience, for example, hostile parenting, addiction and abuse.

In the face of trauma, adolescents can be left with a profound sense of inadequacy, shame and isolation. Trauma can threaten an adolescent’s sense of basic trust and their secure attachment. The environment can be perceived as threatening. Understanding the nature of the trauma and its effects was a significant part of the work of supporting Sara’s development.

Over the course of the therapy, Sara spoke about her partial loss of sight presenting difficulties in her schooling, peer relationships and her relationship with her parents. Sara had missed a lot of school and decided to repeat fifth year in a new school. On the surface there did not appear to be an obvious trigger to her partial loss of sight. However, Sara is approaching the next developmental stage of Emerging Adulthood and if we were to frame her symptom of sight loss in a developmental context we can begin to understand that the prospect of leaving school for Sara might be anxiety-provoking.

It is so important to have a grasp of what the undercurrent of this developmental transition is, because what percolates up to the surface and expresses is a kind of psychiatric symptom or psychological symptom.

(McConville, personal communication, November, 2014)

Sara engaged well, made good contact and spoke about being in therapy with me for the long haul. I got the sense that I was one of a handful of people who ever took an interest and listened to her. With the ongoing bullying and hostility at home, Sara’s experience of adults was one of failing to protect her, and harmful. She felt devastated, worthless and lonely. Her confusion and questioning, ‘Why me?’, ‘What is wrong with me?’, ‘It’s my fault?’ seemed to result in her turning inward and withdrawing. Becoming interested in Sara’s life, reframing, educating and normalising helped her to put words on her life experience.

One theme that kept repeating in the room was that she truly believed that her sight loss was a result of not wanting to see the conflict in the house any longer. ‘I can’t see it and I don’t want to see it anymore’ she would frequently say. We explored her blindness as a creative adjustment/ metaphor. ‘What do you not want to see?’, ‘Do you feel seen?’, ‘What comes in and out of focus?’ She truly believed that her sight would return when the hostility ceased. She felt stuck and hopeless and it was important for me not to join Sara in this place. ‘Was her loss of sight helping her to sit with her anxiety and resolve the conflict she was feeling?’, ‘If I can’t see the conflict at home then I won’t feel anxious?’

Her partial loss of sight also made Sara visible to both her parents and professionals. Was this a secondary gain for her?

Field intervention work
Emerging adulthood can be a stressful and emotionally complex time that evokes anxiety and grief. The way an adolescent negotiates this development period is largely shaped by formative experiences in childhood and adolescence, many of which occur in the family. Adolescents, like Sara, who lack support in the field can feel overwhelmed or unprepared to face the transition. For Sara, leaving school and moving out into the world was controlled tightly by her mother. Whilst her sister and her brother were able to move away to fulfil their dreams, Sara was resigned that she would have to stay at home well into adulthood. In addition, her desire to be treated like an adult was being diminished by her sight loss as her parents’ concern resulted in them parenting Sara like a child.

Whilst individual work with an adolescent is useful, it is always important to attend to family process, particularly parent-adolescent relationships, which shape developmental dynamics. I was curious about the father’s experience of the sight loss, his perception of what life was like for Sara, relationships within the family and the level of contact in the room. My initial sense of the father was that he was supportive and appeared to have a good grasp of what life was like for Sara. He spoke as if they were comrades. My invitation to them both, to make contact, fell flat in the session. Instead the exchanges that took place seemed ladled with shame and frustration. Following this meeting Sara experienced increased hostility at home. I felt disappointed that the father seemed to lack the capacity to be more receptive and supportive.

I felt that without engaging the mother the ongoing work would be stifled and limited. I invited Sara and her parents into a joint session as I was curious about the legacy of the trauma and how it might have impacted on Sara’s development. I also wanted to evaluate the mother’s level of functioning and her contact style.

At the beginning of the session I was aware of the mother’s resistance as she sat in the chair with her arms folded, looking at the floor. It was likely that shame was present; that somehow she felt she had contributed to Sara’s issue. Shame and support are polar opposites and I was aware that the family needed to be supported during the session. My posture of openness, curiosity and warmth appeared to neutralise her resistance and she softened considerably. We began to look at the family dynamics and it became apparent that the trauma had compromised her identity as a mother. She was clearly experiencing PTSD and had become an angry, controlling woman. As the session progressed she got in touch with sadness around her sense of redundancy in the world and in the family. I felt it was important to get the three of them to talk together and acknowledge the experience as so much had changed in the family since the trauma.

I invited the three of them back the following week and we spoke further about the impact of the trauma. Sara’s mother became increasingly aware of the impact of the accident on her, and her subsequent impact on family life. She wondered if Sara was afraid of her as she could be so aggressive in her contact style. I noticed Sara listening intently and turning towards her mother. At this stage it seemed that there was sufficient ground and safety for Sara to voice her phenomenological experience in and outside of the home. This opened the space for the family to speak about the previous ‘unspeakable’ controlling aspect of family life.

In the subsequent individual session Sara reported that life at home was becoming increasingly more relaxed and that everyone seemed happier. Sara also reported that she felt her eyesight had improved a tiny bit.

It is hard for an adolescent to define who they are when they are dealing with the effects of trauma. Most adolescents want their experiences to be heard, to not be judged and to be taken seriously. If I had paid too much attention to her symptom, her partial loss of vision, then I would have run the risk of it becoming embedded in her experience. Instead, working symbolically with the sight loss and bearing witness to her phenomenological experience helped Sara to become more self-aware of her needs, which empowered her to find her voice, be seen and to begin to carve out a vision for herself in the world. This was undoubtedly supported by the parental dialogue which further validated her experience and allowed her to become visible in her family. This began to translate out into the wider world.

Circumstances led to there being a break in the sessions for a period of six weeks. When she came back Sara couldn’t wait to tell me that her sight had improved dramatically. Her belief of her sight returning when the conflict diminished became a reality for her.

Jennifer Foran is an adolescent psychotherapist in private practice in Primary Care Psychotherapy, Naas, Co Kildare and The Blue Lotus Centre, Celbridge, Co Kildare. She is a graduate member of the Blackfort Adolescent Gestalt Institute and has recently become a member of the Overstaff Team on the Post-Qualifying Diploma in Gestalt Adolescent Psychotherapy at the Blackfort Adolescent Gestalt Institute: Tel: 0868599328.

References:
McConville, M. (1995). Adolescence: Psychotherapy and the Emergent Self. San Francisco: Jossey-Bass.

Oaklander, V. (2006). Hidden Treasure: A Map to the Child’s Inner Self. London: Karnac Books.

Starrs, B. (2014). Contact and Despair: A Gestalt Approach to Adolescent Trauma. British Gestalt Journal, 23, 28-37.