A Clinical Process for Working with Adolescents

Introduction

According to the UN Convention on the Rights of the Child adolescence spans the age range 10 to 19 years and incorporates very different developmental capacities and expectations. Adolescence is divided into early, 10 to 13 years, middle 14 to 17 years and late adolescence or early adulthood which some place as 18 to 21 years or beyond. It represents the transition from childhood to adulthood and is characterized by physical, intellectual, emotional and sexual growth and development. Some parents anticipate this life phase with dread, their concerns escalated with comments like ‘Just wait till they are a teenager!’ but others navigate the challenges without incidence and enjoy the new relationship this offers with their child. 

For the purposes of this paper the focus will be on middle adolescence, the 14-to-17-year age group who are completing their schooling and making choices about their productive identity, earning or learning, the nature of their relationship with family, friendships and sexuality. Brain changes are progressing and while able to think abstractly and consider the big picture frontal lobe development is such that good decisions are not always made in times of strong emotion. Understanding this contradiction is important for both parents and practitioners supporting young people and their world to manage the challenges of this life stage. 

However, it is not only the young person facing tumult and change. The family is confronted with the task of realigning its rules and expectations to allow the adolescent room to experiment and make mistakes in order to learn who they are and how they will relate to their expanding world. Some families find this particularly distressing and may engage in an escalation to control which results in greater effort by the teenager to assert their independence, triggering more controlling actions from the parents. 

Presentations to Therapy

Clients at this age present in two characteristic ways. They may have been brought by parents, school or statutory authority to be ‘fixed’ or have decided they need help for some difficulty they are experiencing. Both presentations can be problematic for the practitioner. When a young person is forced into therapy, they often present determined not to cooperate. Parents will announce at the beginning of the session that their child has told them that they will not speak and nothing the practitioner does will make a difference. They may also speak of failed attempts at therapy the uselessness of past practitioners, and how this is unlikely to be any different. This commencement point for therapy can feel like a challenge from both adults and their offspring and it is the unwise practitioner who is spurred to prove them wrong. 

Alternately the adolescent may be eager to engage in the therapeutic process having spoken with friends who have assured them that this will be helpful for them. While superficially this feels like a better place to start it too carries its own risks. The young person may come with a clear idea about diagnosis and treatment and in particular pharmacological solutions. They may be unwilling to engage in any other dialogue or consider other options for treatment determined as they are to receive a mental health diagnosis that will give them a particular standing in their own social network. Both presentations put the practitioner at risk for both a loss of neutrality about the young person and their difficulties and symmetrical escalation between client and therapist which inevitably ends in destruction of the relationship. This relationship will have mirrored those with parents, teachers and others in authority and cemented the difficulty rather than disrupted it. Most adolescents can out escalate adults in their capacity to think intellectually as clearly as the adult but emotionally willing to say and do things beyond what the adult is willing to do. 

Challenges for the Practitioner

The question of how to create an effective therapeutic relationship that is similar enough to their request and expectations to allow joining to occur but different enough to effect change is the first of several dilemmas the practitioner faces. This can be a stage of brash certainty and assertiveness that can make them harder to connect to but beneath this is often an endearing and vulnerable desire to trust. 

A different challenge is raised by the relationship between the world of the family to which the young person belongs and their external socio relational world. Developmentally, this life phase sees the young person becoming increasingly independent of their family of origin while retaining a more adult relationship of attachment. This means they require a degree of privacy and responsibility independent of the parent and therapy must respect this. Finding this proper balance is one of the challenges of working with people of this age and stage. It is crucial that they are kept safe physically and emotionally while also supporting processes of individuation and differentiation. Sometimes the boundary issues are created more by parents and others in authority than the young person themselves and once again it is a delicate balance to retain a positive connection with others in the world while protecting the young person’s integrity. 

The stakes often feel higher working with this age group. The fact that they have access to a broader world beyond that of the family and cannot any longer be physically constrained opens the possibility of both growth and development and increased risk. As a physically mature body a young person can challenge an adult with potentially serious consequences for both parties and other relationships. They are also capable of accessing substances and taking potentially life-threatening risks that frighten both parents and practitioners. The lack of fear that may accompany activity with peers can result in risky actions that would not occur alone. The temptation to exercise control over the young person by the practitioner mirror other adults in their world and escalate the difficulties. 

Managing the Therapeutic Process: The Protective Value of Bower(Note)

 The processes and protocols of Bower(Note) are helpful in managing these challenges. It provides an external focus that is designed to remediate the inequality inherent in the therapeutic process and properly co-locates responsibility to both manage the process and effect change. From the outset the focus is on explaining the protocols that direct the session. This avoids the uncomfortable face to face attempts by the practitioner to join with the young person who is either confident about how the session should unfold or determined to avoid connection. Effectively the practitioner takes charge of the session, setting clear boundaries and making the lines of authority and responsibility clear. 

Beginning each session with the client’s request allows a clear articulation of their expectations of therapy and for the practitioner to negotiate a request that is achievable. For example, if the request is for a diagnosis of ADHD in order to be prescribed dexamphetamines, the practitioner can explain that this is not something they can or will do but are happy to refer to someone who can. It may also allow for a conversation about the request, what is informing it and if there is another way the underlying issue could be addressed. A conversation about the client’s difficulties concentrating and subsequent school failure may allow another request to emerge. Equally it may become clear that the goal is to source medication to sell to friends. 

The agenda which details the process of the session and a clearly negotiated request allows the client to understand how time will be spent in the session and the basis for advice. This process of shared responsibility and transparency is mirrored in the advice process where there is an expectation that client and practitioner share the task of effecting change. In effect there is an almost seamless rebalancing, so therapy becomes a collaborative activity rather than a contest. 

 Follow-up allows for the planning of the next session’s agenda which allows both parties to have had the opportunity to reflect on matters that need to be discussed and ensures the burden of directing the session does not sit with the practitioner alone. Finally, collecting feedback allows the client to comment on the process and practitioner to respond. 

Word and Image

The note taking process with all clients entails the use of A3 paper and minutes of the meeting taken in the client’s full view in printed bright lettering and where possible, with their collaboration. This is particularly effective in the drawing of an ecogram, an extended family tree, inclusive of non-family members. The most reluctant adolescent will often be willing to contribute to the drawing of the image and once co-operating physically will begin to speak. 

Privacy and Confidentiality

As young people move into the wider world differentiation is served by privacy and the need and right to thoughts, beliefs and experiences that are not shared with parents. It is a delicate balance between creating a safe and durable sense of self and engaging in harmful conduct that will undermine a healthy adult identity. This is the tension therapy must manage. 

A key part of any first session is the explanation about confidentiality that is shared with both the client and all the key adults. All parties need to appreciate that confidentiality will be breached if the practitioner ‘rightly or wrongly believes the person or any other is a risk to themselves or any other person’. This specifically references self-harm and suicidality which are frequent presentations with young clients. Should such matters arise the practitioner has established a base for speaking to ensure safety. Ideally this is done in co-operation with the client but if this is impossible safety must always be a priority. 

Other breaches of privacy occur with the disclosure of a major crime or in the event of subpoenaing of notes. Again, these are clearly explained from the outset. 

With less serious disclosures that may put the client at risk but are not of sufficient severity to justify a breach of confidentiality, the practitioner can engage in a conversation about how best to ensure their protection. This may include conversation with the adults or agreements to follow advice. 

Advice

As with all clients the preference for advice, the response to the request, is to cease something that is underpinning the difficulties. This may be an action, like self-harm, excessive drinking or sleep deprivation, a feeling; sadness, anxiety, a meaning ; ‘when people don’t respond it means no-one likes me’ or a belief ‘My life is worthless’. This may then be served by positive actions to support cessation. For example, a noticing task may be set to establish the validity of a problematic belief or an alternative action to self-harm suggested. Understanding the developmental stage and the fact that young people have the capacity to make wise and safe decisions when alone and calm but may make foolish and dangerous ones when with peers may shape the advice given. However, the key is cessation and the recognition that removing something is more powerful and to be preferred. 

Any advice must factor in the wider system and in particular parents and friends. Parent usually have the power to bring the young person to therapy and without their support may prevent this continuing.  It is crucial that any advice also respects their requests, values and concerns.  While recognizing this it is also important to remember that peers are very influential at this life stage and can also move to undermine the therapeutic process. A full ecogram that includes friends and enemies will allow the practitioner to understand key relationships and overtly engage with them. Inviting the young person to bring their close friends to sessions or encourage them to share advice and seek friends opinion can be helpful. 

Working with young people is challenging and requires intellectual, emotional and relational dexterity. Sometimes it also requires a thick skin. Despite this, work with this age group is fun and rewarding with change often happening quickly and dramatically.