Ben ** is a 16 year old high school student. He completed a mental health assessment about four months ago after being referred from his school due to behavioral concerns, poor attendance, and "possible problems with marijuana and other substances". Previously, he attended school-based psychological counseling in the seventh grade and has been meeting with a school counselor regularly for about a year.
( ** Ben is a former customer who has given permission to use his story. His name and some identifying details have been changed to protect confidentiality.)
At the time of the assessment, Ben was diagnosed with a moderate depressive disorder. He also completed screening questionnaires for trauma, anxiety, and various other problems. All scores were well below the clinical level. Despite the school's concerns about substances, there was no formal drug assessment.
Todd and Julie, Ben's parents, have been divorced since Ben's third year. Ben lived with his mother until about a year ago. Todd now has full custody but travels frequently to work. Both parents were pretty decoupled in the counseling process. In fact, Doris, Ben's fraternal grandmother, was the only family member who participated in the assessment.
Doris appeared to be overly involved with both Ben and Todd. She also reported that Julie "is bipolar but doesn't take medication" and "drinks too much, at least if you ask me." Doris also explained that Ben "was probably abused by Julie's ex-boyfriend" but refused to provide further details. "I don't think I should have said anything."
After the assessment, Ben reluctantly entered the service and met with his original advisor for almost two months. At that time, he was referred to me because the original advisor had decided, "I cannot be effective with such a resilient child." The counselor said that Ben's presence was poor and that he was unwilling to get involved when he was present, did not do the homework of the treatment, and "appeared high at least a few times."
During our first meeting, Ben reported: "All other therapists did was say that their office is a safe place to talk about such feelings and crap. You know, the bullshit therapists always say. I bet you'll say it too. "
Numerous studies show that an effective therapeutic alliance is essential for commitment, retention and positive treatment results. However, many adolescent clients are simply not interested in counseling, let alone connecting or building a relationship with a strange adult. This is especially true for avoidable young people like Ben.
Building effective therapeutic alliances with these adolescents can seem daunting even to the most seasoned advisor. In this article, we will explore practical, field-tested strategies for maintaining repeat with avoidable teenagers. But first, let's take a quick look at some key ideas for attachments.
We are not sea turtles
When a mother sea turtle is ready to lay eggs, it goes to a beach and digs a hole in the sand with its rear fins. She lays her eggs in this rudimentary nest, covers them and quickly returns to the sea. At this point, the mother sea turtle has completed all of its educational tasks and has nothing to do with the eggs. Male sea turtles have absolutely nothing to do with their offspring.
When the eggs hatch, the newborn sea turtles flick awkwardly to the sea with floating fins without evading predators on land. If they survive this crazy shot, they are ready to live alone. No nurse ever offers care, teaches them life skills, or protects them in any other way.
Humans are not sea turtles. In our early years, we needed caregivers just to survive. When these caregivers are attentive, protective, and caring, human babies quickly learn that the world is a safe place, their needs are met, and people are happy that they are here. These children are securely fastened. However, if their primary caregiver is not reliable, this healthy attachment process can be interrupted, leading to insecure attachment and possibly life-long challenges related to relationships, self-esteem, and personal development.
There are three types of insecure attachment: avoiding, fearful, and disorganized. Avoiding binding is the most common type of insecure binding. Studies show that up to 1 in 4 Americans fall into this category. This percentage is undoubtedly higher in the clinical setting.
Young children who develop an avoidable attachment style have predictable caregivers who are emotionally unavailable and ignore the child's needs. These caregivers can reject the child if he or she is injured or sick, usually promote early independence and are sometimes openly negligible. As a result, the child learns: "I am alone."
Attachment styles are continuities, so that avoidance-bound teenagers don't all act the same. Nevertheless, these young people often appear defiant, defensive or dismissive. They will likely present themselves as very independent, oppositional, and unwilling to change. You are probably also suspicious of a sensitive gesture.
A little bit more about empathy
Put simply, empathy is the ability to understand someone else's feelings. As consultants, we are taught that empathy is an integral part of all effective therapeutic relationships. I certainly don't agree with that. However, it seems to me that sensitive gestures are anything but one size.
Many reluctant clients of all ages show empathy by saying things like, "Seeking support is a brave step" or "My office is a safe place to explore your feelings." It's like being increase the volume on a secret empathy button. For anxiously connected customers, this could be very effective. However, this is often overwhelming for avoidable teenagers. Life has taught these young people to be careful with such statements. When they hear such statements, they withdraw.
I certainly do not suggest that we switch off our empathy as a consultant. However, in the early stages of building therapeutic alliances with avoidable teenagers, we need to lower the volume. With that in mind, congratulate unavoidably attached teenagers on starting counseling, especially when this is simply the least bad choice, and don't make your office a safe place. You know better.
I think this more nuanced perspective of empathy is an essential foundation for the implementation of the following strategies based on ties.
Getting started correctly
With avoidable teenagers, first impressions are essential to get started properly. Here are four tips to ensure that first meetings are therapeutically productive:
Emphasize the structure of a repeat. Initial meetings often include paperwork, screening tools, and planning for initial treatment. I encourage you to put the stuff aside and spend time getting to know the teenager sitting opposite you. You will have to fill out all of these forms at some point, but if this new customer never comes back, proper documentation and a well-developed diagnosis are not important. You'll also get better answers from teenagers like Ben once you've built a relationship.
Take the parents out of the room. Unlike Todd and Julie, parents or caregivers almost always take part in first meetings. When they do, I meet everyone to discuss the basics, e.g. B. Concerns, my background, and confidentiality issues. I then ask the parents what I think they should know. After I get her perspective, I let her go. This way, most of the first meeting can focus on learning what the teenager wants from the service and maintaining rapport.
Concentrate on what you are ready for. Therapists love to focus on internal motivators and high treatment goals, but this isn't useful for avoidable bound teenagers who want one thing – go and never come back. You will go further by helping them identify external motivators, e.g. B. the fulfillment of the probation requirements or the satisfaction of the parents. By helping avoidable bound teenagers approach these concrete goals, you are demonstrating that you have actually listened to what they said, made you an ally, and kept coming back.
Do not sell the therapy heavily. When faced with resilient customers, you can easily overstate the benefits of engagement. If we didn't believe in therapy, we wouldn't be therapists, would we? However, our enthusiasm can be exactly what an avoiding teenager needs to justify a quick retreat. Instead, present your treatment recommendations objectively and then explore the advantages and disadvantages of engagement. In my experience, most preventable teenagers agree to services when they don't feel compelled.
After successfully completing the first meeting, our next task is to build an effective therapeutic alliance. Edward Bordin (1979) wrote that the therapeutic alliance consists of
1) a positive bond between the therapist and the client, 2) a collaborative approach to counseling, and 3) a mutual agreement on treatment goals. When we strive to fully integrate these elements and really embrace a teen's motivators, we stop being an opponent and become an ally. For avoidable teenagers, we're also becoming a much needed, secure base – perhaps their only one.
To build a strong therapeutic alliance with avoidable teenagers, we need to focus on being trustworthy and connected.
Trustworthiness
Avoiding teenagers have learned to constantly question the honesty of others. It is therefore important that we are absolutely flawless in our trustworthiness as consultants. However, just being trustworthy is not enough. we have to demonstrate it – not just once or twice, but with every single interaction.
Brené Brown (2015) compared trust to a glass of marbles. Every time we prove our trustworthiness, we put a metaphorical marble in the glass. When the glass fills up, trust grows. When it comes to building a therapeutic alliance with avoidable teenagers, there are five particularly important marbles:
authenticity. In the context of a therapeutic alliance, authenticity means being our true, real self when interacting with clients. In other words, we put therapeutic personas and dose reactions aside. Instead, we show who we really are. This should be our goal with all clients, especially avoidable teenagers who are often very sensitive to insincere behaviors or actions – a skill they have learned to master difficult relationships with adults in their lives.
consistency. To be consistent means to act in a predictable and reliable manner. Something that is avoidably tied to young people has probably not seen much. If we are consistent in dealing with these teenagers, we not only show trustworthiness, but also model a new way of being in relationships. Some ways to demonstrate consistency are to always start and end sessions on time, schedule appointments at the same time each week, and keep all of the promises we make.
not judgment. Avoiding teenagers have often learned to notice seemingly minor clues, such as: B. a slight change in facial expression. This is a useful skill in situations where care is unpredictable. In this sense, it is important that we avoid comments, gestures or facial expressions that could be interpreted as judgmental. This may seem obvious, but it can be more difficult than it sounds, especially if a customer frustrates, evades, or attracts us – you know, as teenagers do sometimes.
usefulness. Another way to demonstrate trustworthiness is to provide something useful at every session. This does not mean that a major clinical breakthrough is achieved every week. That would not be realistic. However, there should be some kind of tangible take-away every time we meet with an avoidable teenage boy. Possibilities include a helpful skill, a solved problem, an opportunity to vent, or a meaningful insight – if this adds value to the life of the youth.
transparency. This means being completely open about the therapy process, including our intentions as helpers and what customers should expect from services. Truly transparent therapists spend time examining the pros and cons of counseling, the reasons for discussing certain issues, and the theoretical foundations of the proposed treatment approaches. In other words, transparent therapists strive to solve the riddle of the process. Like a good magic trick, knowing how it works should make it more engaging.
Affinity
According to Edward Hallowell (1993), connectedness is “a feeling of belonging or a feeling of being accompanied. It is the feeling in your bones that you are not alone. “I often describe this deep connection as a feeling. In order for each of us to really feel felt, we have to believe that we are understood, respected and welcomed. We need to feel like we are interacting with another person who has deliberately chosen to join us in that very place and moment.
Avoiding teenagers did not have this lived experience of connection. When we work with these teenagers, we should always strive to model the connection so that their implicit suspicions of empathy are recognized, while helping them achieve more secure attachment styles.
Allan Schore (2019) calls these "connections of the right brain to the right brain". We can intentionally make such connections using approaches that focus on emotions, creativity, and attunement. It seems to me that adolescent therapy usually focuses on problem solving, decision making, psychoeducation and similar approaches for the left brain and ignores the importance of helping clients feel more comfortable with their entire brains.
Here are five simple but effective strategies to intentionally promote connections between the right brain:
Validate and normalize. In the context of his lived experiences, Ben's suspicion, opposition behavior and even substance use were functional. In other words, Ben found value in these behaviors. In fact, he once said, "I think I really want to push people away and I'm good at it. Really good!" We can validate intentions without endorsing problematic behaviors. In the case of teenagers who are bound to be avoidable, this is often an essential step in building therapeutic alliances.
Use the plural language of the first person. The words we use are important. Here is an example: Instead of using the pronouns "you" and "your", switch to "we" and "our". This shift leads to a subtle but palpable change in our interactions with avoidable teenagers. It also helps to affirm that we are together in this process and that the teen's experience is understandable. I'm not sure if customers notice this word usage openly, but I definitely think it makes sense to make the move.
Use more reflections, ask fewer questions. Most therapists ask far too many questions. For an avoidable teenage boy, questions can seem intrusive, annoying, and insincere. It may not seem intuitive, but fewer questions from you actually cause the customer to speak more. Use reflections instead of all of these questions. Avoid carefully worded considerations while you're at it. Instead, stand up for what you say with facts like "That was hard for you". Such statements show connection, not questioning.
Talk less, do more. From a development policy perspective, comprehensive conversation therapy is not the best solution for young people, especially for those who are avoidably connected and do not want to get involved at all. I suggest integrating some no-talk approaches to build a relationship and achieve therapeutic goals. The Exploding Kittens and Fluxx card games are an excellent choice to build a relationship with. They are youth-friendly, easy to learn, and full of opportunities to create metaphors. Preferred therapeutic activities include collages, creative journaling, and walk / talk sessions.
Be fully present. To be present means to focus your attention, your attention, your thoughts and feelings on the here and now – in this case the current session with the current customer. In my view, this requires more than basic attention. It requires being fully engaged from person to person, with no judgment or agenda. This presence can sometimes feel risky, for consultants and for avoidable youngsters. Because of the connectedness, it is worth taking the risk.
Relationships are mutual
Imagine your answer when a customer claims to be in a relationship where the other person refuses to disclose personal information and often makes statements such as "I'm curious why you want to know", even if the question is pretty harmless. Perhaps you would change that client's treatment plan to work on healthy relationships or build appropriate boundaries. I would do it for sure. However, this is what we as consultants do all the time, perhaps based on the assumption that self-disclosure is inherently bad.
It seems to me that we should not expect young people, especially those who are avoidably connected, to be open to us if we are not open to them. I certainly don't suggest that we share every detail of our lives with young customers, but I think we should be willing to disclose relevant information, answer questions out of curiosity, and be as honest with customers as we are it is expected with us In this way we model effective interpersonal skills, show healthy ways to connect with others, and strengthen the therapeutic alliance.
When adolescent clients ask questions of a personal nature, some therapists see this as a form of resistance, as a way to avoid the subject at hand, or as behavior that disrupts treatment. At least sometimes I disagree. Maybe the teenager makes a first attempt to build a relationship with us. Perhaps these questions are a sign that we will become a safe base for the teenager. Maybe we'll see a little bit of change. Why should we close that?
If we distract all questions of a personal nature, we may not reinforce the appropriate therapeutic limits or challenge avoiding clients. Maybe we reject a preliminary connection attempt. Perhaps we show that we are not a secure basis. Perhaps we will reinforce the customer's avoidable retention style.
The meetings with Ben were slow in the first few weeks. He often showed up late, sometimes refused to speak, and often stated that he did not need or wanted no help. One day I taught him Fluxx. He commented that the game was about unpredictability. "I hate that," he said.
In the next session, Ben brought his own game Unstable Unicorns. "It's a complicated game," he said, "but I'm a complicated person and you seem to understand me."
I registered it, took my cards and lost three games in a row. At the end of the session, Ben said for the first time, "See you next week."
John Bowlby (1969) described the bond as a "permanent connection between people" and found that the earliest bonds that children form with their primary caregivers have significant lifelong effects. When we meet with teenagers that are avoidably connected, it is important that we remember the spirits in the room with us. It is important that we intentionally earn marbles. It is important that we make connections slowly but steadily. When we do that, we invite teenagers like Ben to take a safer way of being.
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David Flack is a licensed mental health advisor and substance disorders specialist in Seattle. For 20 years he has been meeting with teenagers and emerging adults to deal with depression, trauma, simultaneous disorders and much more. In addition to his clinical work, he regularly offers regional and national training programs. Contact him at [email protected].
Knowledge sharing articles were developed from sessions presented at American Counseling Association conferences.
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