The Four Most Common Mistakes in Treating Teens

By Jerome A. Price and Judith Margerum

First appearing in The Family Therapy Networker, July/August 2000.

Most therapists agree that teenagers can be among the most difficult clients we see in our practice. They often refuse to attend sessions, refuse to speak when they do attend, swear at parents and therapist, and storm out of the room when they hear things they don't like. Difficult teenagers often argue head-to-head with adults and professionals using arguments such as, "I'm not going to give them any respect if they don't give me respect," and "It's my life." At times such teenagers have thrown objects across the office. One particularly aggressive twelve-year-old girl threw her wooden soled sandal directly at my face hollering, "I'm glad I'm not one of your kids!" Some teens are so direct that they come out and say, "There's nothing you (the therapist) or them (their parents) can do about me."

Any therapist treating domestic violence takes one look at a husband who is dominating and abusing his wife and recognizes that he exercises power over her. Yet, when a teenager threatens, dominates by shouting and imposing guilt and controls her parents by threatening to run away, most therapists fail to realize that abuse is going on.

Adolescent and preadolescent behavior begins at younger ages as our culture educates them more rapidly. Parents are trying to walk the fine line between being authorities and friends with their children. However, this tightrope is precarious and requires a lot more knowledge and patience than, "spare the rod and spoil the child." As psychologist David Elkind pointed out decades ago, children are growing up more quickly and losing their childhoods too early in our fast-moving society. As teenagers become adult-like at earlier ages, they see themselves as "equal" to the adults. Our society isn't teaching them the distinction between being of equal value vs. having equal authority as adults. Teens are extremely vulnerable to believing that they can handle everything and don't need the adults. They are struggling to take control of their lives as parents struggle to give them that control only as they're ready to handle it. There's a natural power struggle.

So, how does a therapist treat a struggle between a teenager and his or her parents? Does he ignore the power issues and treat everyone as equals, or understand the need for order in a child's life through support and leadership. Therapies that advocate support without leadership fail, giving teenagers too much control. They begin to fail in school and get in trouble with the law. The idea of leadership isn't new--Jay Haley, Cloe Madanes, and Salvador Minuchin encouraged therapists 30 years ago to recognize the need for order in a family's existence. The more stuck a case is, the more critical it is take charge of the treatment.

There are four common errors that therapists make with teenagers. They are surprisingly simple to grasp, and they always make matters worse:

Mistake 1: Courting the Teenage Client

The seeds for the countertherapeutic courtship of teenage clients are generally laid in the initial phone call from a parent. The first words out of a parent's mouth often are something like, "The counselor at the school said we need to bring John in for family therapy, but John says we're the crazy ones and he won't come in. He said he wouldn't talk even if he did come in." This is the number one power tactic teenagers use to keep therapy from happening. When therapists tell parents there's nothing to be done if their child won't cooperate, we might as well say, "Sorry folks, but you better get used to your son's running your family."

At our clinic, our typical response when confronting this situation is to tell parents on the phone that we treat kids who "won't cooperate" all the time, and that they, the parents, must decide whether therapy is to happen. We suggest they tell their child that the session is scheduled and she's expected to be there, and if she is not, the grown-ups will meet anyway. We also coach the parents to point out that the adults will be talking about their child behind her back and making decisions about her life. Most kids come to the first session after hearing this. If they don't, we agree with the parents in the first session to change something major at home, and when their child gets angry about the change, to simply say, "Oh, we decided that at the therapy session." Teenagers almost always come to the second family session. As long as parents are reactive, and feel helpless and hopeless, the young person wields the power, dominates, controls, and simultaneously suffers.

Another way that many therapists court teenage clients and make matters worse is by according them the same treatment status as the adult clients. The prevailing belief--not supported by law--that teenagers are entitled to a confidential relationship with their therapists leaves a teenager who is drunk on power thumbing his or her nose at the parents. A lot of therapists operate under the same standard of privacy with their teenage clients that they have with adult clients, which they feel requires them to withhold critical information from parents. Many angry parents come to us because a previous therapist withheld important facts, such as the teen's sexual activity, smoking, drugs or criminal behavior, from them. Confidentiality in families is held within the family and not by individual members. Therefore, the therapist has latitude to share whatever needs to be shared. Seeing a teenager individually creates the illusion of individual therapy, and the illusion of complete privacy.

We see teens alone at times, but almost never for a full session. We make it clear that we're closely involved with parents and we will use our judgement as to what we share with them. After all, what's the point of a teenager telling a therapist he's using drugs if the therapist can't help the teen discuss it with the parents and find a solution? We invite teens to withhold information from us until they decide we can be trusted. We find they share sensitive information with us even though we don't give them a guarantee of confidentiality.

Mistake 2: Telling Parents to Back Off

Teenagers almost always come into therapy complaining their parents are too strict and controlling. As a result, therapists who specialize in individual work with teens often get a misguided impression of what goes on at home and frequently advise the parents of teens to be more lenient - to relax their control. In fact, parents who yell and cajole are usually trying to avoid imposing a consequence on their teen. In that respect, they are actually protective and lenient.

Among the most harmful "back off" positions that therapists sometimes take with families is that young people have an inherent right to privacy outside the therapy room. Many parents we see report that previous therapists actually criticized them for nosy and intrusive actions. Consider the case of Mike, age 15.

Mike's parents brought him to therapy because he was failing in school, acting belligerent and, they suspected, using drugs. Mike spoke self-righteously as he explained his parents' shortcomings--they were too strict and overinvolved in "his business"--as though their strictness justified his drug use, blow-ups and refusal to work in school. The previous therapist, the parents said, had told them to back off and let Mike learn by his own mistakes.

When Mike and his parents came to the second session with us, he was met by a surprise. His mother handed me a small packet of cocaine and said that they had found it in Mike's desk. Caught red-handed, Mike was not the least bit contrite. He shouted, "What were you doing in my desk?"

In an instant, Mike's parents wilted and became apologetic. They went from a useful, proactive, parental posture to a defensive, reactive one. We affirmed that they had every right to gather information about their son's illegal and dangerous activities. With our support, they got tough with Mike and laid down the law. They told him he had to go into drug treatment and they took away the car keys. Furthermore, he was grounded until his grades went up and they unplugged his phone and computer. Finally, they told him they were considering sending him to military school. Once Mike realized he had to take care of business and change his behavior, the case progressed well. His parents then felt freer to be loving and supportive of Mike.

It is crucial to remember that proclamations of privacy by troubled teens are simply ways of concealing things from their parents and maintaining the power position. It is only a teenager who is responsible and doing well who has earned the right to privacy and trust. Therapists who make parents feel guilty about reasonable investigation into their child's activities send the message that the teen is in charge.

The privacy issue extends to many areas. When parents discuss drugs or sex with their teen, they are likely to hear, "It's my body and it's my choice." Through this logic, there isn't much that parents can do to help a troubled child. Therapists must address with parents their right to change their teen's behavior around sex, drugs, smoking and dangerous friends. All of these issues have to be faced and an understanding reached. The more information parents have, the calmer and more in control of themselves and their parenting they will be. Parents who have little information about their child's life are likely to be angry, reactive and inconsistent.

The final and critical area in which advising parents to back off is an error is when teenagers are diagnosed with psychiatric disorders. Too many clinicians seem to believe that the best course when a young person is acting aggressively because of a psychiatric problem is for parents to be patient. The underlying message from such therapists often is, "You as parents don't really understand about this problem and need to leave it to us experts." As parents do less, the problems get worse.

Craziness pays off if the child is not expected to respond reasonably. In our work with parents, we always stress they have a right to expect reasonable behavior of their son or daughter and "repressed anger" doesn't give children the right to be verbally or physically abusive or self-harming. This affirmation helps parents get beyond the too common idea that if they put pressure on a son or daughter who has a psychiatric disorder, he or she will only get worse, . . . and it will be their fault. Structure is a healthy form of pressure. As parents feel more like successful family leaders, the negative emotional pressure abates.

Mistake 3: Improving Family "Communication"

The most pervasive idea in both individual and family therapy is that young people run amuck because the family doesn't "communicate" well. Too many therapists focus on discussing what each member of the family feels without acknowledging any difference in status between children and parents. They seem to believe that children may comment on parents' sex life or spending habits as freely as parents would address the same subject with their child. But when a young person is out of control and drunk on power, this attention to open communication is like throwing gasoline on an open flame. I once told a 12-year-old client who was insulting her parents in a session to stop speaking that way. She leapt up, pointed at me and shouted, "You're a therapist. You have to let me say whatever I want as long as it's what I really feel!" I realized that this is what she had been taught by former therapists. Therapists commonly teach parents and children to speak in "I" messages, and when no power struggle is going on, this practice is perfectly reasonable. However, when adolescents are angry and explosive, there is typically a power struggle going on, and this level of communication inflames it by raising an out of control teenager's status to that of an equal partner with his or her parents.

In power struggles, teenagers challenge parents about the content of an issue, and parents respond in the same vein. Melissa screamed at her father, "This is bullshit! You always pull this kind of controlling shit on me. Everyone else's parents are letting them go to the party. We're not doing anything wrong." He responded to the content, defending himself by saying, "this isn't bullshit." He insisted that he and his wife didn't always control Melissa and that he didn't care what other parents allow. Some therapists might encourage this kind of interaction, thinking the teen and parents are communicating, when, in fact, the teenager is defining the issue and browbeating her parents. The communication approach we prefer simply acknowledges the process of the interaction and keeps parents from lapsing into a defensive position. So with Melissa's father, he might have said, "You know what, young lady? As long as you're talking to me that way, you aren't going anywhere."

Often, we actually coach parents to be more mysterious and indirect by keeping their knowledge and plans to themselves. For instance, as a parent learns more about their son's friends, we encourage them to accumulate that knowledge until is can be used as part of a cohesive plan of action. For instance, if parents learn about an illicit party this coming Saturday, instead of confronting the teen, it may be better to organize several parents to show up there together to break it up. Difficult teenagers often work very hard so that parents don't learn anything about their lives outside the home, while parents usually talk constantly, sharing all their plans and giving away whatever strategies they may be developing.

Teenagers usually will resist their parents' taking control of information by threatening further misbehavior or escalating the confrontation on the spot in an attempt to make parents capitulate. But by paying attention to process and not giving in to the temptation to explain and justify, parents can maintain their calm and gain greater authority.

Mistake 4: Falling Prey to Therapeutic Tunnel Vision

Therapy is usually an individual or family process. But when treating explosive teenagers, we've found that it is necessary to look at an even bigger picture to find solutions. What's the school's role in maintaining this problem? Is the judicial system turning it's back on a family in need? What about the extended family relationships? Could the therapy itself be keeping the problem going, rather than resolving it? In general, who else is involved in the problem and who else needs to be involved in the therapy? Without taking this extra step many therapies of difficult teens will fail.

Mary was a slight woman who had raised her 17-year-old son, Nathan, for 15 years without the help of his father. Nathan, a husky fellow, had become progressively more volatile in the past two years. If Mary told him he couldn't take the car, Nathan went into her purse and took the keys or ripped the keys out of her hand. If she tried to stop him, he literally sat on her or held her down. She'd given up trying to call the police, because he restrained her as if she were a child.

When we suggested Mary recruit a teammate to help her with Nathan, she said, "There isn't anybody." But we were determined, and asked the whereabouts of everyone related to or friendly with the family. Finally, Mary mentioned her brother Jim, a single guy who'd been a hellish teenager himself and now lived a quiet life. Mary brought Jim to the next session and he was more than willing to be "on call" for his sister and nephew. If Mary needed to confront Nathan, she arranged for Jim to be there already. The plan was that when there was another explosion, Jim would take Nathan aside and firmly tell him that this wasn't an acceptable way for him to act. If necessary, he would put himself physically between Nathan and his mom when Nathan escalated. Jim also began doing fun things with Nathan.

One day, Nathan came home, found his mother and Jim talking in the kitchen, and said, "I think Uncle Jim should go home now. You and I need to have an argument." Mary didn't send Jim home that time or the next, and soon Nathan stopped exploding and learned to talk things out with his mother.

Suitable teammates have to be concerned about the adolescent, they need to be strong and adult enough to help take charge, and must have the respect of the young person. Sometimes the therapist has to be the bridge to heal a broken relationship between parents and other relatives before the angry cycles at home can be broken. Therapists must be creative and persistent and refuse to accept that a solution to the family's problems doesn't exist.

Almost all therapists who have worked with teenagers have found themselves stuck in a clinical impasse with an explosive teen and his or her family. Yet it's never too late to make a paradigm shift and help a family by using this clinical approach. First, a therapist must become comfortable with the idea of dealing with power tactics rather than communication skills. Doing so also requires getting used to having teenage clients who don't like the therapist. The more aggressive a teenager is, the more certain it is that they'll try punishing the therapist. When they call me names I usually say, "You can't hurt my feelings because I don't love you. So I'll keep doing what needs to be done."

Second, therapists must be ready for greater problems initially. Most therapists prefer their treatment to calm things down and leave people feeling better. This strong therapy may escalate the problems initially, and this is scary for both therapist and family. The therapist must reassure the family that this escalation is expected and will be momentary. Therapists are mostly kindly helpers, so it's counterintuitive for a therapist who works toward nice outcomes to step toward the fire and heat things up. However, once a therapist has helped parents take charge and has seen the remarkable positive transformation in a formerly tormented teenager, it becomes easier to work this way. Parents start out saying, "It looks like my daughter's possessed." At the end of six or eight sessions, the same parent says, "My daughter's back. She isn't always sweet, but the girl I love is back."

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