Below, I explain how I generally work with teens and their parents.
I. Assessment
The first step of therapy is a good assessment of the problem. We spend the first few sessions getting information about the problem and its history. By the third session, I have generally developed a theory about the causes of the problem and what will help. We then start intervening.
II. Who To See --Teen Alone, or Teen Plus Parents?
A decision we need to make early on is this -- am I going to see the teenager by him or herself, or am I going to work with the teen and parents together.
Now, you may be surprised to hear that I'd even consider seeing you and your teen together. A lot of parents say, "My teenager probably wants to see you alone, not with us." But don't be so sure.
First, you would be surprised how often a teen wants (or accepts) the parents as part of the therapy. And if your teen agrees to this approach, it can be very helpful. Why? It can take less time for your teen to open up to me if you are in the session. Also, parents can be very helpful sources of information. They provide me with their observations, insights, and the history of the child. Even more so, parents are part of the solution. If I can teach parents how to help their teenager, they can do so seven days a week, whereas I can do so only an hour a week.
Further, if the problem involves significant conflict between you and your teen, or if the teen has significant behavioral problems, I will be reluctant to meet only with him or her. Why?
Often your teenager does not necessarily want the same changes you do. S/he may be fine with staying out past curfew or not doing their homework, whereas you want these behaviors to change. And, to get these behaviors to change, I will often need you, the parents, to do something different. That might mean you setting more limits or changing how you communicate with your teen. Either way, I cannot do that if you are not part of the sessions.
However, I am flexible and open to your preferences. Even when I do family therapy, I will meet with your teenager alone at times. And I am open to seeing teens alone if (a) they have no behavioral problems, and (b) they are having problems mainly with moods or with their peer relationships.
III. Confidentiality of Sessions With The Teen I always address the issue of confidentiality in the first session. If I meet alone with your teenager, I will want to give them some privacy. But I will want to give you a general summary of our discussions, enough so that you can tell if we are making progress. I will also make it clear in the first session that I will not keep confidential from you any information that indicates your teen is at risk (e.g., they are using drugs, having unprotected sex, truant from school, suicidal, etc).
IV. Getting Started
The main goal of the first family session is to get your teenager and you relaxed and talking. I usually start out by asking about the positives in the family -- what people like about each other, what goes well, what people are proud of. I also ask about fun topics, such as favorite activities, movies, music, etc. Once everyone is relaxed and talking, we can move on to the problems.
V. Identifying Causes of Problems
My goal in our first few sessions is to form a theory about why the problems exist. I do so by asking many questions. When did the problems start? What have you tried to solve them? When are things better or worse? Generally, by the second or third session, I have a pretty good working theory of why the problems are occurring. I will then be ready to start making suggestions about what will help.
VI. Problems I Treat: What Helps
I treat a wide array of teenage problems. I will list some of them here and the approaches I find have helped.
1. ADHD
If your child is a teen with ADHD, they were probably diagnosed a long time ago. But entering high school can bring up new problems for the teenager with ADHD. This is so because in high school, the schoolwork gets harder, the teen is asked to work more independently, and peer relationships become more important and complex. Thus, sometimes the teen needs to (a) learn new organizational and planning strategies (b) be motivated by the parents to take on more responsibility, and/or (c) build new relationships and social skills.
2. Anger
This problem can arise from many different sources. The anger may be an internal problem (e.g., your teen has a very quick fuse or a chronic tendency towards frustration). The anger can arise from stressful situations the teen is experiencing (arguments with family, starting high school, leaving for college, etc.). Once we identify the cause(s) of the problem, I can use cognitive-therapy, family therapy, and other methods to help decrease the problem.
3. Anxiety
Almost all treatment of anxiety involves helping the teenager to challenge and change unnecessary or false beliefs which cause fear. Treatment might also involve exposing the teen to things they irrationally fear. All of these approaches are done in a gradual way so that the child is not overwhelmed.
(Note: for Obsessive-Compulsive Disorder (OCD), panic attacks, and social anxiety/shyness, see the sections below.)
4. Behavioral Problems: Aggression, Defiance, Non-Compliance
The
treatment of behavioral problems always involves identifying why these
problems are occurring. Behavioral problems may be a manifestation of
underlying anxiety or depression, academic problems, drug/alcohol use,
or even an unidentified medical issue. Or, the behavioral problem might
exist because of an underlying problem in the child's relationships with
parents, siblings, or peers.
Sometimes, the problems arise because the teen wants more independence and fights the parents for it. Solving these problems may require a combination of
individual and family therapy.
5. College Preparation
Often, families and teens come for treatment as they prepare for the teen to leave for college. This stage can bring up anxiety for some teens and parents. Usually, we find that talking about these fears reveals that they are normal and easily calmed. Once in a while, the anxiety is more realistic -- for instance, the teenager may truly not be ready to leave home and live more independently.
6. Depression
The treatment of depression usually involves challenging and disproving unrealistic beliefs that cause depression. This is especially true of negative beliefs the teen has about herself. Another part of treating depression is helping the teen have success, be it academic, social, athletic, etc. There is just no substitute for success when it comes to building self-esteem and fighting depression. A third area of treatment involves making sure the teen's relationships are positive, warm, and loving. These relationships include not only parents and siblings but also teachers and peers.
7. Homework Completion / School Problems
Whenever I hear about homework or school problems with a younger child, I usually want to rule out a learning disability (LD). But with a teen, the school system has usually found out a long time ago if a learning disability exists. Thus, if a teenager suddenly starts having school problems where none existed before, I am more likely to suspect that the cause is a stressor, emotional problem, or (more rarely) a drug and alcohol problem.
For example, your teenager might have started paying more attention to their peer relationships, to the detriment of their schoolwork. They might be having a hard time with the changes of adolescence. I have also seen teens who are quite smart and, thus, have been able to get good grades and yet do almost no homework through elementary school. But when they get to high school, they can no longer skip homework and still keep their grades up, and they now lack the study skills necessary to succeed.
Some teens come to counseling with school problems that are not new but have have waxed and waned for a long time. For example, some teens have a long history of being hard to motivate academically (this is especially true with kids who have ADHD).
8. Obsessive-Compulsive Disorder
This problem is best treated by cognitive-behavior therapy, especially a technique called "Exposure-Response Prevention." In this method, the teen is gradually exposed to the feared object/situation while they prevent themselves from doing their compulsive ritual. Cognitive techniques are also used to reduce their anxiety.
9. Panic Attacks
Sometimes a panic attack is a teen's response to having too much stress and becoming overwhelmed. In such cases, general talk therapy can be effective. At other times, panic attacks take on a life of their own and become the primary problem. This often occurs when the teen misinterprets signs of normal anxiety as instead being the sign of some catastrophic event, such as a heart attack or loss of bodily control. In these cases, cognitive-behavioral therapy is the treatment of choice.
10. Perfectionism
This problem often results from a sensitive teenager who feels deep pain over failures or rejections (real or perceived) and tries to avoid them by being "perfect." The key to successful treatment is helping the teenager feel less pain when facing setbacks.
11. Social Anxiety
As peer relationships become more important in adolescence, teens who are more shy may need help overcoming that shyness in order to socialize and make new friends. Treatment involves the challenging of thoughts that make the teen feel shy or withdrawn, then taking gradual steps toward facing the feared situation. Building social skills is also helpful.
12. Social Skills Deficits
This problem involves teens who have a problematic lack of social skills, such as teens with Aspergers Disorder or a Non-Verbal Learning Disability. I have treated social skill deficits many times. I have come to the conclusion that teaching social skills is not enough -- I also need to help the teen find friends. Why? These teens are often socially isolated. And while learning new skills is important, it does not guarantee that the teen will then make friends. After all, what is the point of learning social skills if you have no friends to socialize with?
Research has shown that social skills training is most effective when it is long-term (versus a six-eight week group). These days, schools do a good job providing such training over the course of the school year. I help supplement that training in a number of ways, such as video-taping the teen as a training tool or teaching parents how to help teens build new social skills.
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