TIFT #77: Helping the Stuck Adolescent

This is a follow-up to the previous post on how treating symptoms and diagnoses is so often unsuccessful because the real source of trouble is underlying immaturity, a very real problem that, unfortunately, has no diagnosis code. In that post, I described the problem. In this one, I discuss some ideas about what one can do.

Negotiating with the two sides of ambivalence

Here are some thoughts for therapists, and also for family members and others involved in the drama of adolescent maturation. The true goal is to come to adulthood, meaning “a subjective sense of full ownership of one’s own life.” Becoming ready for that also means acquiring strengths during adolescence by engaging in challenging experiences. The following partial list of developmental achievements will give a hint as to why this is not a trivial accomplishment:

• Impulse control through practice
• Self management
• Knowing one’s strengths and weaknesses by experience
• Learning one’s own likes and dislikes by making hard decisions
• Moving from values borrowed from family to values owned
• Moving from defiance of parents to true independence
• Navigating society at large
• Learning to engage in deep relationships

To start with, we are working with two selves. We are engaging with the conscious one who wants to grow, but feels blocked at every turn by forces not under their control. Meanwhile, our words and actions are also being heard and interpreted by another self. That one is listening for hope but mistrustful and ready to think we don’t really care or have anything to offer.

One way to think about our role is that the struggling young person is desperate to lower their stress level. It’s as if they were trapped in an arena with a wild animal, facing a row of doors offering possible escape. Some doors look dangerous, but actually lead to safety. Others appear to offer safety but are more dangerous. We want to help, but the young person doesn’t know whether to trust us or not. They are too ready to conclude that we have some selfish or misguided motive and will lead them astray. Thus, we need to establish credibility at the same time we provide a positive influence aimed at avoiding harm and taking steps toward growth by embracing new, scary experiences.

There are a few general principles. Overall, our goal is to contain the client’s deep, but often unacknowledged, terror. If we can do that personally or in concert with others such as family members, well and good, but we also need to be ready to identify situations when our containment is likely to be breached. Those are the points where it may be time to bring in a higher level of care or authority. As long as we are able to contain the stress, the task is to identify which kind of door we are dealing with and to provide positive support without breaking the trust we have gained. 

The gold standard of support is acknowledgment. Putting into words the client’s feelings on both sides is one of the most effective and safest ways to give support without, infantilizing or taking over. Beyond acknowledgment, noticing a strength makes it feel real and increases the client’s sense of ownership. When we acknowledge stress or difficulty (without trying too hard to relieve it), we are also expressing confidence.

Another general principle is that support from all sources needs to be measured according to the client’s ability. Underestimating what the client can handle is infantilizing and discourages growth, while overestimating is setting the client up for failure. Just as this judgment is hard for parents, it is a hard call for professionals, and one where we can’t always be right.

It is surprising how often young people are willing and able to talk about their level of maturity. The more we can discuss these realities in a matter of fact way, the more regulated the emotions tend to become. This is a dance between being, as Harry Stack Sullivan put it, a participant or an observer. It takes agility to go back and forth between participant and observer without being trapped in one stance or the other.

Overall Strategy

Remembering that our client is intensely ambivalent about moving towards growth and independence, we can think of our job as witnessing our client trying different doors representing movement forward toward growth, retreat away from it, or a mix of the two. Here are some typical doors and thoughts about the pitfalls and gains associated with each.

Some doors, healthy and unhealthy

1. The door is a healthy one, representing engagement with life. In this case, we want to give quiet, measured support. “That seems to me like a good idea.” Too much enthusiasm or any pushiness will erode our credibility and lead to thoughts that we are over invested personally in that door. Mistrust will ensue. Depending on the level of trust on the part of the inner self, a potential trap is to lend support an idea which the scared inner child then distorts, so as to demonstrate that our advice is wrong.
2. The door is a healthy one, but the step being contemplated is too big and can’t lead to success. Again, we need to be low-key but offer some reasons why it might not work out. Perhaps we might think out loud about a smaller step in the same direction. —Young person:  “I want to become independent, so I’m going to get on a bus and head West. I’m sure I’ll find a job and good people and make a new life for myself.” —Helper:  “Hmm, I see that you want independence. I’m thinking that plan might be a bit risky. I wonder if a trial run might be possible.”
3. The door is unhealthy: We need again to discourage in a calm and low-key manner while leaving the decision in the young person’s hands as much as possible (as long as irreparable damage remains unlikely). Some examples: 
4. Door:  I'll use drugs to calm anxiety.
5. Door:  I'll take a trip or drop out in order to “find myself,” which won’t work because being away from the stress means no growth either.
6. Door:  Make a too drastic change like moving to a different city that will break the therapeutic support and leave the young person alone and unlikely to find health.
7. Door:  Development of psychiatric or medical symptoms that demand relief. We may have to acquiesce to medical or psychiatric treatment, but in what we say and do, we need to indicate that we don’t see this as a definitive solution. “I’m really sorry you have that problem. I guess we are going to have to make arrangements to get you an evaluation, but I’m not sure that will solve everything."
8. Door:  Even when we think a plan is unhealthy and driven by avoidance, there are times when a young person makes a bold move and rises to the challenge. The best rule I know is that plans that “belong” to the young person should be considered worth at least 1.5 times more than the best options their helpers can come up with. When they do take risks and do things their helpers wouldn’t advise, they are the sole beneficiaries of the learning, positive or negative.
9. The door is suicide or serious self-harm: Here we have to make a binary call. One fork is to interpret the idea as an expression of distress to be listened to but not taken as a plan to act. Our not being too afraid is a strong form of support. On the other hand, if the level of risk is significant, we may need to understand the threat as the terrified inner child breaking out of our therapeutic containment. In that case, it’s best to take the threat at face value. Taking it seriously, even if it means a trip to the emergency room, can act as a deterrent for future use of this “terrorist” tactic as well as an appropriate safety measure.
10. The door involves more stress or danger than the therapist or helper can tolerate. This demands a frank statement and acknowledgment of our limitations. “If you buy a gun, then I will not be able to treat you. That would be more dangerous and scary than I am ready or able to handle, so please let me know what you wish to do.”
11. The door is a blend or “sandwich” of avoidance and healthy movement forward. “Yes, going back to school might help you find your calling, but that’s easy for you, and it might put off dealing with the kinds of challenges that you have had trouble with. Stepping out into the world but in a temporary position might allow you to work on some of the growth areas we have identified.”
12. The door is a “devil’s pact” between helper and young person. Lending support for rationalization of an unhealthy behavior might fall in this category. Giving unneeded tokens of support such as extra time or material help or doing too much for them can also send a message that the young person is not seen as strong enough on their own. These mistakes can create powerful expectations and can be hard to repair.
13. The door involves lending support for a move that might be considered unorthodox. This poses a delicate problem. There are times when supporting something unorthodox can be a demonstration of the helper’s wisdom and willingness to go an extra mile. On the other hand, it can backfire. Making the choice is a matter of judgment and envisioning the pros and cons.
14. The door involves the therapist or helper possibly supporting a choice that will alienate important family members. This one requires “neutrality.” “It’s your decision, but I’m not so keen on seeing you alienate your family.” The reason is that we are in a situation of intense ambivalence. Where family is also ambivalent, the inner self can easily reduce stress by “throwing the helper under the bus,” for example reporting the helper’s words to family, so as recruit family members against the therapy and therapist.
15. The door is (especially for younger adolescents) to act in an obviously immature and problematic way, forcing parents to take control. Here the part that wants to grow has withdrawn entirely. Helpers have little choice but to take control, but can do so with as light a touch as feasible, leaving the young person with as much responsibility as possible. Consequences may be necessary, see below.
16. The door is to provoke other family members, who become anxious, themselves and seize upon the side of discouraging positive steps. Here the helper can show strength and confidence (if warranted) both to the client and family, that there is not yet a need to regress.
17. The door is a healthy expression of individuality and independence, but the family may have trouble accepting the young person’s wish. This requires a determination whether the young person is old enough and strong enough to go against the family. If in doubt, stay neutral. Reflect the young person’s ambivalence and let them decide what to do.
18. The door is that the client looks to the helper for decision making. This would lower the stress but deprives the client of practice in making independent decisions. The tendency may be stronger in a case where the family has been over-helpful, giving guidance that made it easy to avoid the stress of choosing. We may need to stay quiet and let the client struggle with the decision.

I am sure there are many more, in fact, an infinite number of creative ways the mind finds to lower stress by avoiding those difficult experiences that lead to growth as an individual. And there are also an infinite number of positive doors, those that increase stress in the short term, but lead to strengthened skills for becoming the “owner of one’s own life.”

Judgment

From the above list, I’m sure it is abundantly clear that navigating these waters is almost as challenging for therapists as it is for parents. We can’t be right all the time, and, as it is for diplomats, there are often times when any position we might take has potential problems. I would still argue that we owe it to our clients to weigh in to the extent that we have clarity. Often we actually do have more experience and knowledge than they, which is why we are hired. But when unsure, the best we can do is to acknowledge that we don’t know everything and can’t always know what is best. Then the optimal choice is to admit what we don’t know and leave the decision making to the client and family.

Some principles for helpers

The client will likely gravitate towards a variety of good reasons not to do the hard work of growing. Once again, the dialog is with two selves, the conscious one who feels blocked by circumstances and the nonconscious problem solver who is seeking safety and relief. Here are some principles:

• Acknowledge and assume a desire to grow.
• Inform that you support growth, but don’t pressure.
• Recognize that going too fast or taking steps that are too big is a major path to self-sabotage.
• Acknowledge positive steps, ones that go in the direction of autonomy but are not unrealistically large.
• Don’t paint too glossy a picture of what this could lead to in the future, as this can inflame unrealistic expectations or engender mistrust.
• Don’t give unwarranted hope, based on predictions of future success. (I call this “Master Card ad Visa.”) Instead embrace “Cash and Carry,” responding only to what the young person can accomplish in the present.
• Let the individual face personal decisions when they are not too big. Holding back on expressing an opinion gives the person a chance to grow in the skill of making decisions from themself.
• Positive incentives and disincentives can be used by parents, but they must be stated clearly, based on well defined criteria, and adhered to consistently. Inconsistent incentive management betrays a lack of caring.
• Try to imagine the age of the inner self. A twenty-five year old may be functioning at a 14 year old level.
• Don’t suggest jobs or consequences that are regressive, such as asking a teen to do chores that a 10 year-old would do. Requirements are OK, but the best ones are things that will leave a feeling of age-appropriate pride.
• Building on the previous item, here is a way to give sanctions that are constructive:  “Because of what you did, I’ll have to take away your phone for a specified (brief) time, however, if you prefer, you can do X instead, where X is something genuinely positive like hard exercise or something genuinely creative, which, if imposed as a sole consequence rather than a choice, would invite the young person to do a minimal and unsatisfying job.

Best of luck!

Jeffery Smith MD

Photo credit,  Vladislav Anchuk, Unsplash