So.. Your teenager is in therapy: What's really going on?
One of the most common challenges we face as psychologists when working with teenagers is juggling the teenager’s desire for privacy with their parent’s desire to know what is going on and whether therapy is “working” for their child.
Both of these positions make sense.
Teenagers are in a developmental phase of seeking increased independence and autonomy. They are also forming their own identities as separate from their parents. This is a complex process that often involves navigating intense feelings around their changing bodies and sexuality, their increased responsibility and need to make important decisions, and an amplified focus on peer relationships rather than parental influence. It also involves taking risks and making mistakes in order to learn the consequences of their own decisions and actions.
It’s not possible to prevent children from experiencing the ups and downs that come with adolescence. Yet it is often very painful for parents to take a step back and acknowledge they are no longer the centre of their child’s universe in the same way they were when they were younger. This doesn’t mean parents are no longer important though - teenagers are highly sensitive to their parents’ perceptions of them, even if they don’t always show it! And as their brains are still developing, they definitely still need parental support, guidance, and boundaries as they work out the complexities of transitioning from a child to an adult.
But this frequently leads to a dilemma.
Teenagers are often navigating highly sensitive personal situations which involve things they are fearful of their parents’ judgement around. So, it makes sense that in order for them to feel safe to open up, they need to feel confident they can talk about things without worrying about their parent’s reactions.
On the other hand, parents are often worried about their teen, concerned about some of their actions, feeling shut-out or desperate to help but not sure how, or maybe even frustrated that their teen won’t listen or take their advice on board.
So, what is a psychologist’s role in all of this? And what is it important to keep in mind throughout the process?
1. We are bound by ethical and legal guidelines which mean we have to respect your teenager’s right to privacy and confidentiality. Depending on the age of the teen and their capacity to give informed consent, unless there is an imminent risk of harm, we often cannot tell the parents what’s going on, even if we feel it would be helpful for them to know! This is extremely complex in reality, and most psychologists spend vast amounts of supervision time discussing their decision-making around ethical issues such as these. Please rest assured we are not keeping things from you to shut you out. We are always using our clinical judgment to make decisions around what is in the best interests of your child within the framework of our professional responsibilities.
2. We are not taking on the role of being another parent/teacher to your child. Our job is to try to understand and help them navigate the challenges and difficulties they are facing. To do this, we need to work with them on what they feel is important. It is not our job to lecture them, tell them what to do, or to automatically align ourselves with what parents or schools feel is best for them. We will absolutely take your concerns on board where possible, but our treatment plan will be a collaborative venture with them based upon their needs, and this may constantly evolve. We won’t encourage unhelpful behaviours they may be engaging in, but we also won’t condemn them from a judgmental place. Instead, we will work towards understanding what function these behaviours serve, how effective they are for them, and how they can navigate more helpful ways of coping if necessary. We can explore these things with them, but we cannot force them to act differently if they’re not ready or willing to change.
3. Teenager’s often disclose unhappiness in their relationships with their parents. We expect this to some extent. We frequently hear they feel misunderstood, invalidated, judged, pressured, or unable to talk to their parents about things. We understand this is often part of this developmental phase and we’re not sitting back judging you. It’s natural for teens to argue with their parents and to see things differently. If we do feel it is more than typical and it is significantly impacting their wellbeing, we can discuss with them whether they would be open to involving their parent/s in treatment, but we often cannot actually do this unless they consent.
4. Teenagers are often ambivalent about change. There can be many complex reasons for this. We can try to address this ambivalence to help them get the most out of the process, but we also need be realistic about meeting them where they’re at. Pushing them too hard too soon to try to engineer quick progress when they’re an unwilling participant is a recipe for disaster.
5. Teenagers often experience ups and downs. Progress is not linear. This is true for all of us, but particularly teenagers experiencing hormonal changes and frequent stressors that rise and fall in intensity such as academic pressure and challenging peer relationships. This means it might feel like one step forward, two steps back at times.
6. Realistic expectations are critical. Even adolescents with no mental health issues still experience mood swings, episodes of distress, anxiety around things like exams and academic performance, stress around navigating social dynamics, and increased withdrawal and desire for time alone in their bedroom. These things may be ongoing throughout the teenage years, and do not mean therapy is not “working”. Sometimes a teenager managing their mental health without getting worse is actually a significant indicator of progress as it’s very easy for things like depression and anxiety to spiral drastically in adolescents. Whilst some teens may notice rapid improvements, for others, remaining relatively stable in their functioning may actually show they’re benefitting quite significantly.
7. Sometimes the non-judgemental space is what the teen is really seeking. Many adolescents are reluctant to use strategies between sessions. Many believe these things to be a “chore” like extra homework or are sceptical about them working. Many half-heartedly try them once before declaring “tried that, didn’t work!”. We are constantly trying to overcome these barriers and to upskill them in various psychological strategies, but we’re also aware that one of the most evidence-based predictors of change in therapy is the relationship itself. We constantly need to balance making sure they feel heard, understood, and validated, with providing practical ways of addressing their difficulties. On the one hand if they do nothing between sessions their progress is likely to be much more gradual than if they wholeheartedly throw themselves into practicing new ways of coping. On the other hand, trying to push them to use strategies they don’t see the value in will likely just rupture the therapeutic relationship we have with them. We’re walking a fine line and continuously weighing up the best way to help them!
8. Therapy with teenagers very rarely fits neatly into the initial Medicare referral for 6 sessions. It takes time to build rapport and for them to feel a sense of safety with an adult they’ve only just met. It often takes even longer for them to engage in using skills regularly enough to notice a benefit. Teenagers also often have multiple situations they are navigating which pop up between sessions which are really significant to them. This means therapy can take a more winding roundabout course. Trying to stick to a very structured course of CBT without giving them the space to unpack things in a flexible way is often very difficult, because to do that would mean sacrificing the relationship with them thus causing them to disengage.
9. When teenagers are experiencing benefit from therapy, they can sometimes not want this to cease and are fearful if they appear “better” they will no longer be able to come. They can therefore be reluctant to show too much overt progress or can sometimes report new struggles or deterioration if they feel pressure to start coping independently before they feel ready. This means sometimes they have actually made more significant progress than is apparent, and also that stopping because of this progress can unfortunately reinforce them feeling they need to be “unwell” to justify support. Just as parents are navigating a fine line between forcing autonomy and fostering dependence in their teen, we are doing the same. We do not want them to become overly reliant on us or to continue when there is no benefit, but sometimes we see parents thinking the teenager doesn’t need to come anymore, when it’s actually the ongoing extra support that’s allowing them to stay on track. If parents are able to support a continuation of therapy as “maintenance”, this can sometimes allow the teen to fully embrace recovery. Not every teen will need this, and not every family can afford this. We certainly don’t intend to create guilt for those who can’t, but often if teenagers are secure in the fact they can come fortnightly, monthly, or even just odd sessions if crises pop up, it can free them up to not worry about whether support will be withdrawn if they no longer appear so anxious or depressed.
10. We are not trying to take your place in your child’s inner circle. We are acutely aware of how your child is part of your family system and that the strength of your relationship is immensely powerful to their wellbeing. We do not want to become their closest ear at the expense of them turning to you. What we are trying to work on is helping them to have an additional space where they can speak to someone neutral without judgement, to make sense of their experiences without worrying about the consequences of sharing this information, and to feel validated in their feelings as they navigate their ever-evolving identities. We often spend sessions upskilling teenagers in assertiveness or helping them work out the best way to discuss things with parents, teachers, or peers. We also often encourage gentle reflection on other people’s perspectives (including parents!). These things often improve their relationships over time, as does the process of therapy itself. If we can give them a positive experience of help-seeking it can sometimes pave the way in the future for them to trust that opening up to others can serve them well should they find themselves struggling.
11. We feel privileged to be working with your teenager and we get how hard this is for you as well as them. We understand you may not see the value in your hard-earned money being spent week after week without clear indicators of change. We are passionate about how early intervention at this stage of their lives can significantly shape their mental health futures, and are also aware of how progress can be hard to define for parents when you’re not privy to all the details about their lives. We appreciate your patience. We empathise with how stressful your role is as a parent, (particularly when faced with issues like self-harm, suicidal thoughts, depression, school-refusal, severe anxiety, disordered eating, emotional outbursts, and challenging behaviours)! We acknowledge your commitment to your child’s wellbeing in seeking help for them, and we are constantly striving to do the best we can to support this!
