Working with Teens: The Good, the Bad and the Ugly

Working with Teens: The Good, the Bad and the Ugly

by Donna Moss
While shepherding her own children through adolescence, Donna Moss soon realized that working therapeutically with teens was a whole different challenge.

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I never set out to work with teens.
I never set out to work with teens. For many years after I started my private practice, people would ask, “what is your specialty?” and I would demure. I thought it was pretentious to say I’m a “specialist.” I didn’t feel like a “specialist.” I also thought it would be boring if I specialized. I wanted to mix it up (a little ADHD?). But I soon found myself gravitating to adolescents and young adults, and them to me. Given my years of training in family therapy, it started to feel natural that I would work with this population, those not-quite-children but not-quite-adult people who most therapists feared. And then I had two teen girls of my own; one now 20. What better breeding ground for insight could there be, I thought. Boy, or should I say girl, was I wrong!

Girls Will Be Girls

A therapist can no more easily treat herself and her family than a doctor can heal herself. As far as I can tell, my own family problems stem back generations. Mark Wolynn’s recent book called, It Didn't Start with You: How Inherited Family Trauma Shapes Who We Are and How to End the Cycle lends some credence to this assertion. Jewish-check, anxiety-check, narcissism-check, mental illness-check. And the list goes on!

I sought to correct all that with my girls. Clearly, I overreached.
I sought to correct all that with my girls. Clearly, I overreached. Not only did it not help to hold myself to exacting, unrealistic and perfectionistic standards; it was in fact, impossible. Fast forward to last weekend, my girls now 20 and 17, fistfighting (I kid you not) over a sweatshirt.

My sense of failure runs deep but I am thankful that I was blessed with pure luck with these two. My insights are largely useless. My husband, however, excels at mediation (he’s a lawyer after all), and he has filled in the missing pieces on numerous occasions. We make a good team. Nevertheless, my girls have taught me a number of key things:

1. Each kid is different.
2. They teach you.
3. The “0-60” phenomenon of the teen brain is alive and well.
4. Use humor.
5. Be strong. If you are emotionally weak, they will have no one to push against, leading to a failure to launch.
6. No matter the age and stage, be patient. As soon as you master it, it changes. 


Mary and her Parents

There are some cases that make me feel like a complete idiot. Take the case of Mary. She never wanted to be there. My first tenet of teen therapy is that they have to own it. It’s their life. If I am doing all the work, something is wrong. It took me a long time to realize this one. It’s great to get them when they’re young enough to change but old enough to understand, which I’d put at 17-- a beautiful age! Raring to go to college yet clinging at will to parents, kids this age are a pleasure to help. Change comes fast and furiously and if you’re lucky you’ll get hugs in there too! They go off bolstered by the therapy, and they don’t come back. On the other hand, if they are there against their will it’s a different story. We know this. No therapy is going to work by force.

Mary had a history of acting out and strict, somewhat eccentric parents who did not understand her difficulties (see “Far from the Tree” by Andrew Solomon). With this mismatch, things got off to a miserable start. She was returning from a multi-thousand-dollar wilderness program of questionable long-term repute. “Please fix her from here,” her parents dumped on me. And so I did, sort of. She continued awful acting out, rages, mood-swings, and long before I knew it there was a team of professionals all over the case. No problem. We continued to integrate her back to home. But the back-to-family part never happened. You see, the parents were the problem. This is hardly uncommon. Now they were avoiding me. They were done. I tried to explain to no avail that their participation would be key. More avoidance. So, we continued weekly until the girl simply said “this entire enterprise is futile. I give up.” What a sad case indeed when parents induce helplessness in their teens. Where will all her energy go, I wondered sadly. The case had fizzled out before my eyes. After questioning my abilities, I concluded that this was case was doomed from the start. Her only channel was anger and that wasn’t a channel I was on. Thankfully there was group therapy to warm the soul and I gladly referred her to the care of another clinician.

Group Therapy with Teens

Witness however, Cecilia. Her case was the best! Coming from a childhood of unspeakable trauma, she was rescued by a relative and set on another course. When she came to group therapy, she was literally an outcast from school, home and family. The group embraced her. She lit up each week. In my group there are no restrictions except on gossiping and phone use. I actually pretend that I am the most casual and chill person on earth so that they talk as freely as possible. It’s like when you’re driving your kids to the mall and they’re in the back seat, with no eye contact, finally telling you the most important thing they ever shared. That is my posture in the group. The more I lay back, the more they seem to talk. These kids have no other avenue to ask questions about sex, drugs, birth control, family, siblings, mental illness, physical issues, sexism, racism and relationships. They even accept academic support from me. I become like a big sister in the group, and it works. Cecilia grew to become her class president. She vented for a solid two years about her childhood. She was made to feel normal. She heard from other kids of all backgrounds. They all became “normal” together- normalized by the group process. Who doesn’t have a crazy mother/father/sibling/uncle/friend/teacher? My god, they were normal! Just the celebration of that became the group creed. We welcomed newcomers with near joy. Parents waiting outside would never have believed it. Their angst-filled, moody, belligerent offspring had finally shed their shells. I almost never told anyone my secret. Do you want to know the secret to teen group therapy? Pretend you’re not there, do not wince at disgusting revelations about sex, and by all means allow cursing of all stripes and colors.

Do you want to know the secret to teen group therapy? Pretend you’re not there
As the “core group” began to solidify I worried if I was being effective and compulsively tried to “deepen” the conversation. As I began to relax, they were able to tell me that they liked the group just the way it was. Just talking, venting, sharing and taking turns. It soon became clear that my need to control and get it right and my own insecurities still plaguing me after all these years of experience were beside the point. The group had sustained itself. Nevertheless, the interventions I made aimed to reinforce the shared group values and purpose, the universal nature of the teenager experience and the shepherding of the inner self to the surface despite fear. I also increasingly pushed the more reticent members to link up their past with their present, thus gaining insight for the first time. Finally, I was “motherly” in that I could see from where I sat that life would ultimately deal them their share of traumas, yet I knew they could withstand it by holding that space for them, quieting down my own thoughts. By testing their judgment or lack thereof with their peers, they gained the self-knowledge to withstand pain rather than avoid it.

Teens and Divorce

Parents have often asked me what the best/worst age for a child to be at the time of divorce. There are many answers to this. First off, it depends not only on the age at divorce but rather on how the parents handle the divorce that really matters. Second, all ages suck, period, end of story. But divorce in the teen years royally sucks. Social/emotional development is significantly impacted. What the research says is not pretty: not only does the effect of divorce on teens have a huge impact for years, but also, it lasts forever and ever. The researcher Judith Wallerstein has asserted that unlike a parent’s death which has a beginning, middle and end, divorce just goes on and on. Once again, the teen brain, volatile as it is, is not prepared and will surely rebound with rage, defiance, profound risk behavior, testing limits and all the things you tried as a teen but on steroids (social media strikes again). So, buckle your seatbelts on this one and seek help early and often.

One of my teen clients of divorce casually sent a nude photo to a boy in 10th grade
One of my teen clients of divorce casually sent a nude photo to a boy in 10th grade. The next day, it traveled around the school with the speed of rumor and she found herself in the hospital dealing with a new diagnosis- humiliation. With one parent working round the clock and the other nowhere to be found, she did what anyone in that situation would do, she went underground. The numbing, cutting and sheer embarrassment got worse. She started cutting school too. Each setback snowballed mercilessly. We had to get her back to herself. The therapy consisted of gradually starting her activities again, putting it behind her and structured-only phone use. To this day, she calls me every year on my birthday and says, “if it wasn’t for you, I’d be dead.” She is now a successful hairdresser hoping to open her very own shop. Her parents' divorce was the hardest step from teen to adult, but she got by because she persisted, used her strengths and had a passion.

Older teens feel lost, insecure and socially stigmatized after divorce. The post-divorce financial uncertainty adds to the overall stress. College plans can change. One divorce created a situation with the parents telling their twins in my office, “surprise, we can no longer pay…” Plus, shuttling between two homes can be disorienting, to say the least (or in the case of my own parents’ divorce, jetting between two coasts). Parents often dwell on how and when to tell their children that they are getting divorced, rather than the aftermath. Just like birth plans, divorce plans go awry. Better to sort it out for the long-haul than have it scripted in the short.

I try to help the teens in therapy by “joining” with their rage. Damn straight your parents suck. They are the ones who should be here! Once I do that, and establish trust, rapport and confidentiality, it is easy to win their hearts and minds. I provide gentle support and strategies for coping and self-care while reminding parents that part of the confusion is normal teen angst. If parents make the common error of ascribing all behavior to the divorce, then guilt steps in and over-compensates in many forms including the of throwing money at the child, which rarely helps.

More times than not, my job is to mitigate confusion. You cannot believe what’s in these kids’ heads. For younger kids, they go right to the most concrete --will my room be pink at Mom’s house still? Can I have two stuffed animals-one for each house? If my parents separate, will I ever see dad again? Are my grandparents still going to be my grandparents? For teenagers and young adults, it can be far more morose, as it was for me with my own parents’ divorce. “Why why why?” is one refrain. The other is a lurking sense of doom some might call dysthymia. As soon as I labeled that for myself as an adult, I started to get help, including antidepressants. The clinicians’ definition of the word would be a “low-grade depression.” I call it, the lowering of expectations, always second-guessing myself. Demystifying the wild ideas kids and teens formulate goes a long way toward alleviating crippling anxiety and dread. It’s hard enough to grow up without constant stress in this world, let alone have your parents fighting all the time. One family was fighting so badly about the kids’ shoes at each house that I offered to go to Payless and buy them a second set of sneakers.

I now run a successful teen support group for kids between the ages of 13-19. I remember how my losses haunted me at that stage, but I never had the words to feel and let go--I was constantly grasping for meaning or truth that didn’t exist. I tortured myself to figure something out about my family. But all that I got in return were meaningless intellectual insights that couldn’t sustain me. Nevertheless, I did rebound. I got many degrees and certificates, had scores of talented friends and married the love of my life. Economic times have since hit us hard, but our fortitude is paramount.
I model this resilience to my patients through gentle wit, disclosing when necessary that I “get it.”
I model this resilience to my patients through gentle wit, disclosing when necessary that I “get it.” Then reminding them there is no one path; there is no perfect; there is only you, open to the ups and downs, or as my yoga teacher would say, “meeting each moment as a friend.”

It All Adds Up

A perfect case to illustrate when all cylinders are firing in teen therapy is Megan. This teen came in with what I call the “break up story.” Megan, like many other girls with whom I have worked, was a ruminator. So, the task is how to utilize all the teen’s strengths just to make it to another day. Why? The phone (you didn’t think I would forget the social media part, did you?). Because I was an “early adopter” of the internet age and even worked in the field of online production and community building in its heyday, I have always taken a favorable view of technology. That said, if my daughter doesn’t unwrap her phone from her head soon I’m going to throw it into the Hudson River. It is her permanent appendage. There is no doubt in my mind that she would benefit from a screen break. But instead of being that mom who limited screen time, I was actually the mom who was the first on the block to get the kids a phone. That did not make me popular among the neighborhood parents. I prefer to know where they are. On the other hand, I have friends who have their adult kids on “find my friends” which would literally put me in a full-time state of panic. There must be balance.

Megan started cutting in 9th grade because she already had a family history of poor emotional regulation combined with an awkward style and no real avenues for getting her feelings straight. Her father was absent and alcoholic. Her mother was a determined and high functioning administrator who was always on the brink of a breakdown, and who could blame her? Therefore, Megan was accustomed to caretaking not care-receiving, which she desperately needed. In therapy, she was able to use her intellect and motivation for good. I encouraged her to think of things in a less catastrophic/dramatic, black and white and exaggerated way. “My boyfriend friended his ex on Twitter” she would say. “So what!” I would chime. “I’m stalking him. I see he’s online at 3am. I saw him with her. She liked his status.” It goes on. Yes, this goes to his character of questionable trustworthiness. But does it REALLY matter? Growing up in the 70’s and 80’s has made me a bit cynical to what real love is (memories of Kramer versus Kramer dance through my brain). I try to get them from point A- everything matters, to point B- nothing matters.
The therapeutic technique most attuned to this might be called Freud-light
The therapeutic technique most attuned to this might be called Freud-light. What is getting in your way of allowing this process to work? What is coming up as a trigger/resistance? What can we work through/process/vent/feel/release/analyze or simply let go of to move forward? Nevertheless, the point is the phone doesn’t matter! What matters is can he be at the right place at the right time, can he talk and communicate, can you be friends first and foremost, do you even know him, can he get off his phone…? Megan started putting herself first. She got into the college of her choice. A big girl with body-image issues, she bought herself the shiniest red prom dress I have ever seen and danced right through to morning!

What’s my Theory?

Lest you think that I’m just flying by the seat of my pants, there is plenty of theory to support my approaches. I rely on several methods and philosophies, yet I’m not married to one. I lean toward mind/body (Van Der Kolk, Levine), existential, person-centered (Rogers) and family systems (Haley, Minuchin, Bowen), and group (Yalom.) Much of my work is based on the idea that anyone can relieve anxiety by allowing it to flow through you. Just like going to the gym, anxiety is a habit of mind that if practiced will be reinforced. It’s the faulty circuit of fight or flight. It’s the mammalian brain. The goal (CBT and DBT) is to allow yourself to practice a better way of coping. A way with ease and equanimity; a way with kindness and support. A middle way, a way that allows you to press the pause button while you cool off. Getting flooded by one’s emotions is useless, so learning CBT (“I’m a mess and everything is a mess” to “I made a mistake; humans make mistakes and learn from them” makes good sense.” With DBT, “let me calm down for a second--getting worked up is totally unproductive. I’m just going to breathe and let it pass,” you will most likely get results. What I have not done more of until recent years is appreciate the role of trauma in that it can completely derail or retard the above process to the point of paralysis.

Lessons Learned

Therapists may turn away from working with teens because of their volatility and the resultant risks involved in their care. They flake out of appointments, come late, walk out, don’t return calls, and show up high and hungover. Their parents are often difficult, defensive and in denial. Sessions have to be coordinated with who can drive when, a logistical nightmare from volleyball to work to therapy and back all after a parent has put in a full day’s work. In short, it’s a pain in the butt. Nevertheless, teens are fast learners, quick to laugh out loud, they can cry their hearts out one week and the next week show up like nothing happened. They leave you with all the debris while they move on. My kids started doing this in daycare. Sobbing when I left, then an hour later, having the time of their lives. You simply can’t take it all personally. This takes a concentrated effort on the part of you, the therapist and mom, to feel as deeply and sensitively as they do, and then drop the whole damn thing. Only time can teach you that.

What it has taken me my whole adult life to learn is that there is no absolute answer. There is no one truth. There is no lasting stability. There is only you, open to the shattering of reality, embracing the change; knowing that change is the only constant. My history of loss/resilience/loss makes my therapy genuine. My genuine interest in teens, my blessed gifts from my parents, and my profound belief in being curious is what helps the therapy. It’s the turbulence, the roller-coaster, the deep pain and sorrow, and even the helpless confusion that instructs me how to remain flexible, less anxious, more prepared and physically more resilient (Yoga!). I still crave stability, but I have learned to create it for myself both inside and outside of the therapy office.  

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Bios
Donna Moss Donna C. Moss, MA, LCSW-R, is an adolescent therapist who writes about technology and teens as well as other issues in mental health. Moss has written and traveled and provided articles for the Internet and many topics in mental health and wellness. She is an avid hiker, yoga practitioner and swimmer, and is married with two girls and a petulant Husky named Milo. With 25 years’ experience in areas such as infertility, cancer, health, stress, divorce, mediation and relationships, Donna has a broad understanding of many life transitions. She provides supportive, goal-oriented, cognitive/behavioral and proven methods for uncovering past traumas and moving toward healthy living. You can learn more about Donna at her personal website.