Adolescent Psychotherapy

A Radical Relational Approach

Bronagh Starrs

• Publisher: Routledge
• Year: 2018
• ISBN:
  9780429864629
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

Counsellors and psychotherapists are faced with ever-increasing complexity in their work with adolescents. In this book, Bronagh Starrs offers an understanding of developmental and therapeutic process from a relational-phenomenological Gestalt perspective.

Starrs shows how the adolescent's presenting symptom issues are statements of compromised lifespace integrity and demonstrates therapeutic sensibility to the adolescent's first-person experience. Throughout the book, the clinician is offered extensive relational and creative strategies to support integrity repair for the adolescent. The developmental impact of various lifespace contexts are discussed, including parental separation, complex family configuration, grief, adoption, and emerging sexual orientation and gender experience. Therapeutic responses to common creative adjustments are explored including anxiety, school refusal, depression, self-harm, suicide, eating disorders, alcohol and drug use, and sexual trauma.

Adolescent Psychotherapy: A Radical Relational Approach will help counsellors and psychotherapists to develop deeper levels of competency in their work as adolescent psychotherapists, as they navigate the complex and fascinating experience of therapy with teenagers. This exceptional contribution is highly suitable for both experienced practitioners and students of counselling and psychotherapy.

Chapter 1

Development, shame and lifespace integrity

Fourteen-year-old Daniel lives with his mother and two younger siblings. His parents separated during the fifth month of his pregnancy. His father, who was violent and alcoholic, punched his mother in the face and stomach as she sat in the passenger seat of their van. She opened the door and jumped out of the moving vehicle. This marked the end of their relationship. Daniel, the child in her womb, survived. His mother, who has been medicated for depression for over a decade, has been in several relationships since and is now pregnant with her fourth child. Her new partner, this child’s father, has recently moved into the family home. Daniel spends much of his time playing his game console and hanging out with his friends. He was diagnosed with ADHD when he was 6 years old and has been in trouble often in school for disruptive and aggressive behaviour. He is verbally and sometimes physically abusive to his mother and siblings. The school principal has spoken to Daniel’s mother, suggesting therapeutic support to help him manage his behaviour. Both she and the school are at a loss as to how to reach and influence him. The adolescent comes unwillingly to the initial session with his mother, having been promised a new pair of trainers in return for his attendance.

Sixteen-year-old Louise is the youngest of three girls. Her siblings are both studying medicine at college, and she lives at home with her parents. High achievement in academics and career has been a core family value and focus throughout the children’s lives. Louise is a perfectionist, spending long hours studying and sometimes re-starting a homework assignment from scratch late on a school night, if she deems it sub-standard. She is top of her class across all subjects and has never received less than 92 percent in any examination. Louise is also involved in a number of extra-curricular activities, including music lessons, drama and football and is a keen member of the local athletics club. Recently Louise has been losing weight at a concerning rate and looks very thin, although she assures her mother that she is eating sufficiently. She has become vegetarian and has cut wheat and refined sugar from her diet. Louise’s mother is becoming concerned. Her father is less so and feels that his wife’s insistence on making an appointment to see a therapist is an overreaction. Louise feels strongly that there is no problem, though she obliges her parents by attending this one session.

As more and more adolescents find their way to therapy, practitioners are encountering increasingly complex clinical scenarios. Most of these young people, like Daniel and Louise, have been nominated by concerned adults as suitable candidates for psychotherapy. Some engage willingly, responding readily to dialogue and interventions. Others arrive sceptical and oppositional, resolved neither to say a word nor to come back a second time. The adolescent therapist is presented with some intriguing dilemmas: How does she create a rich and meaningful therapeutic relationship with someone who may not even want to show up? How does she recruit him as a client in the first instance? How does she engage with someone whose capacity for self-reflection will, in all likelihood, be limited? How does she understand what is happening, or trying to happen, developmentally in his life? What it is that he needs? How might she intervene to make a difference in the growth and development of this adolescent who has found a way into her office and her life? I have pondered these questions for years and in the process have attempted to grasp the dynamics of the adolescent journey and to appreciate the unique subtleties of therapeutic engagement with this age group.

When an adolescent is referred for psychotherapy, this is generally an indication that there is a lack of support for and momentum within his developmental process. This will often manifest in the emergence of symptoms. For example, the adolescent may present with an eating disorder or anxiety or may be engaging in high-risk or self-harming behaviours. There are three principal categories of referral:

• Direct Issues: The adolescent is or is not doing, feeling or thinking something which is troubling him and/or others. Examples include anxiety, depression, substance misuse, low academic motivation, aggression, etc.
• Indirect Issues: The adolescent’s environment is creating complexity and strife for him. These issues include separation, trauma, grief, adoption, peer isolation, etc.
• Overt Developmental Issues: The adolescent’s ‘attitude’ and ‘lack of respect’ for parents, his ‘treating this house like a hotel’ or battling with parental control are seen as the problem.

Referral typically comes with expectation to eliminate these issues. Symptoms are regularly misinterpreted as instances of maladaptive behaviour and as problems to be solved. It is always advisable to look beyond presenting issues to understand the dynamics which are influencing an adolescent’s experience in the world, as this will help orient the therapist with regard to intervention. Praxis with any adolescent client is predicated on the clinician’s tentative assessment, which is not primarily attuned to symptoms or problem behaviours, but to the underlying, unfolding, developmental drama.

The concept of development

Human experience has always been the subject of fascination for psychotherapists, philosophers, psychologists, anthropologists, educationists and sociologists. Theories of adolescence include biological, cultural, psychosocial and cognitive aspects of experience. Development is understood as the maturation of various functions, such as pathways of sexual energy (Freud and Strachey, 1949), structural cognitive schemes (Inhelder and Piaget, 2013), capacity for social learning (Bandura, 1962) and so on. Schools of psychotherapy have traditionally formulated developmental models as meta-psychological frameworks, often integrating these concepts into their theoretical constructs. These models contain each school’s presumptions concerning what it means to be human and serve implicitly as theories of psychopathology. For example, an anxious adolescent’s presentation might be understood as evidence of intrapsychic conflict, perhaps triggered by emergent adolescent libido; as evidence of family dissonance; or as maladaptive thoughts and behaviour which require modification. How meaning is made of the information presented, depending upon the psychotherapist’s theoretical orientation, will shape therapeutic interventions.

My understanding of adolescent development has been influenced by Gestalt psychology and psychotherapy, specifically the work of Kurt Lewin (Lewin, 1939) and Mark McConville (McConville, 1995), who conceive of the essence of adolescent developmental process from a holistic, phenomenological perspective. Gestalt psychologist Kurt Lewin (1890–1947), in his theory of adolescence Field Theory and Experiment in Social Psychology (1939) asserted that adolescents do not develop in isolation, but that development is an integrative process of biological, psychological and social circumstance which shapes how we construct our experience and move forward in the world. Lewin created the term lifespace to describe this mutually influential ground of environmental and personal elements which comprise the adolescent’s phenomenological and ever-expanding world of experience. It is a dynamically evolving and mutually influential process whose spatial and temporal dimensions are continuous. Perception is constructed and behaviour is shaped at every moment within this interactive self-in-and-of-the-lifespace phenomenon through reciprocal contact.

Our relationship to the lifespace resembles our relationship to oxygen: we are continually breathing in and out; we do this unconsciously, even when we sleep. We cannot see the oxygen and are mostly unaware that we are breathing at all, even though our very existence depends on it. Similarly, our lifespace is the framework within and around which we have our existence. It houses our body, mind, feelings and thoughts; our familial, social, cultural, political and geographical contexts; our biographical context, including pre- and perinatal experience. It shapes everything about us. Self cannot exist outside of this lifespace and is not separate from it. There is no such thing as self-development. There is only self-in-and-of-the-lifespace development. The adolescent’s experience will always make sense when we situate the detail of his presentation within his wider lifespace context.

Contact, for Gestalt Therapy theory is the cornerstone of psychological functioning, referring essentially to the way an individual engages and interacts with the world and with himself. In the magnum opus of Gestalt Therapy, Gestalt Therapy: Excitement And Growth In The Human Personality (1951), the concept of contact was postulated as the defining characteristic of the self, in sharp contradistinction to the dominant intrapsychic psychoanalytic models of the day. The authors spoke of the contact boundary as the concrete, experiential meeting place of self and other. It is the evolution of this meeting place, its organisation and functioning, that Mark McConville offers as the critical issue for understanding adolescent development (McConville, 1995). His model tracks the evolution of the contact boundary via recursive processes of differentiation of the adolescent in the family field. He contends that as the adolescent develops, his sense of differentiation in and from his environment increases and he begins to feel somehow different in terms of subjective experience of himself. These changes lead him to engage his world in new ways.

Adolescence is universally described as a time of separation and individuation. These terms are misguiding: human beings are neither separate nor individual. We do not become separate from our families: we may live without them in our day-to-day world, even managing to maintain rigid psychological boundaries which prevent us thinking about them or feeling into memories from our childhood. However, like it or not, we are imprinted by and forever connected to our formative relational experience. During adolescence our relationship to these relationships evolves with ever-increasing sophistication. Characteristically during the teenage years, adolescents begin to create more definitive boundaries in relation to their families, their peers and the wider adult world. The adolescent’s relationship to the world of other becomes progressively more differentiated as she searches for balance between relational intimacy and personal agency. Development in adolescence is the defining of these contact boundaries (McConville, 1995). The adolescent’s behaviour and experience begins to make greater sense through appreciation of the growth of contact functions through adolescence.

Creative adjustment

As Gestalt therapy theory understands development as the evolution of contact boundary process, the mechanism by which development takes places is conceptualised as creative adjustment (Perls, Hefferline and Goodman, 1951). The adolescent’s lifespace is imprinted with the people and experiences he encounters. This imprint shapes how he thinks of himself and of his world, as well as influencing his contact style within his lifespace. He is creatively adjusting to the conditions within his lifespace at every given moment: attempting to balance his needs with given or perceived environmental conditions. If the lifespace is experienced as generally supportive, then we can expect that the adolescent will come to trust this support and will develop faith in himself and in his world. Similarly, a hostile imprint within the lifespace engenders feelings of exposure and mistrust, creating low expectation of being supported, very often translating into a self-statement of inadequacy, where the adolescent finds himself lacking.

If we attend to an adolescent’s phenomenological experience, we inevitably discover developmental wisdom in any creative adjustment. However, the rigid quality of thoughts and behaviours may have long since outlived their usefulness and may themselves pose the biggest threat to his integrity. For unsupported adolescents these creative adjustments may become destructive and inflexible. Feelings of shame naturally emerge in response to compromise within the adolescent’s lifespace. Lee and Wheeler (2003) describe shame as the experience of one’s needs not being received, potentially resulting in a disconnect both from others and from the need. This is a familiar experience, especially in adolescence, where there is potential for shame at every turn. However, if an adolescent has been persistently compromised and support is typically inadequate or absent, the individual becomes saturated with ground shame (Lee and Wheeler, 2003). This pervasive experience of shame becomes the lens through which he views himself and his world.

There is no such thing as ‘normal’ development; there is only supported or under-supported development. The Gestalt premise of adolescent development as contact boundary development (McConville, 1995), encompassing biological, psychosexual, cognitive and social development in a whole-field phenomenon, together with the concept of creative adjustment as the process by which development unfolds, emphasises that development is neither linear nor pre-determined. This developmental approach orients the clinician to understand an adolescent’s presenting issues not so much as symptoms of a diagnosable disorder but as the manifestation of an under-supported developmental process and of a lifespace situation infused with shame. Each adolescent lifespace experience is appreciated as a uniquely personal developmental narrative, and as such, this approach offers an implicitly respectful, existential model of adolescent development. It follows, then, that all therapeutic intervention emerges from the ground of this appreciation. And so, this theoretical orientation directs the therapist to assess the lifespace conditions that contextualise the symptomatic adolescent, becoming curious about how the adolescent’s presentation is experienced and responded to – a response which includes his parents and also now his therapist. Rather than being a technique-oriented methodology, it is, at its heart, a genuinely existential-relational encounter which creates possibility to deepen and enrich contact – that is to say, to support development.

Unsupported development and trauma

Over the past number of decades, considerable research has been undertaken as we continue in our attempts to understand trauma and its impact on the experience of being human. Recent developments, particularly in the field of neuroscience, have contributed significantly to our understanding. The various modalities, including Eye-Movement Desensitization and Reprocessing (Shapiro, 2001), Dialectical Behavioural Therapy (Linehan, 2015), Cognitive-Behavioural Therapy (Beck, 2011), Sensorimotor Psychotherapy (Ogden et al., 2015) and Psychodynamic Psychotherapy (Jung et al., 1983), have each developed approaches to treat trauma survivors. Divergent methodologies include emphasis on cognitive processing, behaviour modification and physiological experiencing, with varying degrees of appreciation of the complex nature of trauma.

I have long been fascinated in figuring out (phenomenologically at least) what precisely it is that becomes traumatised and how it is healed. My experience as a clinician over the years has taught me that the adolescent is motivated by three principal yearnings. These yearnings are for physiological, psychological and interpersonal integrity. By integrity I mean an experience of wellbeing, security and comfort which emerges when these yearnings are sufficiently supported. The adolescent has a fundamental yearning to inhabit a body which is healthy, able and safe; to have a sense of belonging with others who care for and appreciate him; and to experience himself and his world with benevolence. When I speak of trauma, I am describing an experience which creates considerable disruption and compromise for the adolescent within these physiological, psychological and interpersonal domains of experience. Trauma can be a single event, a cluster of events, or a chronic situation which is negotiated on a repeated basis. The experience falls outside the range of what is normative, and it is not possible for the adolescent to process the experience in the present moment; subsequently he enters a state of alarm and overwhelm. The aftermath of trauma for any adolescent typically includes a detrimental impact on sensory and affect regulation, self and world-concept and interpersonal relating (Van der Kolk, 2015).

The adolescent’s level of distress is commensurate with both the gravity of the situation and the level of support available to him. So, for example, Shane is ambivalent about continuing to play soccer as he and his friends have recently formed a band. When he is not selected for the school team, this does not cause him much consternation. Support comes from his emerging identity as a rock guitarist, his newly forming music friendships and his waning interest in soccer. He shrugs it off, and there is no insult to his integrity. Conversely, when an adolescent is forced to tolerate serious compromise to his integrity without adequate support, he is traumatised by the experience and this contact episode begins to shape how he feels, thinks and behaves. An adolescent who is traumatised by an experience tends to have a vested interest in dumbing down contact and faces many more developmental challenges and vicissitudes than his more supported counterparts. For example, Karen, who has become accustomed over the years to hearing her father’s footsteps ascend the staircase and enter her bedroom, knowing what is to follow, endures an ongoing and pervasive threat to all aspects of her integrity. Due to the years of molestation, Karen experiences her body as a grotesque and dangerous shell which encases her. She trusts nobody, and like many traumatised adolescents, prefers the company of animals to humans. The interpersonal world is threatening: “people are idiots”. Psychologically, there is a tightly held vitriol present in her feelings and thoughts about herself and her world. She despises herself and feels that life is pointless, wishing she had never been born. Karen has recently made several serious attempts to end her life. My young client has known neither body nor relational integrity, resulting in pronounced psychological anguish. Her lifespace has always been a hostile landscape which has not supported her yearnings for integrity. Sadly, for too many adolescents, trauma is the ground of their lived experience. Their trauma happens within the home; within parental relationships. Their legacy includes despair, self-experience saturated with shame and powerlessness and a deep-seated conviction that they are defective human beings. This adolescent’s integrity has been devastated, though as we will see, this devastation is reversible, with adequate support.

Bessel van der Kolk, in his seminal text T...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Dedication
• Contents
• Acknowledgements
• Introduction
• 1 Development, shame and lifespace integrity
• 2 Contact assessment
• 3 Ongoing parental involvement
• 4 One-to-one engagement with the adolescent
• 5 Separation and complex family configuration
• 6 Complex parenting spaces: adoption, fostering and loss
• 7 Anxiety, depression, self-harm and suicide
• 8 Eating disorders
• 9 Alcohol and drugs
• 10 Sexuality and gender: emerging identity and boundary development
• 11 Sexual trauma
• 12 The diagnosed adolescent
• 13 Case management
• Index