Relational therapy for teens: How does it work?

Dear Parent,

You’re worried about your high schooler, so much so that you may have strongly suggested that therapy could help. Or perhaps your kid has asked for support, and you are in the middle of a search for a psychotherapist. This article can help you decide if my approach to therapy might work for your teen. In this post, I describe a (fictional, but representative) client and describe how therapy with me may unfold. In addition, I explain how positive change happens using my relational, attachment-based approach.

Working from a relational perspective with teens

I work using a relational perspective. This means I believe that the quality of our relationships and our capacity to feel close to others affects our emotional and mental health and that the opposite is also true:  how we feel affects how we relate. A teen’s innate tendency towards positive, supportive relationships with family, friends, romantic partners, and classmates can be impacted by many things. Sometimes challenging early life experiences have taught kids that closeness is dangerous. They may have absorbed the message that they are horribly flawed and unworthy of care. Teens are also affected by societal assumptions around and experiences of discrimination based on ethnicity, gender, religion, sexuality, or ability. Some kids are so exquisitely attuned to peoples’ moods and the chaos of the world that they can feel too overwhelmed to connect. In general, my teen clients feel sad, anxious, hopeless, and mistrustful because of a combination of these factors and others.

Many of my teen clients don’t have a deep history of challenging relationships. Their bonds have been with family, friends, teachers, and coaches, with crushes or romantic interests tossed into the mix. Often, but not always, the bulk of these relationships have been positive or benign. Yet my clients often come to therapy feeling broken and disconnected. Their anxiety or depression tells them they are not worthy of closeness. While these troubles don’t always have roots in their relationships, they are ultimately expressed in struggles with relationships.

"Still burning," a mural in San Francisco by Thai graffiti artist Alex Face (Patcharapol Tangruen)

“No one likes me”:  N’s story

IMPORTANT NOTE:  Confidentiality is vital to psychotherapy. It is also ethically and legally required, with some exceptions around safety. This story– and any of my examples – is not from an actual client but is indicative of some common situations I’ve encountered over my years as a therapist.

N is a sophomore who hates the chaos of Berkeley High. Their friendships in elementary and middle school were mixed, with particularly negative memories of a close friendship that ended abruptly and painfully in fifth grade. N currently has “no friends.” Parents say N was a normal “goofy” kid who has always taken time to warm up in new situations.

The N that shows up in my office is anxious and mostly silent, expressing little hope that therapy will help. With some gentle questioning N tells me that social interactions are awkward for them and that they are anxious and boring:  “no one likes me” The only satisfaction N gets is the pursuit of high grades, though recently even doing well in school is beginning to feel like a joyless grind. N says they feel hopelessly unlikeable and sad most of the time

N’s emotional health is intertwined with their capacity to connect and feel good about their ability to form friendships. The harder it is to talk to others the more depressed and anxious N feels. They size up new situations deliberately and carefully, which sometimes feeds into a natural tendency to overestimate and avoid anything that feels risky or “unsafe.” This overalertness to social and physical danger is exacerbated by other things, including difficult friendship experiences, an overwhelming high school environment, and beliefs around their acceptability. Perfectionism also plays a role. N’s social anxiety gets in the way of having any new, likely more positive, social experiences, which only reinforces their negative beliefs about themselves.

Making space for hope

My initial sessions with N are focused on three things:  forming a good relationship, learning how N sees the world and experiences it, and creating a feeling of hope that things can change. We start by agreeing on a structure for our sessions, making them more predictable and less anxiety-provoking for N. Since they often don’t know what to talk about, we decide to start each session with a check-in. Early sessions also include thinking together about what is going on under the surface, with gentle questioning of N’s beliefs about themselves and others. Over time, our developing relationship becomes an example of healthy communication and positive interaction, as well a space to share feedback without judgment.

After about four sessions, with input from N and their parents, I create a treatment plan. What does N want to change? How motivated is N—that is, what are they willing to try outside of my office? What might get in the way of change? While creating a safe, nurturing therapeutic relationship is an ideal foundation for identifying new ways to approach challenges, it is essential that N purposefully tackle these challenges through action. Because this can be scary and unpredictable, we think of creative and playful ways to approach doing things outside of session. I may use guided imagery and “experiments” N can try in the outside world that aren’t too overwhelming. I also work with N to recognize and call upon the parts of themselves that are brave, strong, and confident to support the parts that feel fearful, challenged, and sad.

N and I decide on an initial, achievable goal:  N will choose an ongoing extracurricular activity – a club, job, sport, or volunteer gig – and just show up to it, repeatedly, facing their fears and interacting with others. We believe the process of meeting this goal will lead to other positive changes for N. Together, N and I think about what will get in the way of reaching this goal, with a focus on the feelings N has about it, what their anxious, protective self believes and what other, more confident or playful parts might think. We acknowledge the bravery that N needs to take on this task. We troubleshoot and think about what works and what doesn’t as N approaches their goal. Sometimes we include coping techniques, from deep breathing to mindfulness to guided imagery as ways to calm N’s body when they are overwhelmed. Perhaps we design an experiment around interacting to set the stage, including N’s parents to help N practice for different situations.

Throughout our sessions, I model various ways of relating, being imperfect, and trying things out. It’s not unusual for a teen to feel uncomfortable being direct with me about what is working and what isn’t. They often don’t want to hurt my feelings. Opening space to talk about these things without reacting helps N experience being honest and direct, and strengthens their capacity to understand and accept what they want or need. It also helps them to learn how to communicate nonjudgmentally. These skills will serve N in a variety of ways as they grow into adulthood, helping them weather anxiety and depression and whatever life may toss their way.

Will therapy go on forever?

Nothing lasts forever. There are natural times to stop therapy. If, for whatever reason, therapy does not feel useful or is not working, that is a time to stop, with referrals to other, potentially more compatible, clinicians. Or perhaps a client is moving on to college in a state where I am not licensed to practice. In most cases, however, therapy ends when the client feels better and has shown lasting improvement.

In N’s case, we decided to stop treatment almost four years in, after their first year in a (California) college. N made amazing progress through high school, including connecting with new friends and coping with a stressful college application process. After a rocky first quarter in college, N started to really thrive, getting involved in a intramural sport and identifying a major they were actually excited about, all while meeting with me remotely. The August before their second year, we made a mutual decision that our work was done.

If this resonates, reach out

Now that you have a better sense about how I work, you can decide if I would resonate with your teen. Feel free to contact me to set up an initial consultation.