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Creed Challenging Problems

CBT for Youth

By Torrey Creed, PhD

Many adolescents begin treatment on a different footing from adults. Rather than choosing to start treatment, adolescents may be referred by someone else for behavior the adolescent sees as justified, appropriate, or a part of their identity rather than something to be changed. Other adolescents may be referred for treatment for behavior or situations they feel hopeless or helpless about, and may therefore enter treatment without a sense that therapy could be helpful or lead to a positive outcome. Given this context, an early focus on treatment engagement is especially important with adolescents.

Given that adolescents may often begin treatment with low engagement, the identification of reasons for engaging in therapy is an important early strategy. Tying treatment to what an adolescent really cares about can greatly increase their buy-in to the therapy process. In contrast, treatment goals are often developed in a way that reflects symptom change, but not necessarily reasons why the adolescent might pursue these goals. When asked about treatment goals, adolescents often say things like, “I will be compliant with medication,” “I will be able to manage my irritability,” or “I will attend school regularly.” But are these really the goals, dreams, or aspirations of this adolescent?

Instead, there is great value in learning what the adolescent really cares about. What makes this client feel like it’s worth getting out of bed in the morning? What lights them up inside – or used to have that effect? What kinds of things do, or did, bring joy or pleasure? Framing treatment as a way to build toward these goals can increase engagement in the therapy process.

There are really three key questions related to helping an adolescent articulate these long-term goals or aspirations.

  • What does the teen want?
  • What’s getting in the way?
  • How can therapy strengthen his or her skills to get there?

When helping the adolescent identify these ambitions or aspirations, look for ways to say, “Yes!” to whatever they identify. Remember that the alternative to this strategy is to basically say, “No.” When we’ve asked an adolescent to name what they care about most, responding by saying, “No, that’s not realistic,” “No, that’s a bad idea,” or another “No” can be off-putting and discouraging – the opposite of what we’re trying to achieve.

So what does it mean to say “yes” to a goal?

Some of the goals adolescents generate may be things that they are unlikely to achieve, or something we cannot promise that they will be able to achieve. For example, an adolescent may want to be a professional athlete, a performing artist, or be inspired by some other goal that as therapists, we just can’t promise. By saying “Yes,” we are not guaranteeing that the goal itself will be achieved. Instead, a yes is a promise to believe in the adolescent and their potential, and to support them in taking the next step on the journey toward their dreams. To do that, we can work with the teen to break the long-term goal into small next steps, identifying what we might work on together in therapy.

For example, if a teen wants to be a professional soccer player, we might work with them to identify the kinds of attributes and skills that would set them up for success in that role. A professional soccer player might need to be able to work well with a team, pass a drug screen, read and understand their contract, and not rack up penalties from anger during games. Among those attributes and skills, we help the adolescent identify things that might currently get in the way of their success, and collaboratively consider whether those might become treatment goals. If the adolescent in this example has problematic peer interactions due to anger outbursts, those might get in the way of good teamwork and avoiding penalties. If the adolescent self-medicates depression symptoms with marijuana use, and that combination leads to poor school attendance, those behaviors might interfere with being able to pass a drug screen or being knowledgeable enough evaluate a contract. Treatment goals may then become:

  • Increase positive peer interactions
  • Decrease marijuana use
  • Have no more than one absence from school per month
  • Use coping skills to manage anger

The adolescent may be more engaged in these treatment goals in the context of ultimately working toward a soccer contract, rather than in the context of being told by parents, teachers, or a therapist that these are what he or she should be doing.

Similarly, an adolescent may identify a goal that your clinical judgment suggests is a bad idea – for example, being a drug dealer, or being left alone forever. How do we say “yes” to that? Asking questions to reveal what’s underneath those goals, or why those goals might be important to the adolescent, can be helpful in several ways. First, an adolescent may offer those goals as a way to find out whether the therapist will judge or shame them. If you explore the goal, instead of reacting negatively, you can build rapport much more easily. Second, understanding what made that particular goal compelling to the adolescent can be very important clinical information. For example, if a client says that he wants to be the most successful drug dealer in his neighborhood, the therapist might begin by asking, “What’s important to you about that?” or “What would it mean to you to achieve that?” The adolescent might say that the drug dealers he knows are financially stable, entrepreneurial, respected, socially connected, and powerful – all compelling values and attributes. Therapy goals may address helping him to achieve some of those attributes, which in turn may make his goal of becoming a drug dealer less important to him.

Other adolescents may struggle to identify any long-term goals. Adolescents in this category may have a hard time envisioning a future where they achieve anything they want, or even envisioning any future at all. With these adolescents, a series of questions can help to collaboratively set an initial goal as being able to imagine having a goal at all.

  • What gets in the way of your imagining a different outcome?
  • What would it be like to allow yourself to have goals?
  • How could therapy help you to move closer to where you could imagine having goals?
  • What if we start by working on that (allowing yourself to have goals)?

Ultimately, the long-term aspirations are broken down into small and measurable steps, as demonstrated above, and then translated into more typical treatment goals. The adolescent is likely to end up with similar treatment goals to those that might come from a more standard approach, but connecting progress on these goals to progress in the adolescent’s life goals can increase their likelihood of following through.

This goal-oriented approach can help shift the focus of treatment from symptoms, disorder, and problems to ways to build personhood and achievement.