Adolescent Psychotherapy A Radical Relational Approach
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composure during decidedly tense moments.” All of us who either have teenagers or work
with them will benefit from her expertise.”
—Peter Mortola, Ph.D., Professor of Counseling and
School Psychology at Lewis and Clark College in Portland,
Oregon, and the author of Windowframes: Learning the art of
Gestalt play therapy the Oaklander way
“For years colleagues have raved to me about Bronagh Starrs’ work with adolescents
and their worlds; now I understand why. This book is essential reading not only for thera-
pists, counselors, teachers, and others who work with adolescents (or with their parents),
but also for the parents and families themselves, and others who live with adolescents, love
them, are alternately charmed and frustrated by them (and frustrate them in their turn), find
them at times uncommunicative, unpredictable, even maddening, (and of course drive their
adolescent loved ones crazy as well) – and/or all of the above!
Starrs places the emphasis of her approach right where outcome research shows it
should be: on the therapeutic relationship itself, that crucial contact space which precedes
and underlies all the acronyms and ‘how-to’s’ or ordinary models of other manuals. If this
is a ‘how-to’ book, it’s about how to build that “meaningful therapeutic relationship,” on
which everything else depends. The goal and result are not just the ‘fixing’ of a temporary
symptom, but a restoration of healthy development and growth.
Each chapter offers rich, practical insights, grounded and unified by this clear relational
perspective. I’ve been in practice for over 40 years, have raised six adolescents, and my
foster son is now a high school principal in his later thirties. And in the chapter on Foster-
ing, for example, I read insights that I wish I had had twenty years ago when he was in
his turbulent years. Thank you, Bronagh Starrs, for this gift to all of us who live and work
with the issues of this great inflection-stage of life, and through us to our clients, students,
children, grandchildren and others.”
—Gordon Wheeler, Ph.D., President and CEO,
Esalen Insititue, Big Sur, California, and
author of Gestalt Therapy in the APA book series
Major Methods in Psychotherapy, and co-editor
(with Mark McConville) of The Heart of Development:
Gestalt Approaches to Children, Adolescents, and their
Worlds (Vol. I: Childhood; Vol. 2: Adolescence)
Adolescent Psychotherapy
A Radical Relational Approach
Bronagh Starrs
First published 2019
by Routledge
2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN
and by Routledge
711 Third Avenue, New York, NY 10017
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2019 Bronagh Starrs
The right of Bronagh Starrs to be identified as author of this
work has been asserted by her in accordance with sections 77
and 78 of the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted
or reproduced or utilised in any form or by any electronic,
mechanical, or other means, now known or hereafter invented,
including photocopying and recording, or in any information
storage or retrieval system, without permission in writing from
the publishers.
Trademark notice: Product or corporate names may be trademarks
or registered trademarks, and are used only for identification and
explanation without intent to infringe.
British Library Cataloguing-in-Publication Data
A catalogue record for this book is available from the British
Library
Library of Congress Cataloging-in-Publication Data
Names: Starrs, Bronagh, 1970– author.
Title: Adolescent psychotherapy : a radical relational
approach / Bronagh Starrs.
Description: Milton Park, Abingdon, Oxon ; New York, NY :
Routledge, 2019. | Includes bibliographical references and index.
Identifiers: LCCN 2018034621 (print) | LCCN 2018034958
(ebook) | ISBN 9780429460746 (Master) | ISBN 9780429864636
(Web PDF) | ISBN 9780429864629 (ePub) | ISBN
9780429864612 (Mobipocket/Kindle) | ISBN 9781138624252
(hardback : alk. paper) | ISBN 9781138624290 (pbk : alk.
paper) | ISBN 9780429460746 (ebk)
Subjects: LCSH: Adolescent psychotherapy.
Classification: LCC RJ503 (ebook) | LCC RJ503 .S717 2019
(print) | DDC 616.89/140835—dc23
LC record available at https://lccn.loc.gov/2018034621
ISBN: 978-1-138-62425-2 (hbk)
ISBN: 978-1-138-62429-0 (pbk)
ISBN: 978-0-429-46074-6 (ebk)
Typeset in Times New Roman
by Apex CoVantage, LLC
For Gráinne
Contents
Acknowledgementsx
Introductionxi
1 Development, shame and lifespace integrity 1
2 Contact assessment 10
3 Ongoing parental involvement 26
4 One-to-one engagement with the adolescent 39
5 Separation and complex family configuration 58
6 Complex parenting spaces: adoption, fostering and loss 70
7 Anxiety, depression, self-harm and suicide 86
8 Eating disorders 103
9 Alcohol and drugs 117
10 Sexuality and gender: emerging identity and boundary
development 125
11 Sexual trauma 137
12 The diagnosed adolescent 150
13 Case management 161
Index 166
Acknowledgements
This book is a synthesis of my understanding of the dynamics of development in
adolescence and how psychotherapy can support the unfolding of this process.
Without support and collaboration from others, this book would not have been
possible. My special and foremost thanks and admiration goes to the many ado-
lescents I have had the privilege of coming to know in therapy, especially those
who gave permission for their stories and images to be represented throughout
the book. My appreciation also to the parenting adults who have trusted me help
navigate these young people through their developmental challenges. Identifying
information has been altered to ensure anonymity for both adolescents and parent-
ing adults.
As a critical influence in my evolution as an adolescent psychotherapist, I owe
deep gratitude to Mark McConville for his wisdom, friendship and encourage-
ment over the years. A sincere thank you also to Maeve Lewis and Pat Deery
for their support and guidance through the years. For reading of chapters of this
manuscript, I wish to thank Tim Hannon and Leslie Brown.
I owe a special and ongoing debt of gratitude to all faculty, staff and students at
Dublin Counselling and Therapy Centre. In particular, Paul O’Donoghue, Brian
Howlett, Jennifer Foran and Anne Randolph.
I wish to thank Joanne Forshaw, editor, and Charles Bath, senior editorial assis-
tant, at Routledge, for their interest and support throughout the project. I would
also like to acknowledge Sheri Sipka, production editor, and the production team
at Routledge for their thoughtful attention to the manuscript.
Finally, I want to thank my family. My husband, Colin, for his unwavering
encouragement and his graceful accommodation to my dedication to my work.
I am grateful to him and to Edel, Anita, Stephen and Nicola for their boundless
support and for the sense of belonging they bring to my life. And to Emily and
Odhrán, my niece and nephew – two wonderful emerging adolescents who have
my heart.
Introduction
The aim in writing this book is to offer an alternative to the typical treatment
manuals which are available to clinicians who work with an adolescent client
population. In the last number of years schools, counselling organisations and
those in private practice have experienced a notable increase in both referrals and
direct requests for therapeutic support for adolescents. Many professionals have
undertaken either a child- or adult-oriented training and feel out of their depth
with the complexity of the work with adolescent clients. What follows are my
interpretations and conclusions, from my accumulated experience, regarding the
dynamics of development and therapy with this age group, which have fascinated
me from my earliest days as a therapist. This model is anchored in Gestalt therapy
theory and in recent advances in the study of both neuroscience and developmen-
tal trauma.
Establishing relationally meaningful therapeutic alliances with both the ado-
lescent and his parents and securing the adolescent’s commitment to becoming
a client in the first place require rich appreciation and close attention to nuanced
contact episodes from the outset. Much of the literature is written from beyond
this point, as if it is a given that the helping professional innately possesses the
required contact skills to engage meaningfully with an adolescent. In my exten-
sive experience as a trainer and supervisor, this is certainly not the general experi-
ence for professionals, irrespective of therapeutic orientation, who typically find
themselves challenged by the frequently directionless and bewildering experience
of therapy with a teenager. Many books are written from a cognitive and behav-
ioural modification perspective and are focused on finding solutions for problems.
Strategies are offered which relieve symptoms and outcome is evaluated on symp-
tomatic amelioration in the short term.
This book is unique in that it offers a radical relational methodology which not
only addresses symptoms, but also attends to the adolescent’s wider developmen-
tal process. Therapeutic work with adolescents is approached from a relational-
phenomenological perspective and offers strategic guidance to clinicians from the
assessment process right through to specific clinical presentations (e.g. anxiety,
eating disorders, suicide, etc.) and case management issues. Attention is afforded
to a broad spectrum of clinical tasks, including formulation of a developmentally
xii Introduction
appropriate therapeutic plan, ongoing work with parents, development of a
meaningful therapeutic alliance with the adolescent, ethical and legal issues and
working within a multi-disciplinary context. A methodology is presented, which
provides specific relational techniques for an array of presenting situations, all of
which will be immediately translatable within the therapeutic space for any pro-
fessional who reads the book.
The book’s focus is on demonstrating to the reader the art of contact assessment
and intervention. Exploration of therapeutic praxis includes detailed deconstruc-
tion and elucidation of contact process in the work with adolescents and their
parents – demonstrating a relational approach to working with struggling ado-
lescents. Emphasis is placed on development of the therapeutic relationship and
commitment to the adolescent’s first-person experience. This model of develop-
ment and therapy has been created over 18 years of working as an adolescent
psychotherapist. The first four chapters set out the methodology. Most of the
remaining chapters deal with specific clinical presentations and case management
issues. Rather than simply instructing the reader on what to do, this book also
attempts to illustrate how to do it as I describe the detailed nuances of contact
with the adolescent.
The opening chapter offers an exploration of how presenting symptom issues
are understood from a relational perspective, drawing on and extending Gestalt
therapy theory with regard to defining adolescent developmental process. Chap-
ter 2 deals with assessment in adolescent psychotherapy and includes commen-
tary on differences between counselling and psychotherapy in work with young
people. Several principal difficulties encountered in psychotherapeutic work with
adolescents are identified and management of these challenges is discussed.
Chapter 3 emphasises the art of supporting parents to develop deeper attune-
ment to their adolescent children. Parenting strategy work is described, and
instruction is offered on how to identify and manage family dynamics which may
be influencing the adolescent and the therapeutic enterprise. This section includes
discussion of how the complexity of confidentiality is managed in therapeutic
work with adolescents.
Chapter 4, focusing on one-to-one engagement with adolescents, offers a
deconstruction of the detailed nuances (both verbal and nonverbal) in contact
with adolescent clients to extend the clinician’s capacity to develop trusting and
meaningful therapeutic relationships with this age group. The reader is offered
an in-depth description of how to work with creative process to support contact,
which includes an introduction to a creative therapeutic approach which I have
developed and named Sandspace.
The structure of family systems has changed and very often these dynamics of
family experience create additional challenge for the adolescent as she attempts
to find a newly emerging sense of belonging and identity in the world. Chap-
ter 5 explores the impact of separation and complex family configurations for the
adolescent, paying particular attention to the adolescent’s first-person experience.
A clear relational framework for organising therapeutic intervention is presented,
which includes intervention with parenting adults.
Introduction xiii
Adolescent development occurs within a lifespace context which is often com-
plex and traumatic. The adopted or fostered child’s personal biographical context
creates additional layers of complexity as she rises to the developmental chal-
lenge of taking ownership of the self. And so, Chapter 6 will explore the complex
lifespace dynamics which form self-experience for the adopted and fostered ado-
lescent. Living with parental loss will also be explored. Content will include dis-
cussion of the core existential and phenomenological issues for these adolescents;
appreciation of the challenge of identity integration relating to both domestic and
international transracial adoption; exploring the meaning behind impulsive, anx-
ious and insecure presentation. Strategies will be presented to support the ado-
lescent to find language for and make meaning of his experience; and to explore
family-field dynamics and find ways of supporting parent-adolescent relational
connections.
The following three chapters focus on the most common presenting symp-
toms which are encountered in adolescent psychotherapy. Chapter 7 explores the
dynamics of anxiety, depression, self-harm and suicide. The nature of anxiety,
as a clinical presentation in adolescence, is explored from a phenomenological
perspective and the multi-layers of context enquiry are demonstrated through a
comprehensive case example. Emphasis is placed on fostering both curiosity and
relational connection in the work, rather than employing specific techniques.
This chapter also explores a relational-phenomenological approach to work-
ing with adolescents whose presenting symptom issues include depression, self-
harming behaviours and suicidal presentation. The symptom structure of these
clinical presentations is examined and description is included of how contextually
relevant dynamics influence the adolescent’s self-experience. I outline how under-
supported developmental process, transitional insecurity, the presence of trauma
and wider environmental influences may be shaping the adolescent’s lifespace,
resulting in the manifestation of these symptoms. Relational methodology for
working with depressed and self-harming adolescents is presented.
Chapter 8 offers an exploration of the phenomenological experience of the
eating-disordered adolescent. Readers will be introduced to my specific manner
of working with this client group, which includes an understanding of the deeper,
developmental meaning of the eating disorder for the adolescent and interventions
aimed at heightening the adolescent’s self-concern and choicefulness. Chapter 9
focuses on the issue of impulse-driven behaviour with regard to substance use
and its implications for the developing adolescent physically, psychologically and
interpersonally. Strategies are presented which aim to support the adolescent in
adopting greater choicefulness and ownership of his experience.
Chapters 10 and 11 address the area of sexual development in adolescence. The
prevalence of sexual assault, sexually transmitted disease and unplanned preg-
nancy continues to increase, despite us being more open than ever before in dia-
logue with adolescents about sexual matters. It is evident that information alone
is insufficient for the adolescent to support the adolescent’s adoption of full and
responsible ownership of his sexual identity, and so I present to the reader a meta-
phorical manner of supporting choiceful sexual decision-making and expression,
xiv Introduction
which I have been successfully implementing with clients. Supporting and chal-
lenging the adolescent who has engaged in sexually maladaptive behaviour will
also be discussed. In addition, strategies for supporting the adolescent who is
exploring and embracing his sexual orientation and gender experience are also
offered. Attention will also be given to therapeutic intervention with sexually
traumatised adolescents, supporting their recovery from devastation to a more
empowered and safe experience of lifespace identity. The many aspects of recov-
ery and meaning-making are outlined.
Many adolescent clients have already acquired one or multiple diagnoses.
Chapter 12 offers a phenomenological approach to understanding the adolescent
by exploration of the adolescent’s lifespace dynamics through the lens of diagno-
sis, his capacity to make contact and the manner in which he creatively adjusts in
the world through this label. In it, I attempt to demonstrate how to depathologise
the adolescent’s self-experience through meaning-making and non-shaming inte-
gration of the diagnosis into overall experience, supporting movement away from
a sense of the self as pathologised, to adopting greater ownership of experience
and choicefulness in his life.
The final chapter addresses case management issues which the therapist is
bound to navigate in the course of her work with adolescents. Therapeutic work
with this age group is often situated within a wider multi-disciplinary context
which can create anxiety for the practitioner who may be unclear and uncon-
fident with regard to her and others’ roles in situations where interprofessional
collaboration is required. These anxieties can make it difficult to continue to hold
the adolescent therapeutically. This chapter also defines the adolescent therapist’s
role and responsibilities with regard to child protection, therapeutic, ethical and
legal issues with arise in the work with young people. Strategies will be presented
which support clinicians to adopt greater competence within the wider profes-
sional arena. Broad guidance regarding case meetings, report writing and legal
work will be included.
The focus of this book is to illuminate the transformative possibility of the
therapeutic enterprise with adolescents. In it I offer the reader a weave of my
understanding and case examples which, I hope, will render its contents clinically
useful and immediately transferrable to the clinician’s own therapeutic practice.
My hope too is that it may contribute to the wider attempts at understanding how
to intervene therapeutically to make a difference in the lives of adolescents who
are struggling. It is an immense privilege to steward a lost, distressed adolescent,
through the process of healing, towards the authoring of a personally meaningful
future. I passionately believe that this is always possible with sufficient support.
Unfortunately, however, not every troubled adolescent has access to the extent of
support that he needs.
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, hav-
ing 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 sub-
jects 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.
2 Development, shame and lifespace integrity
As more and more adolescents find their way to therapy, practitioners are
encountering increasingly complex clinical scenarios. Most of these young peo-
ple, like Daniel and Louise, have been nominated by concerned adults as suit-
able 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 mean-
ingful 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, developmen-
tally 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 isola-
tion, 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 psychothera-
pists, philosophers, psychologists, anthropologists, educationists and sociologists.
