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Therapeutic Engagement With Adolescents in Psychotherapy.



Therapeutic engagement of adolescents is critical to maximizing the success of any psychotherapy intervention. Therapists have found that engaging adolescents is especially challenging and that there are several reasons for this. Most psychotherapy models are based on treatments that work for adults. These methods are frequently not conducive to engaging adolescents because of their developmental immaturity, the stigma many adolescents associate with psychotherapy, and adolescents feeling forced into psychotherapy. Existing empirical and clinical knowledge about therapy process, adolescent development, and adolescent interactions with their social ecology can be used to guide psychotherapists working with this population. Engaging adolescents in psychotherapy and establishing a strong therapeutic alliance with adolescents require that therapists express empathy and genuineness, utilize developmentally appropriate interventions, address the stigma, and increase choice in therapy. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
University of New Mexico and Center for Family and Adolescent Research
Therapeutic engagement of adolescents
is critical to maximizing the success of
any psychotherapy intervention.
Therapists have found that engaging
adolescents is especially challenging
and that there are several reasons for
this. Most psychotherapy models are
based on treatments that work for
adults. These methods are frequently
not conducive to engaging adolescents
because of their developmental
immaturity, the stigma many
adolescents associate with
psychotherapy, and adolescents feeling
forced into psychotherapy. Existing
empirical and clinical knowledge about
therapy process, adolescent
development, and adolescent
interactions with their social ecology
can be used to guide psychotherapists
working with this population. Engaging
adolescents in psychotherapy and
establishing a strong therapeutic
alliance with adolescents require that
therapists express empathy and
genuineness, utilize developmentally
appropriate interventions, address the
stigma, and increase choice in therapy.
The prevalence and impact of mental health
issues among adolescents are astonishing. Recent
reports indicate that 1 in 10 children and adoles-
cents suffer from impairing mental illness
(Kessler, McGonagle, & Shayang, 1994; U.S.
Public Health Service, 2000). Depression and de-
pressive syndromes are common among adoles-
cents, with more than 25% of high school stu-
dents reporting persistent dysphoria and hope-
lessness severe enough to affect social and
academic functioning, and 8 to 9% of youths ad-
mitting to attempts at suicide (Centers for Dis-
ease Control and Prevention [CDC], 2002). Five
percent of all high school youths report weight
control strategies that indicate a potential eating
disorder (CDC, 2002). Nearly 27% of eighth
graders, increasing to nearly 54% of high school
seniors, report illicit substance use (National
Institute on Drug Abuse, 2001), with 11% of
high school students having a substance abuse
These mental health problems lead to serious
consequences that include impaired social, aca-
demic, and occupational functioning; increased
risk for behavioral problems; and accidental in-
jury and death. Yet, fewer than one in five youths
in need of mental health services receive the
needed treatment (National Institute of Mental
Health [NIMH], 1999). So, while adolescent
mental health problems are pervasive and in-
creasing, access to treatment is decreasing
(NIMH, 1999). Consequently, maximizing ado-
lescent use of psychotherapy and providing ef-
fective mental health services to adolescents are
significant concerns for therapists (Dakof, Te-
jeda, & Liddle, 2001). However, therapy with
adolescents is thought to be difficult (Church,
1994; Hanna & Hunt, 1999; Liddle, 1995; Mar-
Keri Bolton Oetzel and David G. Scherer, University of
New Mexico, and Center for Family and Adolescent Re-
search, Albuquerque, New Mexico.
We thank Janet Brody, Christine McCormick, John Oetzel,
Tim Ozechowski, and Holly Waldron for their support and
assistance in developing and writing this article.
Correspondence regarding this article should be addressed
to Keri Bolton Oetzel, Center for Family and Adolescent Re-
search, 2700 Yale SE, Suite 200, Albuquerque, New Mexico
87106. E-mail:
Psychotherapy: Theory, Research, Practice, Training Copyright 2003 by the Educational Publishing Foundation
2003, Vol. 40, No. 3, 215–225 0033-3204/03/$12.00 DOI 10.1037/0033-3204.40.3.215
golis, 1995; Sommers-Flanagan & Sommers-
Flanagan, 1995, 1997). In contrast to the adult,
child, and family therapy literature, in which a
variety of therapeutic process variables that en-
hance psychotherapy have been identified, little
empirical work has been done to identify specific
process or relationship variables that enhance
therapy with adolescents (Diamond, Liddle,
Hogue, & Dakof, 1999; Shirk & Saiz, 1992).
In the absence of specific empirical knowledge
about engagement of adolescents (Morris & Ni-
cholson, 1993; Norcross, 2001), researchers and
therapists need to rely on information gleaned
from the therapy process literature, the literature
on adolescent development, and socioecological
studies to better understand how to engage ado-
lescents in therapy. Our intent in this article is to
review the most recent clinical and empirical lit-
erature and then indicate how this information
can contribute to adolescent therapy practice.
First we review what is known about therapy pro-
cess research with adults, children, and families
and extract from this suggestions for effective
engagement of adolescents. Second, we evaluate
salient aspects of adolescent development and de-
duce from these additional means for effective
engagement. Last, we consider the social ecology
of the therapy context and how adolescents re-
gard the therapy environment, how this interac-
tion can lead to barriers to effective engagement,
and how these barriers can be overcome. We be-
lieve that integrating this theory, research, and
therapy practice is vital to therapists and re-
searchers who work with and study adolescents.
The Therapy Process Literature
Contributions From Therapy Process Research
to Engagement of Adolescents
Arguably, the most important component of
psychotherapy is therapeutic engagement and the
therapeutic relationship factors that engagement
entails (Liddle, 1995; Norcross, 2001; Shirk &
Saiz, 1992; Weinberger, 1995). However, thera-
peutic techniques and procedures designed for
engaging adult and child clients often do not
work as effectively for adolescents because ado-
lescents bring unique attributes to the therapy
process that distinguish them from other therapy
populations (Rubenstein, 1996, 1998; Shirk &
Saiz, 1992). Nonetheless, the therapy process lit-
erature can inform psychotherapists on effective
means of treating adolescents.
In general, therapeutic engagement is a recip-
rocal interaction in which both therapist and cli-
ent(s) have a responsibility for establishing an
effective rapport. Psychotherapists initiate
therapy sessions and join with clients by express-
ing concern about the well-being of the client and
other family members and by inquiring about
personal problems (Liddle & Dakof, 1995). Cli-
ents, in turn, are expected to be attentive and
actively involved and not merely compliant
(Shirk & Saiz, 1992). As engagement matures
into an emotional involvement between therapist
and client(s), a therapeutic alliance is created
(Friedlander, Heatherington, Johnson, & Skow-
ron, 1994; Horvath, 2001; Ogrodniczuk, Piper,
Joyce, & McCallum, 2000). This degree of mu-
tual relationship and collaborative working in-
volvement between therapist and client(s) gener-
ates an optimum therapeutic outcome.
A variety of attitudinal, interpersonal, and so-
cioecological factors seem to affect therapeutic
engagement (Robin & Foster, 1989). For ex-
ample, for adult clients, therapist and client first
impressionsare important factors in therapeutic
engagement. Strupp (1993) found that therapists
attitudes toward clients (positive or negative)
tended to take shape within the first few minutes,
did not change later on in therapy, and often cre-
ated a self-fulfilling prophecy. Therapists who
expressed a positive attitude toward their clients
tended to give more benign diagnoses, more fa-
vorable prognoses, and communicated more em-
pathically with their clients. Research findings
have also indicated that clientsperceptions of
therapists predict therapeutic outcome (Blatt,
Zuroff, Quinlan, & Pilkonis, 1996; Garcia &
Weisz, 2002; Strupp, 1993). When clients, as
early as the second session, perceived their thera-
pist as empathic, caring, open, and sincere, more
favorable therapy outcomes occurred.
Child and family therapy process research has
found that therapist flexibility and the capacity to
meet the needs and goals of multiple family
members, particularly parents, are necessary fea-
tures of effective therapeutic engagement (Dia-
mond, Diamond, & Liddle, 2000; Garcia &
Weisz, 2002; Kazdin, Holland, & Crowley, 1997;
Kazdin & Weisz, 1998; Kuehl, 1993; Liddle,
1995; Patterson & Forgatch, 1995; Weiss &
Weisz, 1995). Failure to form a therapeutic alli-
ance can occur as a result of family member re-
Bolton Oetzel and Scherer
sistance or because the therapist provided insuf-
ficient support for the family (Celano, 2000). For
example, because family therapists understand
behavior in a systemic context, family members
sometimes feel blamed just by association and
participation in treatment. Family members fre-
quently do not understand the nature and impact
of family therapy and may resist participating,
especially when treatment is due to an adoles-
cents delinquent or substance use behavior (Bar-
bera & Waldron, 1994).
Moreover, family dis-
tress has been associated with higher rates of
negative family communication (Barton, Alex-
ander, & Turner, 1988). Consequently, absent
constructive input from the therapist (and even
sometimes when it is present), family members
sometimes experience family therapy as a nox-
ious encounter. Finally, there are simply more
participants in family therapy than in individual
therapy, thus increasing the opportunity for resis-
tance (Barbera & Waldron, 1994).
Enhancing Therapeutic Engagement With
Adolescents on the Basis of Therapy
Process Research
These general themes from adult, child, and
family therapy process research may have some
utility in developing strategies for, or at least un-
derstanding hazards to be avoided when, engag-
ing adolescents in psychotherapy. For example,
therapists sometimes have negative preconcep-
tions of adolescents because teenagers can intimi-
date adults (Sasson Edgette, 2001). Working with
adolescents who are offensive or resentful can
affect a therapists initial response, ultimately
creating a self-fulfilling prophecy that results in a
failed therapy.
Empathy and genuineness. Most adolescents
begin therapy in the precontemplative stage of
therapeutic change. Consequently, to avoid early
termination, it is important to engage proactively
and to match therapist interventions with the cli-
ents precontemplative reluctance to change (Pro-
chaska & Norcross, 2001). To this end, psycho-
therapists attempting to engage adolescents in
therapy may need to use judicious advocacy,
which can be expressed in a variety of ways.
Empathy, an empirically supported therapeutic
relationship factor (Norcross, 2001), is necessary
for developing a therapeutic alliance (Greenberg,
Elliott, Watson, & Bohart, 2001; Morris & Ni-
cholson, 1993) with adolescent clients, but is not
sufficient. Many adolescent clients need to feel
that their therapist will understand them and that
he or she will be a source of support (Diamond et
al., 1999; Hanna & Hunt, 1999). Extending non-
judgmental acceptance to adolescents and re-
specting their perspectives are more engaging
than the more traditional neutral stance often as-
sumed by psychotherapists (Rubenstein, 1996,
1998; Sommers-Flanagan & Sommers-Flanagan,
1995; Young, Anderson, & Steinbrecher, 1995).
Moreover, validating adolescent clients by appre-
ciating their rationale and justifications of their
behavior, however faulty or maladaptive, offers
adolescents a way of saving face and building
rapport with the therapist. Ultimately, adoles-
cents will recognize and respond to therapists
who convey that they are committed to them and
their well-being (Sommers-Flanagan & Som-
mers-Flanagan, 1995). Of course there are limits
to the effectiveness of empathy (Greenberg et al.,
2001) and occasions when empathizing with an
adolescent may be inappropriate. For example,
therapists need to use caution and avoid having
adolescents perceive therapist empathy as con-
doning antisocial or maladaptive behavior.
Being genuine in therapy with adolescents is a
critical aspect to engaging adolescents in the
therapeutic process. Adolescents, particularly
those in therapy, detest insincerity and pretense
(Rubenstein, 1996). They respond poorly to
therapists and other adults who attempt to be
coolby adopting youthful mannerisms and lan-
guage (Hanna & Hunt, 1999). Adolescents re-
spond more favorably to candor or being real
(Sasson Edgette, 2001; Young et al., 1995).
Therapist candor is intriguing to adolescents be-
cause of the personal and nondefensive stance
assumed by the therapist. Candor is most effec-
tive if the therapist truly cares for the adolescent
and when it is disciplined, benevolent frankness
that is squarely in the service of young peoples
Adolescents who enter therapy for substance use problems
present unique challenges for the process of therapeutic en-
gagement and can be among the most difficult of populations
to engage (Margolis, 1995). Occasionally we use examples of
substance abuse treatment in this article to illustrate how some
of our ideas are manifested with these more difficult clients.
In many situations, the engagement strategies that are effec-
tive with this particular group of adolescents may be even
more potent with adolescents who have relatively less severe
Therapeutic Engagement With Adolescents
needs and invites them to look at themselves dif-
ferently(Sasson Edgette, 1999, p. 40).
Candor implies telling adolescent clients the
truth. The social nuances and euphemisms of
adult therapy are lost on adolescents, although it
is important to seek a palatable way for adoles-
cent clients to face reality. Because adolescents
may not have sophisticated social perspective-
taking abilities and typically do not share a simi-
lar social ecology with adults, truth telling must
be metered to correspond with the adolescents
developmental capacities and context. For ex-
ample, in the treatment of adolescent substance
abusers, candor entails advocating for sobriety.
The therapist must navigate between confronting
an adolescent with his or her substance abuse,
thereby risking the adolescent feeling rejected,
and not saying enough, leaving the adolescent
believing that the therapist tacitly accepts or con-
dones his or her substance use. In this case and
cases like it (e.g., suicidality, disruptive behavior,
eating disorders), assertion is the most appropri-
ate tactic so that adolescents know that their
therapist is committed to treating the problem.
Challenge and confrontation are useful tools in
treating adolescents, but typically not during the
engagement phase (Liddle, 1995).
Involving parents. Having the cooperation of
parents, either as active participants or in support-
ing roles, may be a key feature to engaging ado-
lescents in psychotherapy (Liddle, 1995; Ruben-
stein, 1998; Weisz & Hawley, 2002). However,
aligning with both parents and their adolescent
offspring can be difficult given their conflicting
opinions and values, the sometimes obnoxious
nature and potential dangerousness of adolescent
behavior, and the need to maintain confidential
relationships. Psychotherapists attempting to en-
gage adolescents in psychotherapy may also find
it useful to avoid ascribing blame to adolescents,
parents, or families, working instead with them to
take responsibility for change. Last, it may be
useful in working with adolescents and their
families to begin by muting intense emotional
issues, thereby attenuating the potential unpleas-
antness of therapy sessions.
Confidentiality. Involving parents while de-
veloping a trusting relationship with adolescents
can raise complicated issues related to confiden-
tiality (Morris & Nicholson, 1993). To begin, it is
necessary to identify clearly who is the client. In
some cases, the adolescent meets individually
with the therapist and is accorded the same rights
to confidentiality as adults. However, family
therapy, in which the family is construed as the
client, and multisystemic therapies afford a lesser
degree of confidentiality simply by the nature of
the therapy. Even when adolescents are accorded
confidentiality in therapy, circumstances arise in
which they report activity or plans that involve
danger to self or others or illegal activity that
presents statutory and ethical obligations for the
therapist to breach confidentiality (Morris & Ni-
cholson, 1993; Rubenstein, 1998). In these cir-
cumstances, therapists must be knowledgeable
about the law and professional regulations re-
garding confidentiality for their jurisdiction and
setting, and how confidentiality rights vary de-
pending on the type of therapy being conducted
(e.g., substance abuse treatment; Brody & Wal-
dron, 2000; Morris & Nicholson, 1993). In any
case, it is important that the therapist explicitly
informs his or her clients about the limitations of
confidentiality as well as his or her practices re-
garding privacy and confidentiality and maintains
an ongoing discussion of this issue with adoles-
cent clients.
The Developmental Literature
Contributions From Developmental Research to
Engagement of Adolescents
Although developmental themes have tradi-
tionally been a central part of child therapy, only
recently have researchers and therapists begun to
consider adolescent development as an important
aspect of psychotherapy with adolescents (Holm-
beck & Updegrove, 1995; Liddle, 1995; Ruben-
stein, 1998; Weisz & Hawley, 2002). Second
only to infancy, adolescence entails the most
rapid and pervasive developmental changes in-
volving physiological, cognitive, emotional, and
social transformations (Holmbeck & Updegrove,
1995; Weisz & Hawley, 2002). Moreover, there
are considerable individual differences in rates of
developmental maturation among adolescents.
Adolescents tend to follow one of several devel-
opmental pathways (Compas, Hinden, & Ger-
hardt, 1995). Some adolescents proceed along
stable, adaptive trajectories or along maladaptive
ones, whereas others vacillate between healthy
and problematic conditions. There are a wide va-
riety of precursors that precipitate maladaptive
trends. One that has received particular note is the
Bolton Oetzel and Scherer
pronounced physical changes occurring in ado-
lescence that can affect an adolescents psycho-
logical adjustment and self-concept.
The public perception of adolescents is that
they are fueled by raging hormonesthat create
considerable emotional lability. Although endo-
crine changes play an important role in physi-
ological and neurological development (Susman,
1997; Walker, 2002), these changes are most pro-
nounced in early adolescence, and the overall ef-
fect of hormones on the psychological adjustment
of teenagersbehavior is overshadowed by socio-
ecological factors (Buchanan, Eccles, & Becker,
1992; Weisz & Hawley, 2002). However, the
timing of pubertal changes is important to under-
standing an adolescents psychological adjust-
ment. Early maturation can expose both boys and
girls to greater psychological risk. Although early
maturation is often a self-esteem boost for boys,
it tends to challenge the self-concept of girls.
Moreover, early maturation often results in
greater disruptive behavior for both boys and
girls because, in part, of exposure to older and
antisocial peers (Weisz & Hawley, 2002). In ad-
dition, neurological transformations almost cer-
tainly have a hitherto unrecognized effect on ado-
lescents and their psychological maturity. Recent
studies (Giedd et al., 1999; Sowell, Trauner,
Gamst, & Jernigan, 2002) have found significant
central nervous system development and neuro-
plasticity throughout adolescence. This neuro-
logical growth may influence executive function-
ing that includes behavioral inhibition, impulse
control, and emotional regulation (Spear, 2000;
Walker, 2002).
In concert with the neurological changes oc-
curring in the adolescent brain, there are a wide
variety of cognitive changes that transpire
throughout adolescence. Ordinarily, adolescents
have acquired a substantial fund of knowledge,
have increased capacities for storing and retriev-
ing memory, and, perhaps more important for the
therapy enterprise, they begin to demonstrate im-
provements in their capacity to process informa-
tion and reason abstractly (Holmbeck et al., 2000;
Holmbeck & Updegrove, 1995; Weisz & Haw-
ley, 2002). These cognitive changes may enhance
an adolescents receptivity to psychotherapy and
help create the potential for him or her to take
advantage of therapies that emphasize cognition
and insight (Cicchetti & Toth, 1996; Holmbeck et
al., 2000). However, cognitive competencies are
highly contextual and situation dependent (Gard-
ner, Scherer, & Tester, 1989; Steinberg & Cauff-
man, 1996), and adolescents may manifest very
different cognitive capacities in different social
settings. In addition, many adolescents from the
clinical population (particularly delinquent teens
and substance-abusing youths; see Margolis,
1995) demonstrate indications of cognitive devel-
opmental delays that often frustrate therapists at-
tempting to engage adolescents in therapy.
Socioemotional changes occur in unison with
physiological and intrapsychic developments
during adolescence. Adolescents seek more inde-
pendence and autonomy than young children, and
over time they negotiate a shift from dependency
on parents and family to a greater emphasis on
attempting to fit-inwith peer groups (Hops,
Davis, & Lewin, 1999). Adolescentsfledgling
attempts at autonomy can be awkward and are
often perceived as rejecting and defiant by par-
ents and other important adults in an adolescents
life. Consequently, parents and other adults fre-
quently feel inadequate in their communications
with adolescents and are unable to manage their
behavior (Holmbeck & Updegrove, 1995). At the
same time, adolescents can have great difficulty
in integrating needs for help and needs for au-
tonomy (Sasson Edgette, 2001). To some extent,
adolescentsinternal working model of attach-
ment may inform the manner in which adoles-
cents pursue autonomy. Adolescents with secure
attachment models may have more success in
validating relationships with adults while meet-
ing their own needs for independence. However,
the population of adolescents referred for psycho-
therapy is more likely to have insecure attach-
ment paradigms (Liddle & Schwartz, 2002),
which can complicate efforts to engage them in
Enhancing Therapeutic Engagement With
Adolescents on the Basis of
Developmental Knowledge
Psychotherapy interventions for adolescents
are frequently patterned after adult intervention
strategies (Diamond et al., 1999; Shirk & Saiz,
1992; Waldron, Brody, & Bolton Oetzel, 2001).
However, the techniques and strategies in adult
interventions do not necessarily translate to ado-
lescents because of differences in manifestations
of psychopathology and problem behavior, cog-
nitive ability, awareness and value placed on con-
Therapeutic Engagement With Adolescents
sequences, as well as coping strategies and abili-
ties (Brown, Creamer, Aboitz, & Taylor, 1987;
Rubenstein, 1996). Consequently, therapists
treating adolescents need to begin their work
by assessing a variety of developmental con-
siderations and determining how these develop-
mental factors may help or hinder therapeutic
Physical maturation considerations. It is of-
ten useful to understand how and when an ado-
lescent entered puberty. Girls who acquire physi-
cal sexual characteristics early are vulnerable to
developing psychological adjustment problems
that sometimes fester into internalizing psycho-
pathology, and both girls and boys with early
sexual development have more contact with older
and often delinquent peers. This creates more op-
portunity and exposure to premature sexual en-
counters, delinquency, and substance use, result-
ing in more advanced psychological problems. A
longer history of problems may result in adoles-
cents being more casual about problem behavior
and less amenable to therapeutic interventions.
Early substance use may also affect the adoles-
cents neurological maturation during a critical
period of development. Knowing about an ado-
lescents experience of puberty may help a psy-
chotherapist anticipate issues related to peer en-
couragement of problem behavior and resistance
that is due to substance addiction.
Cognitive considerations. Troubled adoles-
cents may be less cognitively and socially mature
and less able to understand the rationale behind
treatment and the need for it. As a consequence,
they rarely refer themselves to treatment and of-
ten show much less concern about their problems
than do others (Kazdin, 1996; Shirk & Saiz,
1992). Lacking motivation and understanding of
treatment, adolescents frequently fail to see the
purpose in psychotherapy and doubt that it will
have any meaningful impact on them. These
thought processes make engagement more diffi-
cult and have a negative influence on the thera-
peutic process (e.g., resistance) and therapeutic
outcome (e.g., dropout).
Adolescents express different degrees of cog-
nitive competence across domains and may use
abstract logic and reasoning in response to aca-
demic issues, yet rely on less sophisticated cog-
nitive processes in response to emotionally
charged personal and social situations. Conse-
quently, adolescents often lack the cognitive
abilities and experience to fully appreciate the
therapeutic process. Many psychotherapies re-
quire that clients have the ability to self-reflect,
manipulate complex concepts mentally, bear in
mind the future consequences of behavior, and
consider the perspective of others, while experi-
encing intense emotions. This degree of abstract
and causal reasoning exceeds the capacities of
many adolescents and contributes to adolescents
reluctance to participate in therapy because they
feel at a disadvantage in the psychotherapy set-
ting (Margolis, 1995; Shirk & Saiz, 1992).
As a consequence, a psychotherapist attempt-
ing to engage an adolescent must be prepared to
vary the levels of abstraction and cognitive so-
phistication with which he or she presents ideas
(Weisz & Hawley, 2002). Talking too abstractly
to a cognitively delayed adolescent risks having
the adolescent not appreciate or understand the
relevance of the therapists perspective. Cogni-
tively immature adolescents require the therapist
to use simple inquiries devoid of abstract terms,
concrete examples, and guidance in how to es-
tablish therapeutic rapport. On the other hand,
talking too concretely to an adolescent who pre-
fers higher order reasoning may result in the ado-
lescents feeling infantilized. Adolescents with
sophisticated cognitive abilities have a greater ca-
pacity for dealing with the ambiguities of the
therapy setting and are more likely to respond
positively to conjecture and repartee.
There are forms of cognition that when present
in adolescent clients can either deter or augment
the therapy engagement process. Delinquent ra-
tionalizations are cognitions used frequently by
antisocial adolescents to justify maladaptive be-
haviors (Samenow, 1984). These types of cogni-
tion contain irrationality or illogic that, when
used by troubled adolescents, facilitates contin-
ued maladaptive behavior. These errors in think-
ing are an impediment to therapeutic engage-
ment. They frustrate efforts to build and sustain
an adolescent clients motivation for therapy and
need to be addressed as part of the engagement
process and prior to initiating attempts at behav-
ior change. On the other hand, adolescents who
evince skills at social perspective taking and fu-
ture time perspective are more amenable to en-
gagement tactics that involve self-monitoring, es-
tablishing therapeutic goals, and directly address-
ing the relationship between therapist and client.
Adolescents who use these cognitive skills have
Bolton Oetzel and Scherer
the potential for responding positively to induc-
ing cognitive dissonance by challenging the in-
consistencies between their goals and their
thoughts and behaviors.
Attachment and social maturity consider-
ations. Seeking help, admitting to psychologi-
cal problems or discomfort, and engaging con-
structively in psychotherapy may conflict with an
adolescents striving for autonomy. This may be
particularly difficult for adolescents who have at-
tachment difficulties and little experience engag-
ing constructively with adults. Developing an im-
pression of an adolescent clients attachment
style can be very useful in planning therapeutic
engagement strategies. Adolescentsexperience
with other adults will establish a template of their
expectations for how to relate to a therapist. Most
adolescents in treatment will manifest some form
of anxious internal working model of attachment.
Some will be seeking connection and relationship
as a way of coping with their apprehension. As a
consequence, they will be relatively amenable to
the establishment of a therapeutic rapport and
pursuit by the therapist. Others cope with attach-
ment anxiety through manipulation and sneaki-
ness.In these cases, pursuit by a psychotherapist
will engender more manipulation that can hinder
the establishment of a therapeutic rapport. A third
way that adolescent clients express anxiety re-
garding attachment and relationships with adults
is by being downright dismissive and distancing.
Pursuing a more intense therapeutic engagement
in these cases is likely to engender more distanc-
ing in the form of anger, scorn, and missed ap-
pointments. In these latter cases, to establish en-
gagement, the psychotherapist will need to be
present, available, and self-assertive but eschew
more directive techniques (e.g., prompting, per-
sonal inquiries, confronting) that can be per-
ceived as intrusive and domineering. Last, ado-
lescent clients often find emotionally intense cir-
cumstances overstimulating, and they may lack
effective skills at emotion regulation. Indeed,
these skill deficits are often implicated in the de-
velopment of conduct and substance abuse prob-
lems and precipitate the need for therapy. Con-
sequently, to engage these adolescents effec-
tively, it is often necessary to react to the intense
emotional circumstance surrounding their entre´e
into therapy with a more muted and restrained
Socioecological Considerations
Understanding the Adolescent-
Context Mismatch
Adolescent development and adjustment can
also be conceptualized as a function of the match
between the social environment (Eccles &
Midgley, 1989) and the characteristics of the
individual. Adolescents react physically and be-
haviorally to their environment, and their social
ecology can either augment or deter their devel-
opment. Social environments convey expecta-
tions, values, and preferences (Compas et al.,
1995) with which adolescents may or may not
feel compatible. The psychotherapy setting is a
social environment that adolescents are typically
unfamiliar with and one in which they often do
not feel competent. For many adolescents, a mis-
match occurs between their developmental capa-
bilities and the demand characteristics of the psy-
chotherapy setting. This mismatch offers an op-
portunity for the adolescent to develop new
capacities, particularly if it results in a positive
outcome. However, this mismatch may also over-
whelm the capabilities of the adolescent and re-
sult in therapy engagement difficulties (Compas
et al., 1995; Liddle, 1995; Rubenstein, 1996).
Two issues, in particular, enhance the opportu-
nity for an adolescenttherapy environment mis-
match: the stigma associated with psychotherapy
and the lack of choice adolescents face when en-
tering psychotherapy.
Many adolescents are very suspicious about
the psychotherapeutic enterprise, in part, because
they are in a time of transition and identity con-
solidation that leaves them feeling vulnerable and
unsure of themselves, particularly in a novel psy-
chotherapy setting. At times they perceive psy-
chotherapy as an effort to control them and di-
minish their autonomy (Hanna & Hunt, 1999).
Being subject to a therapists probes about per-
sonal thoughts and emotions can be experienced
by adolescents as intrusive and threatening rather
than as an effort to be supportive and caring.
Often, adolescents perceive therapy as being for
crazyor mentalpeople, those who belong in
a mental hospitalor who are living on the
streets.The stigma attached to receiving therapy
can be quite negative among peer groups and
result in adolescents feeling scorned and ridi-
culed by their cohorts. As a consequence,
troubled adolescents beginning psychotherapy
Therapeutic Engagement With Adolescents
can be quite resistant to the efforts of the thera-
pist, in an attempt to defend themselves and com-
pensate for their perceived vulnerability.
Adolescents are frequently compelled or man-
dated to enter treatment by authority figures such
as a parent, school official, probation officer, or
judge (Rubenstein, 1998). This condition is espe-
cially common in delinquency and substance
abuse treatment when adolescents are required to
seek psychotherapy as an alternative to more re-
strictive forms of treatment (e.g., group homes,
residential treatment centers) or detention (Mar-
golis, 1995). In most, if not all, of these instances
parents, school personnel, probation officers, and
judges frequently have a greater investment in
treatment and awareness of its possible positive
outcomes than do adolescents (Dakof et al.,
2001). Adolescents mandated to treatment are
less likely to participate fully, collaborate, or en-
gage in positive interactions, all of which have
been demonstrated to be hallmarks of successful
therapy (Alexander & Luborsky, 1986; Marzialli,
1984; OMalley, Suh, & Strupp, 1983).
Enhancing Therapeutic Engagement With
Adolescents by Dealing With Stigma
and Choice
Coping with the stigma of psychotherapy.
Directly addressing the stigma associated with
psychotherapy early in treatment is often neces-
sary to engage adolescents. Adolescent clients
have a unique relationship to psychological
symptoms. Frequently, adolescents fail to per-
ceive maladaptive symptoms as problematic, yet
at other times they overestimate the significance
of psychological symptoms and may be ashamed
of reporting them. Consequently, it is frequently
useful to educate adolescent clients and their
families about the wide range of normative psy-
chological experience and experimenting behav-
ior that adolescents engage in and, when possible,
to assure adolescents that their experience is
within normal limits. Adolescents, and some-
times their families, often have inaccurate im-
pressions of psychotherapy and the therapy pro-
cess, which are generally made by media and
stereotype. Hence, it is often necessary, espe-
cially with substance-abusing adolescent clients
in which case stereotypes are insidious, to pro-
vide them with an in-depth explanation of what
occurs in therapy, how it works, and what is ex-
pected of each participant.
Providing choice. It is commonplace for
adolescents in therapy not to see themselves as
needing treatment (Dakof et al., 2001). They par-
ticipate in therapy, at least at its onset, because
otherssuch as the juvenile justice system,
school personnel, and parentswant them to be
in treatment (Melnick, DeLeon, Hawke, Jainchill,
& Kressel, 1997; Sasson Edgette, 2001). This
condition establishes at least two challenges to
the development of an effective therapeutic rap-
port. When adolescents are faced with a lack of
choice or perceive limits to their freedom to
choose, they react, often in opposition to the
therapist and his or her efforts to engage the
adolescent (Hanna & Hunt, 1999; Sommers-
Flanagan & Sommers-Flanagan, 1995). Second,
when adolescents attend therapy because they are
compelled to by external entities, intrinsic moti-
vations are undermined. When this happens, ado-
lescents fail to perceive the relevance of treat-
ment and are more likely to drop out when treat-
ment does not meet their expectations (Kazdin &
Wassell, 1999). Although it is not always fea-
sible, providing adolescents with some degree of
choice about their participation in psychotherapy
may optimize the potential for therapeutic en-
gagement. Allowing adolescents to choose their
therapist, or giving them treatment intervention
options from which to choose, or offering them
the choice of what to discuss in therapy may en-
hance the relevance of and motivation for psy-
chotherapy for the adolescent client, leading to a
higher level of engagement (Church, 1994;
Hanna & Hunt, 1999; Liddle, 1995; Loar, 2001;
Rubenstein, 1996).
A Summary of How to Better Engage
Adolescents in Psychotherapy
The need for effective interventions with ado-
lescents is critical, yet succeeding as a psycho-
therapist with adolescents can be challenging.
However, there is a growing body of empirical
and clinical knowledge about therapy and en-
gagement strategies with adolescents that can
maximize success. However, it is important to
note that there are limits to what a psychothera-
pist can accomplish when adolescents are bellig-
erent, threatening, defensive, and ready for a
battle (Jurich, 1990; Sasson Edgette, 2001). In
treating delinquent and substance-abusing teens,
in particular, humility and recognition of how
little control the psychotherapist has may be most
Bolton Oetzel and Scherer
appropriate (Margolis, 1995). Moreover, it is im-
portant for psychotherapists to recognize that en-
gagement is a process, not a one-time event, and
that effective engagement continues throughout
therapy and determines the intensity of the inter-
vention (Liddle, 1995; Young et al., 1995). Still,
engagement themes are concentrated in the initial
sessions, and there are a variety of methods that
psychotherapists can use to minimize barriers and
engage with adolescents.
Although effective engagement is typically a
reciprocal process between therapist and client,
working with adolescents may require that the
psychotherapist assume more responsibility and
initiative for developing therapeutic rapport.
Adopting a more traditional neutral style and
waiting for adolescents to seek out rapport with
the therapist generally fail because adolescents
frequently do not perceive the need for therapy
and do not initiate therapy contact. Engaging ado-
lescents in psychotherapy typically requires a
more proactive and directive approach. Making a
good first impression by presenting a positive and
hopeful attitude, emphasizing the adolescents
competence, and expressing confidence in the
therapy process is vital (Rubenstein, 1996). Ado-
lescent clients respond best to therapists who are
empathetic yet forthright and assertive, who do
not flaunt expertise, and who are not abrasive or
confrontational. Parents and families are an in-
valuable resource for supporting therapeutic
goals; consequently, finding a means of including
and supporting parents and families can facilitate
the engagement process.
Last, it is especially important to design thera-
peutic interventions that are developmentally ap-
propriate and that take into account socioecologi-
cal factors. An assessment of an adolescents
physical and cognitive maturation and his or her
attachment style will yield information that can
inform a psychotherapist on how to adjust his
or her therapy tactics. Moreover, addressing
the stigma many adolescents associate with psy-
chotherapy and offering choices whenever pos-
sible may facilitate an adolescents entre´e into
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Therapeutic Engagement With Adolescents
... Young people have consistently indicated that the relationship with their clinician is important to them when seeking mental health treatment [26,45]. From the research that has been conducted, the most common factors which young people report improve their engagement with clinicians include being listened to [26,46,47]; experiencing a genuine connection [34,48]; feeling accepted without judgment or stigma [49][50][51][52]; having their autonomy respected [34,49]; a less hierarchical relationship [26,34,49,50,53,54]; a more informal and friendly relationship [34,49,50]; a sense of control and choice in their own care [34], which may be particularly significant for young men [55]; trust [56] particularly regarding confidentiality [46,57]; and empathy and care [49,50,[52][53][54]58]. More supportive clinicians with strong communication, clear acceptance, empathy, and non-judgmental attitudes are valued highly [59]. ...
... The disconnect between the priorities of young people and their adult clinicians could contribute to challenges engaging young people in treatment including high drop-out rates [71]. It is likely that respecting young people's priorities will aid the formation of a strong therapeutic relationship, in order to allow young people to truly engage in and become active participants in therapy [48]. This means reconsidering the ways in which we give voice to young people's perspectives [72,73] and providing more opportunities to explore the complex issue of agency for young people in a system which often provides them with little power [74]. ...
Full-text available
Evidence from around the world consistently indicates young people experience high rates of mental ill-health, but frequently have limited engagement with treatment. One powerful influence on young people’s engagement with mental health care is their relationships with treatment providers. A strong relationship with clinicians may be key to sustaining engagement, reducing dropout rates, and improving outcomes from treatment. However, research into young people’s perspectives on qualities they value in their clinicians has often been limited by traditional methodologies which explore young people’s attitudes to clinicians they have already worked with. This limits young people’s responses and, therefore, our understanding of who an effective ‘youth mental health clinician’ could be. In this study, 94 young people from New Zealand participated in innovative research workshops in which they described their ideal mental health clinician. Thematic analysis identified five themes which summarized these young peoples’ priorities for an ideal mental health clinician: Someone Like Me, Someone I Connect With, Someone Who Protects My Space, Someone Who Treats Me as an Equal, and Someone Who Works in the Right Way for Me. The presence and demonstration of these qualities may support both initial and sustained engagement with treatment, with the potential to improve outcomes for young people. Importantly, the connections between these themes highlight that young people are less likely to value ‘relatability’ as an isolated quality in their clinicians and most desire to work with clinicians who balance a warm and comfortable personal style with professional expertise and boundaries. These findings provide guidance for clinicians from a range of orientations who wish to work effectively with young people as to how they can adapt their approaches and seek feedback to improve their work with young people.
... Similarly, Zimmerman, Abraham, Reddy and Furr (2000) reported that youth in residential care valued the continuous availability of support from adult relationships, and Kendrick (2013) recently highlighted the significance to youth of feeling they are in a family-like relationship. Finally, Oetzel and Sherer (2003) indicated that therapeutic alliance with adolescents was predicted by therapists being rated as empathic, real (i.e., genuine), and having respect for privacy and autonomy. Some of our demographic findings also have parallels in the literature on youthadult mentoring which suggest that girls and boys bring different needs and approaches to the mentoring relationship (Rhodes, Lowe, Litchfield, & Walsh-Samp, 2008). ...
Full-text available
This study examined the perceptions of youth living in residential care about their relationships with the youth care workers who care for them. The data come from an open-ended survey question asking youth to describe the qualities they like about their favorite youth care worker. A total of 738 youth from across 16 agencies participated, and a wide range of topics were described. Using the constant comparative method, we developed a scheme for categorizing care worker qualities and coded all responses to identify the primary themes reported by youth. Eighteen categories emerged including qualities mostly related to interactional styles such as engagement, genuineness, flexibility, understanding, respect, and structure. The categories endorsed by youth differed based on their gender, age, and tenure at the agency. Findings from this work can support residential care agencies' efforts to maximize their fit with the needs, preferences, and best interests of the youth they serve.
... This is consistent with prior research findings that family-based treatments are associated with greater engagement in care [17,86]. Some have argued that the greater engagement associated with family and group-based interventions for adolescents may relate to the social components inherent to these types of interventions [87]. Adolescence, marked by many important socio-developmental milestones, typically includes dynamic changes to the role and identification of supportive others in their lives [16,88,89], and this may be particularly true for JIY [90]. ...
Full-text available
Justice-involved youth (JIY) have high rates of behavioral health disorders, but few can access, much less complete, treatment in the community. Behavioral health treatment completion among JIY is poorly understood, even within treatment studies. Measurement, reporting, and rates of treatment completion vary across studies. This systematic review and meta-analysis synthesizes the literature on rates of treatment completion among JIY enrolled in research studies and identifies potential moderators. After systematically searching 6 electronic databases, data from 13 studies of 20 individual treatment groups were abstracted and coded. A meta-analysis examined individual prevalence estimates of treatment completion in research studies as well as moderator analyses. Prevalence effect sizes revealed high rates of treatment completion (pr = 82.6). However, analysis suggests a high likelihood that publication bias affected the results. Treatment groups that utilized family- or group-based treatment (pr = 87.8) were associated with higher rates of treatment completion compared to treatment groups utilizing individual treatment (pr = 61.1). Findings suggest that it is possible to achieve high rates of treatment completion for JIY, particularly within the context of family- and group-based interventions. However, these findings are limited by concerns about reporting of treatment completion and publication bias.
... They may perceive the therapist providing the treatment as an authority figure, desiring freedom and a departure from therapy. Therefore, the therapy itself may conflict with the patients' need for independence (Block & Greeno, 2011;Bolton Oetzel & Scherer, 2003). The therapist will have to not only understand the developmental stage the adolescent is at and how to keep them engaged but also understand the impacts of their mental health condition and the importance of treating it. ...
... Research has demonstrated that adolescents are particularly reluctant help-seekers of conventional services and even more so if they are part of marginalised groups (e.g. Oetzel & Scherer, 2003). Stigma, mistrust, lack of flexibility, unknown professionals and requirements such as needing a GP or having a fixed abode can all partly explain why some services can be 'hard-to-reach' (Flanagan & Hancock, 2010;CAMHS review, Fountain, Patel & Buffin, 2007). ...
Full-text available
Besani, C., Kavanagh, M. (2013). An evaluation of the relationship of dependency and ward atmosphere in a Adolescent Inpatient Mental Health Service, Clinical Psychology Forum
... Whilst there may be external barriers to accessing services, the way the services operate might also be a factor as YP want a sense of connection with a professional undertaking an intervention (Bolton Oetzel & Scherer, 2003). They want someone who is non-judgemental, empathetic and caring and to feel heard and validated (Hollidge, 2013). ...
Mental health issues are becoming a major global health issue. Problems related to mental health often arise during adolescence as the brain matures. If these problems continue, they have the potential to influence young people’s (YP’s) developmental trajectories and predict future adult mental health problems. Schools are ideally placed to deliver mental health interventions. It is paramount that YP’s voices are heard to ensure the success of mental health interventions. This research aimed to hear the voices of YP about their views and experiences of school-based mental health interventions within two studies. Chapter 1 provides a systematic review and thematic synthesis of YP’s views and experiences of school-based group mental health interventions. This review assessed findings from qualitative studies to help generate new insights into YP’s perspectives of group school-based mental health interventions for YP at secondary-level education. Fourteen articles were identified through electronic databases. Data was thematically synthesised according to established guidelines. Five main themes were identified: sense of agency, experience of content, group dynamics, perception of environment and acknowledging and embracing change. The findings provide evidence that group mental health interventions need to be embedded within educational systems to promote YP’s well-being. This review recommends how these can be implemented and how mental health problems could be prevented in the future. Chapter 2 comprises a qualitative study exploring facilitators and YP’s experiences of a school-based iCBT intervention programme called B-MAY for reducing YP’s anxiety. A total of 31 interviews were completed which comprised 22 YP and 9 facilitators. The data was analysed using a reflexive thematic analysis. Four main themes were found: hopes for programme, ease of use, perceived efficacy of B-MAY and significance of relationships. Findings indicated positive experiences of the intervention programme, with perceived strengths and barriers and suggestions of what an ideal school-based online intervention programme might be composed of. The findings provide an insight into how educators can implement digital interventions successfully within secondary schools with educational psychology support and potential future research.
... Face to face psychotherapeutic method is a traditional approach for treating mental disorders. In individual psychotherapy, a psychotherapist directly communicates with the patient, but most teenagers could not engage in this traditional psychotherapy [15]. Therefore, a new model was introduced in this field where computer-aided communication was added in psychotherapy. ...
Depression, coupled with a cancer diagnosis in early childhood, often leads toward disinclination to psychotherapy, especially in children. However, a possible remedy could be found in video games that could reduce the depressive condition. This study investigates two games and our results show that the ability of therapy embedded game (3D-GIT) is relatively better than the simple serious game (Remission-II) in reducing depressive symptoms associated with a cancer diagnosis. The sample comprised of 60 cancer patients, randomly selected from different cancer hospitals in Pakistan. All the patients were pre-tested using the Center for Epidemiological Studies Depression Scale for Children (CES-DC). The sample was randomly divided into two equal groups: one group played the 3D-GIT game, and the other played the Remission-II game. The games were played four times a week for a month. All the patients were then re-tested on the same scale. Pre-test and post-test scores were compared through paired t-test analysis. The findings of the study support the first two hypotheses that 3D-GIT and Re-Mission-2 are effective in reducing depressive symptoms among young cancer patients. The study results reveal that these video games could be used as an alternative treatment of depression for those who could not or are unwilling to go for counseling sessions with clinical psychologists. However, the results show that there are no significant differences between 3D-GIT and Remission-II games, suggesting that both games effectively reduce depressive symptoms among cancer patients. The study results support that the 3D-GIT game and the Remission-II game could be used to reduce depression among cancer patients.
Aims As the number of people aged 16–25 referred to mental health services rises, the increasing complexity of their presenting needs is apparent. For those with additional communication and interaction differences, psychological assessment may be especially challenging. They often have long-standing histories of interpersonal challenge, do not find making relationships with others easy and can find conventional information-gathering assessments difficult and at times, even unhelpful. Method/rationale Educational psychologists (EPs) can make a distinctive contribution in this area because of: (i) their knowledge of adolescent and young adult development; (ii) their skills in relational connection in time-limited assessment contexts; and (iii) the value they place on person-centred approaches. This paper outlines one approach to psychological assessment that prioritises collaboration with clients aged 16–25 and emphasises understanding the meaning they make of their subjective experience of the world. Findings/implications The use of projective techniques, where a free-flowing response to a stimulus was used as the basis of a dialogue with the client, is described in the broader context of collaborative assessment. Illustrative case studies that serve as the basis for reflection on experience are explored, with common themes identified. The benefits of the approach, especially in terms of supporting clients and for practitioner learning, are highlighted. Limitations This approach, whilst facilitated by qualified and trainee EPs, has been developed in a specialist mul-tidisciplinary clinical context. Challenges in using projective techniques as part of collaborative assessments, as well as capacity concerns as regards ongoing training and supervisory requirements, are examined. Conclusions There are opportunities for the future development of EP practice in this area, as well as promising lines of practice-based research inquiry.
Utilizing focus groups with middle, high school, and university students, this phenomenological study developed a three-faceted perspective on student preferences for the personal and professional qualities of high school counselors. Findings revealed that students value the accessibility of counselors. Informants identified elements of accessibility that include authentic concern, trustworthiness, an interactive presence, unconditional acceptance, and attuned empathy as the primary qualities they prefer in a high school counselor. The findings have implications for the professional development of high school counselors and for those who train, hire, and supervise them.
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Family therapy is often the treatment of choice for culturally diverse clients. This article provides a critical review of culturally competent assessment and intervention strategies for use with ethnic minority families in the U.S. A culturally informed view of the definition of family health and dysfunction is presented, basic structure and goals of family therapy are delineated, and family therapy process and techniques are addressed. Clinical vignettes are provided to illustrate critical points.
Most empirically supported interventions for adolescent mental health problems are either downward adaptations of adult treatments or upward adaptations of child treatments. Although these treatments show respectable effects with teens, a review of the outcome research reveals significant gaps, both in coverage of adolescent conditions and problems (e.g., eating disorders, suicidality) and in attention to the biological, psychological, and social dimensions of adolescent development, The authors critique the field. propose a biopsychosocial framework for the development of dysfunction and intervention, and discuss ways the developmental literature can and cannot inform intervention and research. A long-term goal is an array of developmentally tailored treatments that are effective with clinically referred teens and an enriched understanding of when, how, and why the treatments work.
Two decades of empirical research have consistently linked the quality of the alliance between therapist and client with therapy outcome. The magnitude of this relation appears to be independent of the type of therapy and whether the outcome is assessed from the perspective of the therapist, client, or observer. Although the strength of the connection between alliance and therapy outcome appears to be relatively uniform throughout therapy, the client's report of the early alliance may be the most clinically useful indicator. In successful treatments, the therapist's and client's assessments of the alliance tend to converge over time. Recent research suggests that the therapist's skills and personal factors both influence the likelihood of developing a good therapeutic alliance with the client. Though the relation between the therapist's level of training and the quality of the alliance is inconsistent, it is likely that the more trained therapists are able to form better alliances with severely impaired clients.
Therapists working with teenagers and their parents have the opportunity to assist families at a crucial juncture in the child's and family's development. Successful work can foster a smooth transition to adult autonomy and ongoing harmonious familial ties; failed interventions may have lasting and dangerous implications as teenagers experiment with sexuality, gangs, drugs, and alcohol. The aim of this article is to provide clinicians with a few practical suggestions for overcoming initial obstacles when parents compel their unwilling teens to enter therapy and to establish collaborative and enjoyable ways of making incremental changes that improve immediate functioning and have the potential to promote continued growth and systemic change.
A major challenge for scholars of adolescent development consists of expanding current theoretical models to capitalize on advances in the biomedical sciences. Integration of biological processes into models of adolescent development will enable scientists to construct more holistic and integrative perspectives than currently are available. The urgency for further integration of biological, psychological, and contextual domains in theoretical models stems from the reality that serious ongoing problems remain to be solved, old problems are reemerging, and still other lethal problems are emerging for the first time. The links between endocrine physiological processes and adolescent psychological processes are the focus of this article. The article begins with a brief history of biopsychosocial research in adolescent development. Four models for conceptualizing hormone-behavior research as illustrative of biopsychosocial models are discussed. The article concludes with challenges and directions for future research.