Counseling Techniques for Adolescents (by Andi J. Thacker)

Jeremy Bouma on October 18th, 2018. Tagged under ,,,,,,,.

Jeremy Bouma

Jeremy Bouma (Th.M.) has pastored on Capitol Hill and with the Evangelical Covenant Church in Michigan. He founded THEOKLESIA, which connects the 21st century Church to the vintage Christian faith; holds a Master of Theology in historical theology; and makes the vintage faith relevant at jeremybouma.com.

9780310529446The adolescent years are often difficult ones for parents, teachers, and youth leaders to navigate. “Knowing how to meet the therapeutic needs of adolescent clients and help families navigate this unique season of life can be a challenge for helping professionals,” writes Andi J. Thacker in her chapter from Counseling Techniques: A Comprehensive Resource for Christian Counselors (John C. Thomas, general editor). You will find Thacker’s complete chapter on “Adolescent-Focused Strategies” below. Thacker’s essay offers counseling professionals “therapeutic strategies, interventions, and techniques that can be utilized when working with adolescents” (290).

Counseling Techniques covers a lot more than adolescent-focused strategies. It is a comprehensive reference for the broad spectrum of Christian counseling practitioners and students, presenting counseling techniques through three lenses:

  1. Theory-based counseling, including cognitive, emotional, behavioral, and spiritual strategies, and more;
  2. Constituent-based counseling, with a focus on children, teenagers, couples, and families;
  3. Issue-based counseling, including domestic abuse, self-injury, sexual abuse, shame, trauma and more.

Thacker’s chapter below exemplifies the clinical knowledge, theological sensitivity, and readability you will find in each chapter of Counseling Techniques. It will equip you to come alongside those navigating the “unique developmental stage that can be a prelude to a productive and healthy adulthood” (290). And if you’re an instructor, request an exam copy today and consider it for your counseling courses.

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[God] has made everything beautiful in its time.

Ecclesiastes 3:11

Nothing seems quite as daunting to parents, youth pastors, helping professionals, or teachers as the adolescent years. Recently I was speaking to a group of parents at my church, and a parent made the comment that it feels as though rearing an adolescent is like parenting an alien life form. Although this statement was quite amusing to those gathered, it was evident that many could identify with the experience of this parent. In my private practice, I often have parents who seek help, saying, “She is a totally different person this week than she was last week. I just don’t know who my kid is anymore.” Even though as adults we have personally been through adolescence, for some reason this unique period of development remains a daunting enigma. Popular media outlets often report on the negative side effects of adolescence, highlighting less-than-desirable behaviors.

Counselors and helping professionals are not immune from this experience. Yet Scripture and science alike point to a Creator who intentionally set apart the period of adolescence to be a unique developmental stage that can be a prelude to a productive and healthy adulthood. Knowing how to meet the therapeutic needs of adolescent clients and help families navigate this unique season of life can be a challenge for helping professionals. The purpose of this chapter is to provide you with therapeutic strategies, interventions, and techniques that can be utilized when working with adolescents. In this chapter, you will find an overview of adolescent development and a theological integration of the use of activity therapy, as well as recommendations for utilizing activity therapy with adolescent clients. Brief case vignettes will be used to illustrate different aspects of activity therapy with adolescents.

Theology and Psychology of Adolescence

God, in his creativity, set apart certain periods of time in the lifespan that are characterized by specific developmental processes. At birth an individual is completely dependent on caregivers to sustain his life. But eighteen months later that same individual will be walking, talking, and able to feed himself. During late childhood and adolescence, an individual will undergo significant physical, cognitive, and socioemotional changes that qualitatively change the way he views life, makes decisions, and engages in relationships.

From a theological perspective, some of the characteristic features of the adolescent stage are a reflection of how humans are image bearers of God. The writer of Genesis 1:26–27 references human creation, stating that “God created mankind in his own image, in the image of God he created them.” Scholars have debated this concept, some saying that only the material aspects of man reflect God’s image and others contending that only the immaterial aspects reflect God’s image. For the purposes of this work, this concept will be viewed as being twofold, that is, that the total being of an individual is created in God’s image (Ryrie, 1999). Man’s physical body, as well as man’s nonphysical attributes, such as his intelligence and ability to make decisions, reflect God’s image (Ryrie, 1999). Balswick, King, and Reimer (2005) propose that across the developmental lifespan, being image bearers of God is lived out in what they term “the reciprocating self,” meaning that “the self that in all its uniqueness and fullness of being engages fully in relationship with another in all its particularity. . . . It is the self that enters into mutual relationships with another, where distinction and unity are experienced simultaneously” (pp. 48–49). As each member of the Trinity is in constant and perfect communion with one another, there is also distinctiveness between each member of the Godhead (Ryrie, 1999).

During adolescence, central tasks of development include identity development and differentiation from parents. Even though differentiation is a developmental task of adolescence, differentiation does not mean isolation or complete independence but rather navigating the changing relational landscape with parents and growing closer in peer relationships (Balswick et al., 2005). Adolescents are learning how to be in community with their parents and peers yet be distinct and differentiated, growing in a greater sense of self-concept.

Further, during adolescence, individuals experience a growing ability and responsibility to make decisions for themselves and be self-directing. The idea that humans reflect God’s image by having agency or the ability to make decisions is reflected greatly in adolescence when teenagers are presented with opportunities to make choices. From childhood to adolescence and onward into emerging adulthood, an individual’s opportunity to make decisions grows and expands to include more facets of one’s life. For example, a toddler has few opportunities to make decisions for herself, but as she grows into childhood, those opportunities to exercise agency grow and continue to grow through adolescence, culminating in emerging adulthood when she quite possibly could be making most decisions for herself. Adolescence is a time when her agency can flourish as she explores her identity. This specific aspect of development exhibits how individuals as image bearers reflect the characteristic of God also having agency (Evans, 1990).

Understanding the Lord’s unique design during each developmental stage informs a counselor about developmentally appropriate practices. In this section, I will explore the unique qualities that characterize the stage of adolescent development.

Adolescent Development

Adolescence has traditionally been viewed as a period of human development characterized by “storm and stress” (Santrock, 2015). However, more recently researchers have highlighted the creative ingenuity of adolescents as an opportunity for great growth and exploration (Siegel, 2013).

Determining the age at which adolescence begins and ends has become increasingly ambiguous in light of new concepts of emerging adulthood and increased scientific knowledge of brain development (Broderick & Blewitt, 2010; Siegel, 2013). Gil (1996) reports that adolescence has generally been defined as a time between ages ten and twenty-one; however, he limits the period to age eighteen because a person is considered a legal adult at that time. For the purposes of our discussion, adolescence will be defined as ages thirteen to eighteen. Some of the strategies, interventions, and techniques discussed in this chapter are applicable for use with preadolescent clients, ages ten to twelve, as well as emerging adult clients, ages nineteen to twenty-five.

Erik Erikson (1950, 1963) described the major developmental task of adolescence as identity versus identity confusion. During this time, adolescents are exploring different roles, values, attitudes, and preferences in an attempt to define their identities and seek greater independence from their families in anticipation of autonomy in adulthood. However, to focus on independence from family would be too narrow a view of adolescent growth and development. Balswick, King, and Reimer (2005) describe the proclivity of adolescents to prefer time with friends over time with family as a normative aspect of adolescent development. Although independence from family is a natural outgrowth of adolescence, because of the inextricable human need for connection, the need for close interpersonal bonds with peers is absolutely crucial to healthy adolescent development. Because of these aspects of adolescent development, treatment of adolescents should include an awareness of identity formation, increasing autonomy and independence, and a growing sense of peer group connectedness.

Siegel (2013) utilizes the acronym ESSENCE to describe the key features of adolescence. ESSENCE stands for “emotional spark, social engagement, novelty seeking, and creative expression” (Siegel, 2013, p. 12). During this period of development, the brain is undergoing a renovation in which many changes are occurring. These changes will essentially lead to more cognitive control, greater emotional regulation, increased self-understanding, and greater social functioning (Siegel, 2013). These specific changes are related to the dramatic transformations that occur in the prefrontal cortex of the adolescent brain.

In addition to this, neurons (brain cells) will make more connections in the brain, but the brain will also begin the pruning process in which the number of basic neurons is reduced to create more efficient functioning. Additionally, the process of myelination will occur to increase the coordination and efficiency of neuronal connections (Miguel-Hidalgo, 2013; Siegel, 2013). Adolescents are also more likely to engage in risk-taking behavior because of their bent toward novelty seeking identified by Siegel (2013). Increased novelty seeking is due in part to changes within the brain that lead to neural activity utilizing dopamine, which creates a drive for reward coupled with a lower baseline secretion of dopamine in the brain (Siegel, 2013). Further, adolescents exhibit hyperrationality in which they are aware of the risks of behaviors yet place more emphasis on the possible positive outcomes of such risky behavior (Siegel, 2013), lacking the greater self-awareness and self-regulation abilities that future brain development will provide. Because of this, adolescents are more prone to impulsive behavior, novelty seeking, and possibly addictive behaviors.

Characteristic of this life stage is the tendency for adolescents to push away from their parents in preparation for launching, coupled with an increasingly closer connection to peers. Therefore, peer relationships and seeking ways in which to demonstrate autonomy occur frequently in adolescence (Clark & Rabey, 2009). The push and pull of autonomy-seeking behavior can sometimes create distress between the adolescent and parent, as well as angst within the parent-child relationship. Helping parents and adolescent clients navigate this normal yet stressful experience is crucial in therapy.

Also inherent to this life stage are the physical changes ushered in by puberty. During this time, an adolescent’s brain will begin to be stimulated by the hypo- thalamus to produce sex hormones (Broderick & Blewitt, 2010; Santrock, 2015). The production and release of these will trigger a series of changes in the body that will, in the end, result in multiple bodily changes and the ability for an adolescent to be sexually reproductive. Inherent to the process of puberty is also the emergence of sexual attraction and sexual identity. A discussion on this specific area is beyond the scope of this work, but Yarhouse and Hill (2013) provide a developmentally thorough and theologically sound explanation of this aspect of adolescent development.

This discussion of adolescent development, while not exhaustive, demonstrates the “remodeling” that occurs in the life of an adolescent (Siegel, 2013). For a more robust explanation of adolescent development, please refer to Recommended Reading. Understanding these basic changes is crucial to the therapeutic process in that therapists play the role of educator for both adolescent clients and their parents. Providing useful information on normal development eases parental fears and helps manage parental expectations of their adolescent child. Further, reminding parents that the characteristics inherent to this developmental stage are a God-created reality confirms the belief that we were created by an infinite being who created with intentionality and purpose. This information is also helpful to the adolescent in that it helps the client navigate the sometimes rocky waters of “remodeling” that will occur (Siegel, 2013).

All of these changes indicate that adolescence is a time of immense transition. For some, adolescence is a time of excitement and eager anticipation of the future. But for others, it is characterized by confusion, relational discord, and possible negative consequences that accompany risk-taking behaviors. Therapeutic services offer a great opportunity for adolescents and their parents to navigate these issues well.

Theology and Creativity

Every aspect of life testifies to a theology of creativity. From nature to humanity, God’s creativity and design are on display for all to witness (see, e.g., Gen. 1; Rom. 1). As humans, we are set apart and unique from all other creation because of the imago Dei, meaning we bear God’s image (Ryrie, 1999). Humans share in the likeness of the Father by exhibiting a desire and ability to create (Bauer, 2013). Furthermore, we have the opportunity to participate in God’s creativity, as well as demonstrate personal agency as we share in the process of artistic expression (Hart, 2000). God made us as creative agents, meaning that we are innovative, imaginative, inventive, artistic, and resourceful. This same creativity and sense of agency, knit into the very being of humanity, is present within the therapeutic relationship and can act as a catalyst in the therapeutic process.

As mentioned previously, Siegel (2013) has highlighted the creative nature of adolescence. Some of the most culturally defining and imaginative ideas were brought forth in the minds of adolescents. Teenage inventors have developed methods to transport refrigerated vaccines without electricity or ice, provide clean water sources for underprivileged regions, and screen for communicable diseases (Wheeler, 2016). These examples of adolescent ingenuity and creativity are only a small example of the powerful ideas that have sprung forth from developing minds. Therefore, the use of creativity within adolescent counseling creates an environment in which adolescent clients can comfortably express themselves.

Furthermore, some research has indicated that expressive therapies allow a client to access different aspects of their personal experience that might not be readily accessible with exclusively talk therapy (Badenoch, 2008; Kestly, 2014). For these reasons, activity therapy offers a therapeutic context in which adolescent clients can thrive therapeutically and developmentally.

Case Studies

Case One

Casey is a fifteen-year-old female who presented for therapeutic services due to depressed mood and withdrawn behavior. Casey reportedly has not exhibited previous behavioral or emotional concerns and lives in a stable home environment. Casey has recently begun therapeutic services with me. I had already conducted an initial intake session with Casey’s parents. After explaining the therapeutic process and limits of confidentiality, I obtained Casey’s informed assent to proceed with therapeutic services.

Case Two

Jake is a thirteen-year-old boy who presented for therapy due to aggressive behaviors at school. Jake’s mother reported that he is very bright yet has been struggling socially with peers, as evidenced by disagreements in the classroom and withdrawn behavior from friends. Jake’s mother reported that she is recently divorced from Jake’s father and has full custody of Jake. Jake’s father is reportedly inconsistent in his involvement in Jake’s life. Jake is an only child.

Case Three

Lauren is a sixteen-year-old female client who presented for counseling due to issues related to being adopted. She came to counseling approximately six months ago and completed fifteen sessions with me prior to beginning group activity therapy. Heather is a seventeen-year-old female client who started counseling approximately five months ago, shortly after her parents divorced. Heather completed twelve individual sessions with me prior to starting group activity therapy. I suggested group activity therapy for these clients because of their similar developmental stage and the presenting issues related to family concerns. Further, I continued to work with both clients individually in addition to group activity therapy. Additional information on selecting group participants can be found in Bratton and Ferebee (1998).

Strategies, Interventions, and Techniques for Counseling Adolescents

Counseling methods and techniques guide you in your therapeutic practice. Various strategies, interventions, and techniques include cultivating a relationship with the adolescent, parental involvement, and creating a sense of autonomy or ownership for the emerging adult. The following section outlines specific guidelines and principles for working with adolescent clients and their parents. Following these guidelines, I revisit the case vignettes and outline examples of how to implement these practical strategies and interventions with the clients described in the previous section.

Beginning the Relationship

The beginning of any therapeutic relationship should be characterized by relationship building with the client. Scripture highlights how God created people for relationship and that through relationship one finds healing (Pyne, 2003; Thompson, 2010). The story of the Bible highlights how God created humanity within the context of both vertical and horizontal relationships in that we were created to be in relationship with God and our fellow humans (Gen. 1:26–27). However, the entrance of sin into the world marred these vital relationships, resulting in relational rupture (Thompson, 2010). The ultimate form of repair of this rupture came in the form of substitutionary atonement when Christ willingly died on the cross in our place (Ryrie, 1999). From this, we see a foundational example of the cycle of hurt and healing in our world. Sin causes relational rupture, yet relationship brings repair and healing. The therapeutic relationship is a context in which this pattern plays out regularly. To achieve this type of relational repair, building a strong therapeutic alliance with both the adolescent client and the client’s parent(s) is crucial.

Building a strong therapeutic alliance involves several techniques. You demonstrate empathy, genuineness, and unconditional positive regard, creating an environment in which the client can feel safe and understood (Fall, Holden, & Marquis, 2010). The concept of unconditional positive regard is akin to the theological concept of grace. Lightner (1991) references grace as God’s kindness or favor to those who are undeserving. Whereas a counseling relationship is not between an almighty perfect being and an imperfect creature, showing grace or unconditional positive regard to a client demonstrates Christlike love and builds a sense of safety and trust in the therapeutic relationship. An atmosphere of safety allows the client to freely explore life issues and circumstances while knowing you are fully accepting of his personhood.

Other techniques involved in relationship building include reflecting feelings and reflecting content. The importance of the therapeutic relationship cannot be overstated in adolescent counseling because adolescent clients do not typically present for counseling on their own volition. Generally, parents of adolescent clients have initiated therapeutic services without gaining the support or consent of the adolescent. Thus, building strong therapeutic relationships can help adolescent clients gain a willingness to participate in therapy. Furthermore, approaching the therapeutic relationship with a spirit of patience is necessary. Because adolescents, generally speaking, do not initiate therapy like adult clients, the progress and pacing of the relationship may be much slower. This can feel discouraging; however, it is developmentally normal because of the therapeutic circumstances.

Relationship building does not cease once a therapeutic alliance is established. Rather, these same skills and techniques continue throughout the entirety of therapeutic relationships and serve to provide clients with an experience of “feeling felt” (Thompson, 2010). “Feeling felt” is the experience in which clients perceive that you truly understand their experience and “get them.” This experience not only builds trust in you and the therapeutic process, but it also creates healing neurologically for clients (Badenoch, 2008; Thompson, 2010).

Parental Involvement

An integral aspect of any counseling with minors is involvement of parents or main caregivers. For the purpose of this discussion, I will use the term parent to identify those individuals who are legally responsible for the care of a minor client.

From a legal and ethical perspective, in many states clinicians must obtain written consent to provide treatment to a minor client (Sanders, 2013). Based on this requirement, clinicians must have contact with the parent(s). Additionally, it is important that the parent(s) feel connected to the clinician as well as to the therapeutic process. Without the support and participation of the parent(s), it is unlikely that therapeutic services will be successful (Kottman, 2003; Ray, 2011). You can foster a sense of connectedness with parents by maintaining appropriate and timely parent consultations.

Meet first with the parents. The initial therapeutic appointment should be reserved for meeting with the parent(s) solely without the adolescent client present. The purpose behind excluding the minor client in the initial parent consultation is to allow the parent(s) the opportunity to speak candidly about the presenting problem (Ray, 2011). Further, it allows the therapist to gain an understanding of the parents’ expectations for therapy. Often parents enter therapy with expectations that might be beyond the ability of the therapist or the scope of the therapeutic experience. Having the opportunity to level set for the parents builds appropriate expectations and helps avoid frustration regarding unmet expectations further into therapy. Obtaining a detailed developmental history of the adolescent client during the initial parent consultation is imperative. This will guide your conceptualization and treatment planning of the client. Additionally, it will allow you to have a better sense of the presenting problem, any developmental delays, and the nature of the parent-child relationship.

Adolescent sessions and parental consultations. I recommend conducting individual therapeutic sessions with the adolescent client approximately three to four times following the initial parent consultation. After the third or fourth individual session with the adolescent, you can conduct a parent consult to inform the parent(s) of treatment updates, client progress or regression, or possible parenting skills to implement. Follow-up parent consultations can be conducted with or without the adolescent present. I recommend that you seek to include the adolescent client in parent consultations so as to contribute to a sense of trust within the therapeutic relationship. This sense of trust could be violated if an adolescent client perceives that you are sharing with the parent(s) what she has said in confidence. Although the parent has the legal right to the information shared in the counseling session, it is not realistic to expect the adolescent client to share candidly if the counselor shares every detail of sessions with the parents. Parents often will be in favor of a degree of privacy between the counselor and adolescent client to foster trust (Sanders, 2013). At times, this guideline might be unavoidable due to the circumstances of the situation.

The importance and impact of contact with parent(s) of minor clients goes far beyond that of legal requirements and extends to include the benefit of the adolescent, parent(s), and other family members within the home. For this reason, parent(s) should be regarded as active agents in their adolescent’s treatment. Additionally, due to the relational nature of the parent-child dyad, adolescents often present for therapeutic services with relational challenges within the parent-child relationship. For this reason, utilize this relationship to bring healing and restoration within the parent-child dyad.

Additional Considerations with Parents

Handle parent feelings with care. A unique aspect of working with adolescents is that a clinician must also be prepared to work with the client’s caregivers. In my clinical experience, and in my personal life as a mom, I have found that the role of parent is one of the most sanctifying and challenging God-ordained experiences that an individual will encounter. Parenting provides a consistent reminder of one’s human finiteness and frailty. Quite often the parents who have entered my practice present with a myriad of emotions about the situation. While feeling love and concern for their children, parents might also feel anger, despair, inadequacy, excited anticipation, fear, and so on. It is of utmost importance that you handle parents’ feelings with care and concern, being mindful of the challenging nature of parenthood.

The strategies outlined below can be helpful tools to impart to parents. However, listening to any objections or concerns a parent might voice regarding the effectiveness or applicability of the presented strategies is imperative. Whenever making recommendations to parents, I always post these suggestions as optional tools that might be beneficial in their parenting toolbox. I want to support and facilitate the parents’ autonomy to choose what strategies and tools fit best for their family relationships.

Choice giving. One of the crucial tasks during adolescence is a pushing away from parents to establish a sense of increasing autonomy for launching (Broderick & Blewitt, 2010; Siegel, 2013). However, adolescents still have a need to remain connected to their parents (Clark & Rabey, 2009). This natural movement away from caregivers while still needing to remain connected can create a certain degree of anxiety for parents. To help with this transition, encourage parents to provide the adolescent with age-appropriate responsibility to increase good decision making and encourage an increasing level of independence. One option for facilitating autonomy and independence is teaching parents to utilize choice giving. Choice giving is a strategy that can be utilized with young children as well as older adolescents. Choice giving has a twofold function in that it provides the opportunity to learn how to make decisions and can be used for disciplinary purposes (Landreth & Bratton, 2006). Parents should provide their adolescent children with age-appropriate opportunities to make decisions in order to encourage independence. An example of this might be the adolescent client deciding what elective classes to take in school or what extracurricular activities to participate in. The end goal is that the adolescent will move toward increasing autonomy so as to be able to make wise decisions when he launches from the home.

Just as they would do with younger children, parents of preadolescents and adolescents should utilize choice giving when disciplining them. Choice giving for disciplinary purposes allows adolescents the opportunity to build an internal locus of control in which they practice making decisions and bringing themselves under control (Landreth, 2012; Ray, 2011). Using choice-giving language for disciplinary purposes, such as “If you choose to be late for your curfew, you choose not to use the car tomorrow night” is encouraged. The parent allows the adolescent the opportunity to make this decision knowing that her decision has consequences either way. This practice has the inherent goal that the adolescent will begin to role play consequences of behavioral choices and further understand the relationship between cause and effect and personal responsibility.

Contract setting. Another area of concern for parents of adolescents is boundary setting. At times, an adolescent and his parent will present for counseling with specific areas of concern regarding inappropriate behavior. Many times parents present feeling helpless and uncertain of how to set and maintain appropriate boundaries for their adolescents. Using contract setting helps the parent and adolescent client have a clear understanding of the expectations and boundaries within the family atmosphere (Sells, 2004). When using contract setting, parents identify the top two to three concerning behaviors of the adolescent to address. In conjunction with the adolescent and parents, you help facilitate a discussion in which the parents and adolescent decide on appropriate consequences for these behavioral concerns. The behavioral concerns or boundary violations, along with the consequences, are recorded and posted in a public area in the home. Having a predetermined plan allows the parent to feel empowered, and it allows the adolescent ownership in the discipline process. Participating in contracting with parents allows adolescents the opportunity to role play consequences prior to engaging in behaviors that would violate family rules.

Balancing faith discrepancies. My experience has been that many parents seek counseling services with a Christian counselor due to religious beliefs. Whereas parents might be Christian, the adolescent client might not always ascribe to the parents’ religious beliefs. When integrating psychology and theology, I seek to honor both the wishes of the parents and the wishes of the adolescent. To do this, I am respectful of the parents’ preferences that I will maintain a certain Christian ethic in my practice, while also being mindful of the adolescent client’s desire not to explore the subject of spirituality. I follow the client’s lead and will explore spirituality and religion to the extent that the adolescent client is willing. However, my biblical worldview guides my actions as a clinician and informs my viewpoint of human creation and the world.

Activity Therapy with Adolescents

Activity therapy is to adolescents as play therapy is to children. Where play therapy serves to reach the child client’s unique developmental level, activity therapy does the same for adolescents. In this way, activity therapy serves to bring forth the inner world of an adolescent that may otherwise be kept guarded from others. Activity therapy builds a bridge between a client’s inner world and his concrete experience, allowing for greater mastery over life circumstances that might be experienced as unmanageable (Rubin, 2005). Furthermore, because activity therapy utilizes multiple senses, some feelings and thoughts that are out of the client’s awareness or that are difficult to express can surface (Bratton & Ferebee, 1999).

Due to the nature of activity therapy, metaphors and symbols in creative expression provide a nonthreatening manner for the client to express self (Bratton & Ferebee, 1999; Rubin, 2005). The experience of counseling can be anxiety provoking for any client, especially an adolescent who has not willingly chosen to attend counseling. Sitting across from another can sometimes feel threatening and overwhelming for the client. Having the opportunity to move one’s body or be creative in session can lessen the pressure felt by the adolescent. Further, Malchiodi (2007) has indicated that the use of expressive therapies allows the client to progress toward action, express feelings and thoughts, and implement new ways of acting.

Activity therapy can be utilized in a directive or a nondirective manner. A directive activity therapy approach is where you select and initiate activities with the client. A nondirective therapeutic approach occurs when you allow the client to lead and select specific activities. Frequently, a blend of both directive and nondirective therapeutic approaches is used. Bratton, Taylor, and Akay (2014) recommend that the counselor take a flexible approach in terms of directive versus nondirective activities. Specifically, you monitor the client’s unique needs and developmental level, and you are guided by a personal theoretical orientation (Bratton et al., 2014).

In the case of nondirective activity therapy, having multiple activities on display and available for the client to select from is helpful. Examples of this might include expressive arts and crafting supplies, such as paints, modeling clay, colored pencils, markers, pens, developmentally appropriate color pages, knitting materials, and so forth. With more directive activity therapy, you will present a specific activity for the client.

One example of activity therapy is utilizing expressive therapies or expressive arts. Expressive therapies allow for the experience of the client to be expressed as a symbolic representation of his inner world (Rubin, 2005). When expressive activities are used in this manner, the activity serves a similar function to the role of play in counseling with children. As play is the natural form of communication for children (Landreth, 2012), the activity becomes, for the adolescent, the form of communication, and the created product becomes the client’s words. Utilizing activities in adolescent counseling can serve as a means to an end or an end in itself. Activity therapy can serve as a way to lessen the client’s anxiety, for all the energy is not focused on talking, and can also allow the client and the counselor to gain new insights into the inner workings of the client. Themes regarding how the adolescent client feels, experiences life, and behaves can emerge through expressive activities. Oaklander (1988) explains how activity and creativity serve as a means for projection and how projection originates within the person and illuminates what the client cares about and the client’s sense of self. Many times the progression of the healing process is evidenced in the created activities of the client when these types of expressive activities are utilized repeatedly in the therapeutic relationship. For this reason, maintaining photographic records of the client’s created work is valuable.

Structuring and implementation. As you maintain the role of supportive companion on the client’s journey of self-exploration, you should follow several guidelines when utilizing creative expression in therapy. To begin, structuring of the session is vital to allow time for instructions, creative expression, and processing. Allowing time during the session for processing to occur is essential, although a client may not always be able to assign words to the metaphor and meaning of her creation. Allowing time to process one’s creation provides the opportunity for the client to debrief the activity and reflect on the experience (Crane & Baggerly, 2014). A general guideline for session structuring is to allot five minutes for instructions about the activity, twenty to twenty-five minutes for the activity, and ten to fifteen minutes for processing. Giving a client a five-minute warning prior to the end of the allotted activity time is helpful so she can wrap up her creative process. If expressive activities are being utilized in a group therapy setting, the time allotted for sharing and processing should be increased to account for each group member. I recommend allotting more time for a therapeutic group than for an individual therapy session.

Processing. When beginning to process the client’s activity, allowing the client to assign meaning to his creation and avoiding placing personal projections on the created work is vital (Lombardi, 2014). Suspend your judgment and avoid making interpretations while translating what you hear and see from the client (Oaklander, 1988). The client is the expert on his creation, and you only need to seek to gain a deeper understanding from the client’s unique perspective. Additionally, honor the vulnerable expression of the client evidenced through the activity and, therefore, do not touch the client’s creation or give evaluative feedback about the product. When processing the client’s created process, ask open-ended questions about the client’s experience of creating, as well as how the client feels about the overall product. Examples of these questions might include “How did it feel to participate in this activity?” or “How do you feel when you look at what you created?” Because of the deep and reflective nature of expressive activities, using therapeutic pacing that is slow enough to allow for sufficient time for the client to reflect and process is crucial. You can also ask processing questions regarding aspects of the client’s created activity. These types of questions might include “What do you notice about this part of your creation?” or “What’s going on in this part of your work?” Additionally, noticing the client’s process while creating is helpful—specifically, any emotional responses exhibited while creating or the amount of time allocated to a specific aspect of the activity. If a certain aspect of the process appears particularly meaningful, note this to the client and ask if he can share about what was being experienced during the creation process.

Through the process of creating, a client’s inner world will be projected through the activity (Oaklander, 1988). Many times this inner state comes forth in the form of a metaphor. When beginning to process a client’s experience and creation, initially remaining in the metaphor is key (Oaklander, 1988). If the client is developmentally at a place in which abstract processing has begun and he demonstrates emotional readiness, you can move out of the metaphor into the practical application of this experience to the client. Remember that moving out of the metaphor brings the vulnerable subject matter into the present realm, and that can increase anxiety for the client (Oaklander, 1988). Be sure to evaluate the readiness of the client prior to moving out of the metaphor (Bratton et al., 2014).

Prior to the end of the session, allow a few minutes to check in with the client. This time allows him to continue feeling that you understand, as well as allowing him time to move out of the affective realm into a more cognitive realm. Moving into the cognitive realm allows him the opportunity to move out of the therapeutic space and proceed into the next activity for the day without feeling completely exposed emotionally.

Creative materials. When utilizing activity therapy, specifically creative activities, following guidelines regarding what type of artistic medium should be used at certain junctures in the therapeutic process is essential. Landgarten (1987) suggested that counselors start clients with the most controllable medium and then progress to the least manageable medium. Because less controllable means of artistic expression can elicit strong and surprising emotions, beginning with a medium that creates less threatening feelings is helpful (Bratton et al., 2014; Landgarten, 1987). Bratton and associates (2014) further suggest that counselors account for the amount of structure presented in an activity and how much the activity relates to the client’s issues, the directness of their questions when processing, and the combining of different media into one activity. A visual representation of Landgarten’s (1987) guideline is provided in table 14.1.

table14.1

Consider several factors when deciding how to progress therapeutically with different expressive mediums. Also, consider the artistic medium that is most effective for the client, considering that clients show preferences for certain types of creative supplies. Some clients might prefer materials such as modeling clay more than drawing supplies. Allowing the client to lead in this area is important, and utilizing a different artistic medium each week is not necessary (Bratton et al., 2014). However, following the guidelines of progressing through the use of materials from more manageable to less manageable, as noted below, is important.

Therapeutic space. When utilizing activity therapy, the therapeutic space has to be arranged in a manner conducive to this approach. Conduciveness includes but is not limited to therapeutic materials and furniture arrangements. Displaying expressive materials and activities in the office allows for spontaneous creative expression. Be sure to utilize expressive materials that will not interfere with the integrity of the space. Specifically, I advise that you not include materials that might cause damage to the therapeutic space. Including such materials would create an environment in which you are not able to be fully accepting of the client and permissive with the creative process. If space and finances allow, additional resources, such as a stage with costume materials, a woodworking area, sewing supplies, or other physically expressive activities can be useful with adolescents. Additional information regarding the therapeutic space can be found in Bratton and Ferebee (1999).

Because of the nature of activity therapy, you should utilize a great deal of personal creativity in developing and implementing expressive activities. Many scholarly resources discuss the use of expressive activities, such as poetry, drama, photography, music, and movement, in counseling. A list of resources regarding specific expressive activities, as well as methods for processing these activities, is available in Recommended Reading at the end of this chapter.

The counselor. The person of the counselor is a crucial aspect of the therapeutic process. As a carpenter would seek to maintain the integrity and usefulness of the tools he uses, so you must seek to do the same. The counselor is one of the greatest “tools” utilized in the therapeutic process (Thomas & Sosin, 2011). Diligently working to know oneself and understand how the therapeutic process influences you is essential.

Utilizing expressive therapies adds a new element to the therapeutic experience for both client and counselor. I urge my supervisees to gain personal experience utilizing each artistic medium prior to incorporating the medium into therapeutic practice. The rationale for this practice is to further increase self-understanding but also to help them empathize greater with the client’s experience. Rubin (2011) explains that in-depth knowledge cannot be attained from simply reading about the subject of expressive therapies; rather, the counselor must gain knowledge through experience by interacting with as wide an array of artistic media as possible.

My own training in the area of expressive therapies began in my doctoral program, where I had the opportunity to participate weekly in expressive activities. This process deepened my appreciation for expressive therapies, increased my self-understanding as a person and a counselor, and provided me with a rich understanding of the therapeutic process as it relates to expressive therapies. Whereas experiencing expressive therapies in a university setting is not an option for some counselors, the act of incorporating the personal practice of expressive therapies is possible.

You can accomplish this goal in several ways. One way is to seek therapeutic services from a counselor who is experienced in the area of expressive therapies. Another way to accomplish this goal is to find a supervisor who is trained in expressive therapies and will utilize this modality throughout the supervision experience. You can also participate in a small consultation group in which each week the group utilizes and processes a specific expressive medium. Finally, seek more formal training by attending seminars or university classes that specifically teach expressive modalities. Whereas activity therapy is an effective avenue for facilitating therapeutic healing, other therapeutic techniques and modalities are also very helpful when working with adolescents. Many therapeutic modalities allow for integration of different therapeutic techniques. Therapeutic activities can be integrated into a wide range of theoretical orientations to bolster the positive impact of the therapy for the client. Additional resources for evidence-based treatment of adolescents is listed at the end of the chapter.

Case One

My office is equipped with a table for expressive activities, as well as an area for sand tray therapy. I introduced the concept of activity therapy to Casey by explaining that sometimes certain activities like expressive arts can be helpful to the therapeutic process. I asked if Casey would be willing to try an expressive activity. Casey somewhat reluctantly agreed, and I provided Casey with instructions. I shared with Casey that she would have about twenty-five minutes to work on her drawing, and then she would have time to process her drawing. I asked her to draw a picture of her life. After twenty minutes, I gave her a reminder that she had five minutes to complete her drawing.

After twenty-five minutes, I began the processing phase of the session. To begin, I asked Casey to observe what she created and notice any feelings she had as she looked at her drawing. I was careful to pace her questions and reflections in a slow manner so as not to overwhelm her and to provide ample time for client reflection. Casey reported feeling sad when she looked at her drawing. I asked her to share about what she drew. She shared that she drew her life, which she described as “lonely.” Casey explained that she drew herself alone in a world where everyone passes by and does not notice her. I was intentional to reflect the feelings and emotions stated by Casey. Throughout the processing time, I was intentional to allow Casey to assign meaning to her drawing by asking her to describe aspects of the drawing. I did not label parts of the drawing as “the lonely part” or the “sky” or “sun” until Casey had done so. Casey and I spent the remainder of the session processing parts of her drawing. Because the therapeutic relationship had just begun, I chose not to explore in depth the loneliness she reported feeling. Specifically, I spent the majority of her time reflecting her feelings and not asking what was causing her to feel lonely. I made this decision so as to continue working on establishing the therapeutic alliance prior to asking more directive reflection questions. To wrap up the session, I asked Casey how she was feeling after completing the activity. I thanked Casey for her honesty and vulnerability.

Because the therapeutic relationship was not yet established and I did not yet know how Casey would handle the expressive activity, I was intentional not to move too quickly with her. During the early stages of counseling, focusing on building a strong therapeutic relationship is vital. Additionally, many activities utilized can help improve conceptualization of the client. Because Casey voiced feeling lonely, it was crucial that I sought to “see” and “be with” Casey in a manner in which she felt valued and understood.

Parental involvement is a critical aspect of therapy with minor clients. Because the relationship with Casey was new, I progressed by conducting two more individual sessions with her then conducting a parent consultation. Because of her age, I allowed Casey to choose whether she would like to be present for the parent consult. I wanted to facilitate an atmosphere of trust and safety, communicating to Casey that I would not keep secrets from her by disclosing aspects of her counseling to her parents without her knowledge. During the parent consultation, I would provide a time for Casey’s parents to voice concerns, comment on progress observed, or ask questions. I would also facilitate an opportunity for Casey to share with her parents anything she would like to share. The purpose of this time with the parents and the adolescent client is to model healthy communication skills and facilitate parent involvement in the therapy process. The subject of loneliness came to light from Casey’s first session. If this topic persisted in subsequent sessions, it might be appropriate to address this theme with Casey and her parents to discuss possible social support networks that might be beneficial for Casey.

Case Two

At this point, I had completed four sessions with Jake. During the first four sessions with him, I noticed his unique interest in building and creating. Jake was immediately drawn to the building materials like LEGOs and large cardboard blocks. During the first few sessions, Jake proceeded to create an object and then destroy the object. I was consistent to reflect Jake’s feelings while constructing and deconstructing. During the fifth session, I asked Jake to create an object that represented anger. During the creation process, I noticed that Jake became angry when he could not manipulate the materials in the manner in which he desired. When it was time to process, I asked Jake to share about what he created. Jake described the object he created while I continued to attend to him and remain within the metaphor. I suspected that part of Jake’s anger was due to his parents’ divorce and his father not being as involved in his life. However, because Jake was in the developmental stage and because he had not voiced this being the cause of his anger, I chose to remain within the metaphor during the entire processing time. I allowed Jake to assign meaning to what he created and sought to reflect back the information that he was providing. At the end of the session, Jake spontaneously destroyed the object he had created.

There are differing opinions regarding the therapeutic use of certain building materials like LEGOs. I have found that LEGOs allow for creativity and construction within the therapeutic setting. Be sure to utilize building blocks and LEGOs that allow for creativity and that are not part of a set to build a specific object.

With this client, I sought to follow his natural inclination toward building materials. I did not seek to introduce other creative mediums because he continued to be drawn to the building materials. It is not necessary to introduce new creative mediums every session.

Through the first few sessions, I was able to observe the client’s anger and utilize creative expression to explore this feeling. Furthermore, I did not explore beyond the scope of the metaphor because of Jake’s developmental stage. Remaining within the metaphor allowed the experience and process to be manageable emotionally for him. Exploring beyond the metaphor would bring the reality of the situation to the forefront and would be too anxiety provoking at this point in therapy for Jake. I chose to continue to remain in the metaphor while processing activities with him and sought to reflect the experience of anger represented in his creative expression.

Because Jake’s father chose not to participate in the therapeutic process, all parent consults were conducted with Jake’s mother. Jake was given the option of attending parent consults; however, he chose to wait in the waiting room. To protect Jake’s privacy, I did not disclose specific behaviors or statements Jake made during session. I did share with Jake’s mother the theme of anger that Jake was working on in session. This provided an opportunity for his mother to share about areas where she had observed his anger manifest at home and in school. I suggested that Jake’s mother practice naming Jake’s emotions in the moment to help him feel understood. Because Jake had acted out aggressively in anger by breaking or throwing toys, I taught Jake’s mother limit setting and choice giving to facilitate self-responsibility and create appropriate boundaries for Jake’s behavior. I chose to follow up with Jake’s mother every three to four sessions to monitor therapeutic growth and provide parenting support.

Counseling with minor clients often means working with divorced parents and blended families. The counselor must be aware of legal caveats associated with each individual case. Specifically, consulting the legal custody agreement provides guidelines for how a professional can proceed therapeutically and which parent can and must provide written consent for treatment. Counselors should consult with legal experts where there is confusion regarding the legal caveats of a counseling situation.

Case Three

I had conducted five group activity sessions with Heather and Lauren. Because of the nature of the relationship between both of the clients and me, and because of the deep relationship between the clients themselves, the group experience was rich with deep processing and interpersonal connectedness.

One of the goals of a group activity is that group members will gain an increasing amount of self-direction and be free to utilize internal resources (Bratton et al., 2014), so I was flexible in allowing these clients to be self-directive in the creation process. Expressive activity media were displayed in the counseling room in an inviting manner in which both clients felt free to utilize different materials. During the sixth session, Lauren and Heather decided together to create collages around the theme of helplessness and loss of control since much of the therapeutic time to this point had been spent processing those things. To allow for ample time to create and process, I structured their group activity sessions in increments of one hour and fifteen minutes. After creating for approximately thirty-five minutes, the clients began to process their activities. Initially Heather shared about her collage, followed by Lauren; however, because of the depth of the therapeutic relationship, the dialogue that followed was a back-and-forth flow between the two clients. I continued to listen actively but allowed opportunity for both clients to lead the process. I made note of similarities between the clients’ experiences as well as how the theme of helplessness and loss of control impacted their current functioning. Because of the emotional and developmental readiness of both clients, I was able to move beyond the metaphor represented in the collage activity to explore more direct applications that emerged from their collages. To conclude the session, I asked both clients to reflect on their experience in the session and allowed time for both to share their experience with the group.

Conducting group activity therapy sessions is more of an advanced therapeutic skill due in part to the need to attend to more than one client. However, group activity therapy can be extremely beneficial to adolescent clients. Because of the social engagement aspect of adolescence, group activity therapy is uniquely suited to meet their developmental needs (Siegel, 2013).

One unique aspect of activity therapy is that the client may become more self-directive in the therapeutic process (Bratton et al., 2014). This will hopefully occur in a group therapeutic process as well. As illustrated above, once a group or client has established a stable therapeutic alliance, the client can become more of an active agent in the activity selection process. I allowed both clients to lead in the session and decide what activity to pursue. Throughout the time, I was consistent to attend to the emotional needs of each client and reflect the stated themes evident from the process. As the therapeutic relationship continues, the counselor must be mindful to maintain good attending skills and also be verbally reflective of the process that is occurring in the group dynamic. As with the case vignette, when clients show readiness developmentally and emotionally, the counselor can pursue processing on a deeper level that at times might go beyond the metaphor represented in the creative activity. As with every activity, the session should be brought to a close by checking in with clients about their experience and summarizing key points of the session.

Group activity therapy provides a unique opportunity for adolescent clients to connect with one another and gain peer support in a safe environment. Parental involvement in therapy is also very important when working with groups. Although the adolescent clients are participating in group therapy, the parent consults should be conducted individually to maintain appropriate confidentiality for clients. I chose to conduct parent consults with each set of parents every three to four group sessions. During the parent consults, I updated Heather’s parents and Lauren’s parents on their child’s individual progress.

In the case of my client Heather, because her parents had recently divorced, I provided the option to meet with her parents together or separately to respect their relational boundaries with one another. Her parents chose to meet at the same time with me to promote effective co-parenting. This allowed me the opportunity to brainstorm with Heather’s parents how they could promote consistency for her as she lived part-time with each parent.

While meeting with both sets of parents individually, I provided recommendations that group activity therapy continue because the intervention was beneficial to the therapeutic growth of both clients. I discussed with each client’s parents evidence that demonstrated how their child was benefiting from group activity therapy. Heather presented with more emotional regulation, and Lauren demonstrated an increased ability to connect relationally with Heather and other peers at school. Further, I was careful to monitor whether either client was ready to terminate individual therapy and continue solely with group activity therapy.

Additionally, I provided time for the parents to provide feedback on their child’s progress, voice concerns, and ask questions. It is not uncommon for parents to be curious about the other client in the group and ask questions about that client’s progress, goals, behavior, presenting problem, and so forth. This curiosity at times grows out of a natural concern of parents that their child might be getting close to another adolescent who might negatively influence their own adolescent. In these moments, reflecting on the parent’s concerns for her own child and reassuring her that groups are carefully selected with the well-being of all clients in mind is important. Further, one of the roles of the counselor is to model and discuss healthy relationship boundaries and monitor the group dynamic to prevent or address unhealthy relationships or behaviors. However, it is imperative that the counselor maintain confidentiality and not discuss the other client’s progress with the parents, even though some parents will persist in seeking information about other group members. Gently and respectfully enforcing boundaries on confidentiality and HIPPA at all times is essential.

Conclusion

God created humans in his likeness as image bearers to be creative agents. Because of this innate creativity, utilizing creative expression within the therapeutic context allows for a deep and rewarding therapeutic experience that can bring forth healing on many levels. Adolescent clients are uniquely primed to benefit from therapeutic services that incorporate creative expression and can benefit greatly from this type of therapeutic technique.

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Recommended Reading

Green, E. J., & Drewes, A. A. (2014). (Eds.). Integrating expressive arts and play therapy with children and adolescents. Hoboken, NJ: Wiley.

Kendall, P. C. (Ed.). (2011). Child and adolescent therapy: Cognitive-behavioral procedures (4th ed.). New York, NY: Guilford Press.

Landgarten, H. B. (2014). Family art psychotherapy: A clinical guide and casebook. New York, NY: Routledge.

Malchiodi, C. A. (2006). Expressive therapies. New York, NY: Guilford Press.

Oaklander, V. (1988). Windows to our children: A Gestalt therapy approach to children and adolescents. Highland, NY: Gestalt Journal Press.

Rubin, J. A. (2005). Child art therapy (Deluxe ed.). Hoboken, NJ: Wiley.

Rubin, J. A. (Ed.). (2016). Approaches to art therapy: Theory and technique. New York, NY: Routledge. Sweeney, D. S., Baggerly, J. N., & Ray, D. C. (2014). Group play therapy: A dynamic approach. New York, NY: Taylor & Francis.

 

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