Practical Psychotherapy With Adolescents
In Practical Psychotherapy With Adolescents, Dr. Alice K. Rubenstein demonstrates her approach to working with adolescent clients. Because of the complexity of their lives, adolescents often have difficulty describing their feelings and identifying the source of stressors. Dr. Rubenstein helps adolescent clients to identify their feelings and the factors contributing to the problems they are dealing with, and then helps brainstorm possible solutions. In this session, Dr. Rubenstein works with a 15-year-old boy with behavioral difficulties, family conflicts, and academic problems. She helps him find ways to reduce the tension with his father and address some of the problems he is having at school because of his recently diagnosed attention-deficit/hyperactivity disorder.
This video features a client portrayed by an actor on the basis of actual case material.
The multiple stressors facing adolescents today have made the task of surviving the transition from latency to adulthood extraordinarily difficult. Therefore, it is not surprising that many adolescents who enter therapy have multiple problems with the multiple systems with which they interact—home, school, peers, and community. Working with these adolescents requires the therapist to use a variety of therapeutic strategies, including client-centered, cognitive–behavioral, psychodynamic, and, most important, problem-solving and systems interventions. Dr. Rubenstein's therapeutic approach, which integrates these various models, can be described as "practical psychotherapy" or "doing what works."
By the time adolescents enter treatment, they are often angry, depressed, oppositional, or simply "burned out." Dr. Rubenstein wants to replace their feelings of helplessness with hopefulness and their perceived powerlessness with the possibility of change. She attempts to accomplish this by forming an alliance or partnership with the adolescents in which she is their advocate with the various systems in their lives. She helps them explore their behavioral choices and the consequences of these choices. Together, she and the client examine the systems with which they interact, work on developing specific and focused plans to reduce the stressors in these environments, and, simultaneously, examine how their behavioral choices in these systems may interfere with their goals.
Dr. Rubenstein sets no limits on what adolescents can talk about in session and few boundaries on who they will involve in their work. If adolescents have come to therapy because of behavioral difficulties, they are usually quick to explain that the problem is not their fault—the fault is their mother's, father's, teacher's, or the other kids.' For most adolescents, the fault lies elsewhere. And very often, this is at least partially true.
Often individuals in the systems in which adolescents are involved either do not understand their developmental needs or do not know how to meet their needs. Dr. Rubenstein encourages adolescents to invite to a therapy session anyone they feel it would be helpful to meet with together. This communicates to adolescents that her primary partnership is with them, not with the "authorities" with whom they initially expect her to be allied.
From the outset, Dr. Rubenstein wants to reduce the unnecessary stressors in the adolescents' environment quickly and effectively. When confronted with a systems problem, she will brainstorm with adolescents to identify the problem, the contributing factors, and the alternatives for resolving the problem. Together, they develop a "plan of action" to occur between sessions with the understanding that although she is their advocate, they must do the work. In this way, they can claim the success as their own.
This negotiation between patient and therapist is a way of modeling for adolescents a skill set that many of them lack: identifying the specific stressors that are causing them difficulty, becoming aware of the choices they have in their lives, deciding among them, negotiating with others to actualize these choices, and taking responsibility for the consequences of their choices.
When adolescents legitimately need the power of her position to intervene with one of their systems, however, Dr. Rubenstein does not hesitate to use it. For example, she will write a letter to school personnel to help remove a depressed adolescent with body image issues from gym class. However, she will insist that the adolescent work with her to draft the letter and that they contract for some kind of physical activity outside of school. She will not simply let the adolescent "off the hook." Where change in the adolescents' systems is not possible, she works with them to develop survival skills.
Dr. Rubenstein's alliance or partnership with the adolescent is achieved, at least in part, by modifying the therapeutic environment to decrease the adolescent's sense of powerlessness in working with an adult. Adolescents form quick impressions as to the trustworthiness of an adult. Often, her credibility in this regard is decided on before they are seated. She considers the physical environment of her office to be key to this first impression. She has no desk, as desks can be a symbol of authority; to many adolescents, they portray power and control. She has two L-shaped couches and an upholstered chair. She has no "assigned" seat. The chair is not "hers," and she offers it freely. Her shelves are not filled with books and journals, but with assorted knickknacks she has collected over the years. Her diplomas and certificates are tucked away in a file cabinet. Many adolescents struggle with school, and they do not need to see how learned she is.
Dr. Rubenstein's personal style also invites partnership. Her dress is casual and comfortable; she often wear pants and a sweater. Because many adolescents come to therapy from school or work, she offers them a snack. Food is nurturance. She is careful to avoid what they call "shrink talk." Most important, she does not corner them with silence—she talks. Frequently, she uses humor to make the situation more comfortable. she always keep in mind that these adolescents want and need concrete results. Insight can come later. As one adolescent advised, "Just don't ask me how I feel!"
To summarize, Dr. Rubenstein's overall goals in working with adolescents are to open their eyes to the possibilities of changes in their lives by fostering their belief in their ability to make changes in their environment and themselves, and to help clear the path for these changes when they cannot do it alone.
Dr. Rubenstein identifies her approach as "practical psychotherapy." What does this imply to you? To be more specific, what do you expect of her? Will Dr. Rubenstein be active or passive? Will the session be structured or unstructured? Directive or nondirective? Will it focus on the past or on the present? Will the session focus on behaviors, on thoughts, or on feelings? What do you expect to be the relative balance between attention to technique versus the interpersonal interaction?
Alice K. Rubenstein, EdD, received her doctorate from the University of Rochester. She is a founder and partner of the Monroe Psychotherapy and Consultation Center in Rochester, New York, which provides individual, family, and group psychotherapy for children, adolescents, and adults. The center also offers consultation to schools, community service agencies, and family court.
Before entering independent practice, Dr. Rubenstein was the supervising psychologist at the Convalescent Hospital for Children, a community mental health center for children and families.
Dr. Rubenstein is a distinguished practitioner of the National Academies of Practice as well as the 1996 recipient of the American Psychological Association (APA) Division 29 (Psychotherapy) Distinguished Psychologist Award. She received the Jack Krasner Award for Significant Contributions to Psychotherapy in 1988 and was president-elect of the APA Division 29 in 1996.
Dr. Rubenstein is an editorial consultant to Psychotherapy and was coguest editor of the Psychotherapy special issue, "Adolescent Treatment: New Frontiers and New Directions" (1995).
She serves as an adolescent health care consultant to the APA Public Interest Directorate and was a member of the APA Presidential Task Force on Adolescent Girls: Strengths and Stresses. She is chair of the Division 29 Task Force on Children and Adolescents and coauthor of Psychotherapy With Children and Adolescents: A Guide for Parents, published by APA Division 29.
- Bratter, T. E. (1976–1977, Winter/Spring). The psychotherapist as advocate: Extending the therapeutic alliance with adolescents. Journal of Contemporary Psychotherapy, 8( 2), 119–127.
- Bratter, T. E. (1990). From adversary to advocate: Collaboration between school personnel and the psychotherapist who works with adolescents. In E. R. Margenau (Ed.), The encyclopedia of private practice (pp. 977–991). New York: Gardner Press.
- Eccles, J., Midgley, C., Wigfield, A., Buchanan, C., Reuman, D., Flanagan, C., & MacIver, D. (1993). Development during adolescence: The impact of stage–environment fit on young adolescents' experiences in schools and in families. American Psychologist, 48, 90–101.
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- Rubenstein, A. (1992). Clinical issues in the treatment of adolescent girls. In B. Wainrib (Ed.), Gender issues across the life cycle (pp. 17–21). New York: Springer Publishing Company.
- Rubenstein, A., & Zager, K. (Eds.). (1995). Adolescent treatment: New frontiers and new dimensions [Special issue]. Psychotherapy, 32.
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