634 INITIATING THERAPY WITH ADOLESCENTS

She called only once, but on many subsequent occasions she said that knowing she could call gave her strength to handle situations she had felt incapable of resisting previously.

This type of supportive help has been offered to most of the adolescent girls in the series studied, and the patients have not taken unfair advantage of the therapist’s off hours. In all cases the patients have seemed to sense the support and encouragement a t times of crises. Other patients tested the therapist’s liking for them in other ways.

Pam, 14, was fearful of all interpersonal relationships. Although she appeared per- fectly healthy while hospitalized, she was unable to adjust to any situation which was not well structured. An attempt was made to return her to school. During the first week she called a number of times during the day to be reassured that she was doing the right thing and to have repeated details on where she was to catch her bus. On one oc- casion early in therapy, she asked the therapist to pick her up at school. This was done. After four months of therapy, the patient was discharged from the hospital to the home of her parents. Two weeks following discharge, she called at midnight to say she had started to run away from home, was cold, and did not know what to do or where to go. It was obvious that she was again pushing for the therapist to come for her. This time, with the therapeutic relationship well established, and after four telephone calls, Pam was able to walk back home on her own and face her parents. On the following day she called to say she had finally been able to do something-“Maybe I don’t have to goof all the time.”

Gradually, the patients are able to begin assuming responsibility for their own actions. Their acting out subsides rather rapidly, but there re- mains a need for activities and interests to use their energy. The therapist then utilizes the information gained from the earlier casual discussions with the patient of special interests and desires.

Ruth, a rather pretty, plump, bashful girl of 15, was referred by the court. She was enthusiastic about the beginning of high school in the fall and all of the opportunities she felt it would offer. She verbalized a strong desire to be accepted by the high school students, in the hope that she could then break away from the “park crowd,” which she felt had been detrimental to her reputation. Psychological testing proved Ruth to be in the superior range intellectually. In all of her contacts and relationships a t school there was a consistent tone of self-depreciation. She spoke of an interest in debating but was fearful of asking to join. She was encouraged to try this and was subsequently helped with her feelings of not being as smart as the rest of the group. Gradually, as she was con- sistently chosen to participate in all of the important debates, her self concept brightened.

At this point the patients usually have obtained some symptomatic relief. However, they may never get to the stage where retrospective analysis of the development of an attitude is achieved.

Of equal importance in the gradual improvement is the parental partici- pation in the total treatment program. Every effort is made to involve par- ents in therapy. Parents of adolescents seem much more difficult to involve in therapy than parents of younger children, and seem less ready to assume responsibility for the child’s symptoms. The teen-ager’s own declaration of independence helps the parents to avoid this responsibility. Also, we

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believe that the stereotyping that we discussed earlier adds to this problem. If all adolescents are disturbed, why should the parents get excited? Of all mental health problems those of the adolescent lend themselves best to moralistic interpretation. I t is so easy to see adolescents as deliberately choosing to be bad. Their size and mental agility are quite misleading. Be- cause of these factors only limited environmental manipulation may be possible in the home. Yet, symptomatic improvement a t school may be achieved where the girl feels capable and accepted.

In the case of Sue, whose mother was described earlier as an immature woman seek- ing her “lost youth,” therapy with the mother proved extremely beneficial. This mother began looking at herself, and rather quickly expressed her resentment at having missed something by her early marriage. By the end of the first six months of weekly interviews, she had modified the way she dressed, was less flippant, and found more satisfaction in seeing herself as a mother. Sue’s adjustment a t the present time has proven the most stable of the girls under consideration.

When the family structure is destructive and parental involvement in the treatment program is impossible, we recommend foster home placement.

This was done in the case of Jane, whose father refused t o recognize his own destruc- tive role in her illness. H e was critical of both her socially acceptable behavior and her antisocial activity. As stated previously, this case was referred back to the juvenile court, the parents were deprived of custody, and a foster home placement agency was given custody of Jane. With the cooperation of the foster parents as well as the agency case- worker, we could begin to help Jane develop her positive interest and ambitions. The patient was an active participant in the planning for the type of foster home she was to have, and was allowed to visit the home prior to placement.

We found that we were limited in the extent to which we could manipu- late the environment, not only because of the parental wishes, but also because of the particular needs of the child.

In the case of Pam, whose parents had totally rejected her, we also considered foster placement. Pam saw her parents as erratic, inconsistent and impulsive adults whom she could depend upon for nothing; but paradoxically, she was forced to look to them for emotional rapport, for they were the only important people in her environment. During her hospitalization an attempt was made to provide her with experiences pre- viously denied her. We felt that she needed spontaneous, ungrudging warmth from an adult over a prolonged period in order to develop some sense of security. When plans for her discharge were discussed, she expressed ambivalent feelings about returning home. She appeared to have a need to prove to herself either that her parents really did not want her, or that if she tried harder, they would find a place for her if for no other rea- son than to assist in the housekeeping. We felt that if the therapeutic relationship continued long enough, the child would begin to identify with the therapist’s ideals and wishes, and to acquire a sense of her own worth as a person. I f the pain of parental re- jection could be dulled somewhat through the sense of a strong relationship with a more accepting adult, the patient would be able to tolerate and handle her feelings despite the lack of change in the parental attitudes. We had in mind also that a t some future date she would be better able to deal realistically with the idea of a foster home.

It is apparent that we are willing to accept limited results as an outcome