All service providers are taught that building rapport with a client is incredibly important, and when working with teenagers that rapport becomes crucial. Many teens and young adults already feel as though they are not being heard or that their thoughts and feelings do not matter, which is why being able to communicate with these younger clients is that much more important.
What they do not always teach is how to achieve this with a particularly difficult client. This was the issue with which I was tasked a few months ago, when a particular client was admitted to KidsPeace for residential care.
This TRICARE client was admitted to one of KidsPeace’s male Residential Treatment Centers late last winter, following an inpatient hospitalization for increased aggression and suicidal threats. What made this client particularly unique was that he had never had any kind of therapy, other than seeking guidance at his local church. It was reported that this client was adopted around age 4, and struggled with forming close attachments to his adoptive parents. These parents had also confirmed a history of defiance, a lack of pro-social skills, and aggression that had progressed from verbal threats to physical actions. This increase in physical aggression is ultimately why this client was hospitalized; he was not following home expectations, and when he was redirected for not doing so, he lashed out against his mother – pushing her and causing injuries. At that point the parents felt hospitalization was the next step.
One of this client’s particular struggles was attention-seeking behavior, therefore when he was admitted to a local hospital’s inpatient program, he continuously reported suicidal thoughts, threatened suicidal actions, and continued to struggle with aggression, — all likely attempts to seek the attention of others. When thinking about it logically, negative attention is often much easier to attain than positive attention. When people make the right choice, it often takes others a while to notice or comment on such behavior, whereas when people make a poor choice, it seems as though this is noticed fairly quickly. For example, think about abiding by the speed limit. We are never pulled over by the police for following the speed limit, but most people can relate to being pulled over with a police officer approaching the car, stating, “Sir, are you aware of how fast you were driving?”
The fact that negative attention is easier to attain than positive attention had been unintentionally reinforced for this particular client for years. Over time, his way of getting the attention of others escalated, causing him to become increasingly aggressive, leading to this residential placement.
When this client was first admitted to KidsPeace, the treatment team immediately noticed similar attention-seeking behaviors. When these patterns of behavior were mentioned to this client, his aggression would escalate significantly, making it almost impossible to process in therapy. After multiple attempts to discuss how this client would go about seeking the attention of others, the only results were extreme outbursts or increased physical aggression.
It was time to take a different approach, to go back to the basics and rebuild that rapport with this client. The firm approach that was originally being utilized with this young man was no longer productive, unlike how it had been in his first few weeks of treatment when the original rapport was built. This observation was discussed in detail with the client’s parents, which was very important as well, because gaining trust from all members involved in a client’s treatment can make or break the therapeutic process. Although these were difficult conversations to have, as I was ultimately admitting that my original approach had been effective for only a short period of time, it was necessary to develop a more appropriate approach for this client, with the help of his parents.
This led to a major shift in our therapy sessions. Originally, this client would become argumentative and would become impatient, stating that he did not understand why therapy was taking so long to help him or why I, as a therapist, had not, “fixed him” yet. As I became gentler in my challenging of this client in sessions and I ultimately became more of a support for him in his eyes, he seemed to become more patient with the therapeutic process, more trusting of the treatment team as a whole, and more open about his thoughts and feelings, both in and out of therapy sessions. His parents also appeared to be more confident in my clinical assessments and seemed more willing to try different therapeutic approaches with their son.
One of the most important steps forward was when this young man was willing to admit that my assessments of him were typically accurate. The therapeutic relationship now built with this client was very strong, and it let me ask him if he was seeking the attention of others through his behaviors without him getting angry or escalating those behaviors. He was eventually able to communicate his needs appropriately to the treatment team and to his family, and was able to make progress – for which he was positively praised, gaining the attention he had been hoping for all along.
This young man successfully completed his treatment, with the help of his family and his treatment team, ultimately gaining the skills needed to communicate effectively, cope with negative thoughts and feelings, and overcome obstacles that he may face moving forward.