ABSTRACT
Adolescents who are transgressive, who do not respect the rules, aggressive in the family and at school, who enact behaviors that are dangerous to themselves and others, desperate parents, involved in symmetrical escalations or flattened on renunciatory positions... how can we be of help to them? What lenses can help us decode the meaning of such explosive behaviors, and at the same time, what strategies can we use to build effective intakes, taking into account the character of urgency that these situations present? The article aims to discuss methods of intervention, which can be applied in the management of these difficult situations, accompanied by theoretical references and clinical exemplifications.
Keywords
Transgressive and rebellious adolescents-Therapeutic alliance-Multidimensional Family Therapy (MDFT)
INTRODUCTION
Years ago, I edited the Italian edition of David Taransaud's engaging book "You Think I'm Evil. Practical strategies for working with aggressive and rebellious adolescents" (Taransaud, D., Rangone, G., 2014). As I clarified in the introduction to that volume, it was not only a highly interesting experience but also one that transported me back to the days when, freshly graduated, I began working as a psychologist in a juvenile prison in Northern Italy. I vividly recall the intense and conflicting emotions that overwhelmed me during my consultations with the incarcerated youths, meant to provide the judge with insights that would influence his rulings. Expecting to encounter a frightened boy and prepared to offer solace, I was instead met with mockery or even a veiled threat. I braced myself to not be intimidated and struggled to hold back tears in front of what seemed a desperate child. Knowing why that boy was imprisoned did not simplify my task. How could such a sad and withdrawn young person be responsible for such severe actions? The family therapy training I had just begun was certainly beneficial, not only providing comfort by reminding me that reality cannot be solely understood in simple cause-and-effect terms but also encouraging me to explore the developmental contexts of these youths, bolstered by the assertion that "A phenomenon remains inexplicable as long as the field of observation is not broad enough to include the context in which it occurs" (Watzlawick, P., Beavin, J. H., & Jackson, D. D., 1971). My lack of experience at that time likely limited my effectiveness, but those encounters ignited my ongoing passion for working with 'bad' boys, a passion that has never left me.
BETTER BAD THAN NOTHING…
During a supervision meeting with an educational community, the educators discussed a situation that had caused them considerable surprise. Several months prior, they had welcomed Davide, a fourteen-year-old described as rebellious to every rule and very difficult to manage. They had adopted a strategy of positively reinforcing the boy's appropriate behaviors, which, thanks to the development of an excellent relationship with the referring educator, proved successful. Progress was noted at school, and his relationships with peers and adults had significantly improved. The educators never missed an opportunity to praise the boy. Until one day, completely unexpectedly, in response to yet another well-deserved praise, Davide burst out, "Can you stop saying that I am good? I am BAD! Get it into your heads, I am BAD!" It was not easy for the educators to recognize that Davide, having grown up in an adverse environment where aggression and rebellion were his only means of survival, could not easily abandon such a significant part of his identity. In the book previously mentioned, Taransaud introduces the useful metaphor of the omnipotent self and the wounded self to indicate that while it is true that behind the aggressive and rebellious behaviors of adolescents there is always a suffering part in need of affection, it is also true that this vulnerable part is often held hostage by a stronger one, which cannot be easily ignored or dismissed. Instead, it must be acknowledged and honored as it has served a protective and vigilant function. The author suggests numerous intervention techniques that can be used with adolescents, not only in therapeutic contexts but also educational ones, aimed at allowing the expression of these contradictory parts that are difficult to verbalize. The use of drawings, comics, films, stories, music, songs, and videos based on the adolescents' interests is proposed (Taransaud, D., Rangone, G., Pasculli, C., 2017).
WORKING WITH THE FAMILIES OF 'BAD' ADOLESCENTS: BUILDING THE ALLIANCE
The first challenge for the family therapist is gaining the adolescent's attendance at sessions, which is not always easy. Adolescents are not children; their presence in therapy must be earned. Increasingly, parents are seeking help for their adolescent children who exhibit rebellious and aggressive behaviors. Often, these parents will indicate from the outset that their child will likely refuse to participate. Many of these adolescents have already undergone years of individual therapy and are reluctant to engage with psychologists again. This represents a significant barrier. While venturing into individual treatment of an adolescent is not advisable (except in cases of severe dysfunction where family ties have been severed for the minor's protection, but even then, other adult figures should be involved), treating only the parents is equally problematic. It is important to remember that for a child, a small degree of understanding from a parent about the struggles they have endured is often more impactful than complete understanding from a therapist. Working only with parents is not recommended: ignoring the adolescent's perspective risks missing a comprehensive understanding of the issue, not adequately addressing the risk factors involved, and foregoing the contributions of a key player in the situation. Therefore, the initial step is to work towards building a team that includes the entire family to address the problem most effectively. But how?
Meeting with the parents and gathering the history of the problem, properly contextualized within the family, is crucial. Special attention should be given to situations where the child may have suffered injustices without recognition and proper protection. We may uncover unmet needs, dissonances, misunderstandings, and even real traumas, sometimes occurring in extra-familial contexts but which have been severely underestimated.
Mr. and Mrs. Bianchi sought help for their son Mauro, nearly eighteen, who is enrolled in a vocational school. His academic performance is poor, and what is more concerning for the parents is his behavior towards them. He does not recognize their authority, shouts and breaks objects when opposed, insults them, and does not respect any rules. At school, he is often insubordinate towards teachers. He stays out at night and turns off his cellphone to avoid being tracked. From gathering the family's history, it emerged that Mauro was previously enrolled in a different high school, and the change occurred following certain events at school during his first year. With some difficulty, the parents reconstructed the events: Mauro had witnessed repeated acts of bullying perpetrated by an eighteen-year-old at the same institute against his best friend, and had intervened to defend her. The result was that the bully began to heavily target Mauro, even threatening his life. Mauro did not tell his parents but started to refuse to go to school until, as the situation worsened, he broke down in tears and confided in his parents, who then informed the school. However, no action was taken against the aggressor, and the situation was severely underestimated. Mauro requested a change of school, which was granted. Almost four years have passed, and the small, skinny kid has grown into a tall, robust young man… now he is the one who scares others!
The parents, with appropriate support, were able to connect the past events to the current problem. But how to secure Mauro’s attendance at therapy sessions? The boy had undergone a year of individual psychotherapy and was reluctant to see a psychologist again. The strategy employed was to remove Mauro from the position of “defendant number one” and to help the parents to recognize their part of the responsibility. After careful reflection on the events that had marked Mauro’s history, the parents realized that it made sense to come home and tell their son the following: “They told us that we have been doing some things wrong with you, and to help us, they need to talk to you. So, they would like to meet you”. This approach laid important groundwork. First, the parents acknowledged, albeit in a general way, their responsibility in the occurrences at home. Second, they attributed competence to Mauro. Remember, adolescents have a strong need to be valued and respond positively to all interventions that highlight their ability to think and critique.
Mauro accepted the invitation. In a calm and polite manner, he immediately clarified his stance: “I came to talk but I have no intention of doing any psychotherapy!” The conversation unfolded smoothly, with Mauro providing many descriptions of what was happening at home and willing to express what annoyed him most and also what he would like to do with his parents (“I would really like to go for an aperitif with my dad…”). He politely declined to discuss past events (“Ah yes, but I was young then, I didn’t know how to defend myself…I don’t want to talk about it”). A lot of work had been done before it was possible to connect with the weak and fragile boy that no one had defended, but above all, it was essential to create those conditions of safety that allow (to use Taransaud’s metaphors), the omnipotent self to permit access to the wounded self.
Mauro’s case helps us delve into the basic principles of treating these delicate situations. Recognizing the competence of all family members, working to build an alliance that can only be based on the certainty of gaining an advantage from the treatment, highlighting not only the responsibilities of each in constructing and maintaining the problem, but also the possibilities of intervening to promote change, are undoubtedly the cornerstones of an effective intervention. Parents must be supported in fulfilling their indispensable role usefully, without abdicating their parental role, but identifying important aspects and distinguishing them from those of secondary importance. A backpack left in the hallway may irritate the parent, but is not as dangerous as throwing and breaking objects or disappearing for an entire night, while requests for closeness, mediated by adolescent categories (going for an aperitif), should always be welcomed and valued. Of course, it will be the therapist’s responsibility to prepare the parent for the possibility that the much-anticipated invitation may initially be refused (“Yes, okay, but not tonight”).
Another cornerstone of treatment is flexibility: sometimes, the therapist must be willing to leave their setting to explore the patient’s territory.
A colleague, deeply engaged in treating these difficult situations, told me that an adolescent had agreed to talk to him only if he was willing to accompany him on a bike ride. The colleague accepted (the service was located in a rural context that facilitated this practice), and the boy showed openness and availability. After a few “sessions” conducted in this manner, the colleague proposed continuing within the service, and the adolescent accepted without difficulty.
Even holding a joint session with parents and child can be a hard-won but indispensable goal. It is useful to negotiate with the adolescent about their presence in the session according to their preferred mode: they can listen in silence, delegate the therapist to present their point of view, and intervene only if they feel inadequately represented, or they can fully take on the responsibility of presenting their opinion.
An adolescent, after expressing his reluctance to participate in a joint session, agreed only after being assured that he could remain silent throughout the meeting. He thus appeared with his parents and assumed the position of a prisoner: lips sealed and arms behind his back. After 20 minutes of rigorously maintaining this difficult stance, he began to intervene, and the session turned into a lively and constructive exchange.
Another important aspect is the therapist’s willingness to explore the adolescent’s world, the things they like, their references. This operation, seemingly trivial, may not be easy for the therapist who, as an adult, may fall into the trap of expressing value judgments, showing disapproval, or giving advice in the face of narratives with meanings that are difficult to share. It should not be forgotten that these stories are often deliberately provocative, aimed at testing how willing the adult is to be guided in exploring unknown territories with hardly shareable content.
Alessandro had agreed to come to the session after the meeting held with the parents alone but had immediately clarified that he would not stay for more than half an hour. Since he had dropped out of school and did not seem to have any other interests (besides associating with questionable peers), I asked him what he liked to do during the day. Alessandro began to explain in detail the online game he was assiduously playing, which involved participation in extremely violent situations where the goal was the physical elimination of opponents, carried out in various ways but always absolutely terrifying. Supported by my ignorance on the subject, I started asking questions and requesting clarifications, keeping negative emotions at bay as those scenarios provoked them. Alessandro eagerly provided explanations, even using examples (“Have you by any chance read The Lord of the Rings?”) that could somehow bring me closer to this subject so distant from me. Meanwhile, time was passing, and the half-hour was almost up. As the agreed time ended, I walked Alessandro to the door, but he stopped in front of the book-filled bookshelf and unexpectedly exclaimed, “So many books! Have you read them all?” I began to explain that some were old university texts, others I had only consulted, and others I had read entirely because they had been useful in my work. Alessandro interrupted me and asked if he could take a look at one book in particular. It was the book “L’adolescenza ferita” (Bertetti, B., Chistolini M., Rangone, G., Vadilonga, F., 2004), written years ago by myself and other colleagues. He started flipping through the book. “But these are all stories of kids… did you see them all?” We stayed to chat a bit; he was very interested in hearing about the work we did at the CTA (Adolescent Therapy Center), work that I made clear was aimed not only at the children but also at the parents because if there’s a problem concerning a child, the parents are certainly involved. We parted with a new appointment, to which Alessandro arrived punctually and eager to talk. And therapy began.
Exploring the other’s territory, without preconceptions or prejudices, usually leads to the possibility that our interlocutor is willing to explore our territory. In other words, if we want to be recognized as competent, we must first attribute competence to the other.
A VALUABLE REFERENCE: THE MULTIDIMENSIONAL FAMILY THERAPY (MDFT) MODEL
Many of the insights mentioned find extensive discussion within H. Liddle’s MDFT model (Liddle, H.A., 2016), specifically dedicated to treating adolescents with substance abuse and behavioral problems. It is an intervention model with excellent evidence of effectiveness that emphasizes the importance of constructing interventions that, being aimed at a multidimensional phenomenon, are themselves multidimensional. The treatment process involves not only the family in its various components, parent(s) and child(ren), but also other significant systems in the adolescent’s life. Of particular importance is the school, whose involvement in problem management Liddle pays special attention to. Again, building an alliance is crucial. Far beyond a simple exchange of information, working with the school involves building a significant collaboration, with operational support (“your problem is also my problem. Together we can solve it”). But other contexts can also be fully involved in treatment, both institutional (educational community, prison) and recreational, religious, etc. Another important aspect of this model is the premise that motivation is malleable, meaning it can be built, gradually earned. This applies to both adolescents and adults. During the training conducted in Milan in 2016 at our school, Alessandra Marotti (Marotti, A., 2006), a collaborator of Liddle, shared this anecdote:
A single mother refused to visit her son in prison, citing the lack of a car as an excuse. In reality, the prison was easily accessible by public transportation, and the reasons for the woman’s reluctance to visit her son were different. Without delving into these aspects, Marotti offered to drive her to the prison, anticipating that they would have a chance to chat along the way. Surprised by the proposal, the woman accepted. It was the first session of a fruitful therapy.
Another important aspect concerns the timeliness of the intervention. The MDFT model reminds us that time is important and that adolescents with behavioral problems can cause very serious incidents in a short period. Therefore, prompt action is essential. This leads us to reflect on how institutional timelines often do not align with the characteristics of these sometimes-explosive situations. The MDFT model is also based on the idea that the therapist alone is insufficient: it is necessary to build a team consisting of, in addition to the main therapist, an assistant therapist and/or other educational figures who can promptly intervene in other significant systems besides the family.
Although, as family therapists, we are more familiar with situations where parents seek help, and it is the adolescent who needs to be won over to therapy, we must not forget that there are contexts where it is the adolescent who seeks help, and it is the parents whose presence needs to be secured. Consider school counseling services, where access is often supported by a teacher or even classmates, and where the involvement of parents cannot be taken for granted. It is not uncommon for the adolescent to oppose it. However, if the problem presented is of a certain severity, it is evident that the presence of the parents is indispensable. Here too, it is necessary to be flexible and equipped with strategies. The adolescent might be immediately willing to meet only one parent, or might prefer the therapist to meet the parents alone, or might ask to remain silent during the meeting… as we have already seen, it is essential that the operator, without losing sight of the goal, adapts to their interlocutor.
RISK MONITORING
When working with these situations, it is essential to keep in mind that the therapist may become aware of situations involving a risk (for someone within or outside the family) that may not be manageable within the therapy room. Great attention must be paid to these aspects. The therapist can fall into the trap of underestimating the risk or becoming overly frightened. Often, underestimation of the risk occurs when the therapist overestimates the importance of the relationship established with the adolescent. This relationship is of extraordinary importance, but if the situation is too serious, it certainly cannot guarantee the interruption of dangerous behavior and therefore the necessary safety.
An adolescent used to go out in the evening with friends, abuse alcohol, and ride a scooter without glasses, despite being very nearsighted. The explanation was that he really enjoyed the sense of risk and challenge that came from moving quickly through the city, with a vague and blurry vision, fueled by alcohol. He confided in the therapist, who naturally told him to stop the dangerous behavior; the boy agreed that it was better to stop, but then he returned to the session and admitted that he had done it again…
Not proceeding as the law and the professional code of ethics prescribe to ensure the necessary protection of the minor is often not due to a lack of knowledge of the rules but to the difficult management of emotions that can overwhelm one in such delicate cases. The frequency with which this happens should prompt us to operate on two equally important planes: on one hand, promoting not only instructional training and supervision that enhance all operational aspects, including the management of emotions evoked by these cases; and on the other, supporting the usefulness of teamwork and the possibility of seeking consultation and support in the face of potentially destabilizing situations.
CONCLUSIONS
This exploration of the complex and vast topic of treating aggressive and rebellious adolescents and their families is by no means exhaustive. Many themes deserve further exploration, but I wish to emphasize the importance of several aspects discussed here. Foremost among these is the concept of flexibility: working with this caseload often requires the ability to leave one's comfortable setting to enter the territory of our interlocutors and demands the use of creativity and imagination. Integrating rigor (avoiding the trap of "whatever works") and flexibility is not easy, and it is always desirable for the therapist not to work alone. Other professionals, such as educators, can become part of the team addressing the issue, and it is necessary to be open to considering, beyond the family, a multitude of significant contexts, which can contain valuable resources. Especially when multiple services and institutions are involved, as happens when the adolescent is responsible for crimes or engages in dangerous conduct, it is important to be available to construct coordinated and shared aid projects. The task is not easy; it requires tenacity, not getting discouraged, learning to appreciate even small achievements—a truly significant challenge!
BIBLIOGRAPHY
Bertetti, B., Chistolini, M., Rangone, G., Vadilonga, F. (2004). L'adolescenza ferita. Un modello di presa in carico delle gravi crisi adolescenziali. FrancoAngeli.
Liddle, H.A. (2016) Multidimensional Family Therapy: Evidence Base for Transdiagnostic Treatment Outcomes, Change Mechanisms, and Implementation in Community Settings Family Process, 1-19
Marotti, A. (2006). La terapia multidimensionale della famiglia. Itaca (28)
Taransaud, D., & Rangone, G. (2014). Tu pensi che io sia cattivo: strategie pratiche per lavorare con adolescenti aggressivi e ribelli. FrancoAngeli.
Taransaud, D., & Rangone, G., Pasculli, C. (2021). The Rage for Life. Una storia di sopravvivenza e di speranza. Fabbrica dei Segni.
Watzlawick, P., Beavin, J. H., & Jackson, D. D. (1971). Pragmatica della comunicazione umana. Astrolabio, Roma, 35, 1-47
Per gentile concessione della Rivista “Quaderni SIRTS”. Questo articolo è stato originariamente pubblicato sulla Rivista “Quaderni SIRTS”, N° XXX, anno XXX, sito internet: www.sirts.org/quaderni
