The relation to the therapist plays a crucial role in therapy. Experiences of confidence, trust and support are central in this helpful relation. Additionally, the therapist should be trustworthy and experienced.
Confidence, trust and support
The adolescents pay a great deal of attention to the therapist. They wonder who the person in front of them really is; they notice differences in the therapist’s way of being, changes in, for example, hairstyle, the way he or she talks and so on. They try to know their therapist. It is a one-way relationship, and as one said: ‘It is a person who is close to me, but for whom I am just one out of many. And that, also, is very special’. In this relationship, the patients nevertheless experienced safety and comfort facilitated by the fact that the adolescent did not have to fear the consequences of what they said: ‘All the time, in a way I tested the limits of what I could say without being afraid of being judged’. Trust and confidence were crucial for a safe therapeutic relationship, expressed by one this way: ‘In one way, I can say whatever I want, without what I say backfiring on me’.
Being vulnerable and crying in front of another person can be relieving. Feeling irrational and destroyed, the importance of trust and confidence was clearly described by one adolescent: ‘Having someone else helps a lot. It’s a place where it is okay to be weak, it’s okay not to know what you are talking about, what you should do, who you are or anything’. Another way confidence and trust were experienced was more directly connected to what the therapist was saying. One adolescent who really seemed to rely on the therapist said: ‘I took all that he said to heart. I had such strong faith in him that I felt everything he said was right. Because he was one that I trusted’. Another adolescent experienced a reduction in feelings of suicidality and anxiety as well as a strong decrease of panic attacks shortly after entering therapy. Her explanation for this improvement centred on the safety of therapy, not necessarily on the therapist: ‘I felt that being in therapy, no matter whatever happens in there, also can give safety, or help a little, in itself’.
Another way in which the relational work contributed to improvement was through support. Although, as one of the adolescents saw it, you basically have to do the work yourself, the relation played an important role: ‘What I needed was the guidance and support from a person with a little more competence than me’. Support from the therapist was for another adolescent the only real support she experienced in her process of deciding whether to quit school and move in another direction in her life. Feeling all alone, without support from family or friends in what was most important to her, therapy became the only place where she experienced support: ‘It was very satisfactory feeling that somebody felt it was a good choice for me, that I should do it, and understands it and actually supports me fully and entirely’. This support made things less lonely and easier to stand up for when her choice was questioned.
Central in the relation, and important for improvement and progress in therapy, were the roles into which the adolescents placed their therapist. One adolescent looked upon her therapist as an ordinary person. Being a good girl, she tried to be nice and polite in shaping the relationship with the therapist. This caused her to avoid talking about what she saw as difficult or problematic. She did not want the therapist to think in a negative way about herself or people she cared about. Gradually realising that this pleasing attitude was hindering her in speaking freely, she progressed when she changed her view of the therapist: ‘I actually began to look upon him as a therapist and not just an ordinary human being I was to make a good impression upon. This was very important for the whole treatment’.
Another adolescent made an opposite change in her relation to the therapist. Her experience was of a silent therapist, just sitting and listening to her. The focus on her and her problems sometimes made her feel she was getting worse. A turning point arose when she realised that the therapist was not just a typical therapist but quite a nice man with a life of his own. She then gradually acknowledged the therapist as an ordinary human being she could trust: ‘I then, actually, saw him more as a friend I could confide in’.
While the former patient needed the ordinary person to become a therapist, the latter needed the therapist to become an ordinary person. Changing their views on the role of the therapist was crucial as it helped the adolescents to develop themselves through the further relation with their therapist.
Trustworthy and experienced
When describing how the therapist contributes to improvement, the adolescents emphasised a therapist that in different ways is dependable, experienced and trustworthy: ‘He seemed so experienced and talked with such self-confidence. So I became quite convinced, like “okay, what he says is actually true”’. The same patient experienced a crucial turning point in therapy when the therapist opened himself up a little, giving a focus other than on her and her problems: ‘He disclosed some of his own experiences. And I felt that was the real turning point between the two of us. And then I actually saw him more as a friend I could confide in’. Another adolescent attributed what made her trust and rely on the therapist more to the role and position: ‘It is something with him being educated… it’s his job, in a way. It has a lot to do with the authority he had as a therapist, I think’. One adolescent felt that the therapists’ gender had great influence. She felt much better off with her male therapist than her former female therapist. She explained this as being partly because she had expected a female therapist and partly because the one she got was good at talking: ‘He was somehow good at articulating and expressing himself and could somehow ask the right questions’. He was experienced as a reassuring therapist in that he was quiet until she began to talk. The adolescents need for being in focus and to have another person’s time and attention was important. This was for one of the adolescent’s the main experience of what the therapist had done and, actually, what she felt she needed in therapy: ‘It was a person sitting there listening to me. And just listened to me and only wanted to help. One that actually sat there listening and talking’.