Question 1

Question 2

How do you find identifying values with adolescents, given that they are still in the process of developing their identities and values?

Sheri Turrell · Accepted Answer

I absolutely love the opportunity to explore values with adolescents. Given their developmental stage, it’s the perfect time to help them sort out who and what matters, and the qualities from within themselves that they want to embody throughout their day.  Adolescence, for many, is a time in which young people are naturally trying on identities and experimenting with who they are and discovering what matters, so values work fits perfectly.  As teens work through developmental tasks of identity formation and individuation, giving them the opportunity to identify what they can control (values-based behavior) is very appealing and well timed.  As we bring forth our own curiosity and sense of the teen as someone who matters, who we want to hear from and are curious about, they get the space to open up, dream, feel important, cared for, and nurtured, which further adds to the reinforcing nature of the work. That said, when we try to connect teens to what matters, unwanted thoughts such as ‘not good enough” and emotions of shame, sadness, frustration, disappointment and resentment, to name a few, will often come along for the ride and derail the work. It’s rarely easy or linear and often something we return to, with greater clarity over time.  That said, ‘canned’ ways of exploring values may need to be adapted slightly to be developmentally appropriate.  For example, you might ask a teen what they would hope teachers, parents or friends would say about them if they were being honoured at their next birthday or their high school graduation as opposed to their 80th birthday party.

Question 3

Have you used ACT with Conduct Disorder/ODD presentations in young people?

Sheri Turrell · Accepted Answer

When I hear ‘ODD” I instantly start thinking about ‘parent/child’ mismatch and want to get the parents involved from the beginning.  A thorough behavioral analysis of what is happening between parent and teen helps tremendously, not only to understand what is unfolding, but can help to highlight fusion and avoidance for all involved.  Working on the ACT processes with parents first so they can create a safe space for their teen to have emotions and be understood is generally how I’d go about it, speaking very generally. There may also be some work to do in order to defuse the teen and the adults from an ODD diagnosis, which carries associations of blame and shame for the teen (and parents too). An emphasis on values and committed action, while trying to uncover the function of the behavior, will be of paramount importance. With teens who struggle with behavior that would be characterized this way, even less ‘severe’ versions of ‘conduct disorder” behavior, I often integrate the Collaborative Problem-Solving approach of Dr. Ross Greene (https://www.livesinthebalance.org/parents-families) into my work.

Question 4

I'm after some ideas for metaphors to help with defusion with adolescents?

Sheri Turrell · Accepted Answer

I have to say, the best metaphors are the ones that my clients generate, either on their own or as something that unfolds during a session.  If you are new to ACT and the use of metaphors, there are many in ACT for Adolescents that you may find helpful as is or change them up as you like. Some of my personal favourites include the idea of thoughts as words on a computer screen, can you minimise them (they are not ‘gone” or ‘deleted”); looking at thoughts from a distance like you might look at your favorite band on stage, just stand back and watch, don’t jump on the stage and try to push the band members around or shove them off the stage, just stand back, at a distance, and watch, notice how they move around, how they change position or how new songs emerge, and just watch;  thoughts as peers in a classroom, each sitting at a desk, look at each one, and make a choice about who you want to work with or hang out with; thoughts like toilet paper that got caught under your shoe, you don’t want it, it does not feel good, you might feel embarrassed, yet can you look at it, notice it, and choose to take steps towards what matters, and take the toilet paper with you? I will often turn these into actual experiential exercises where possible or do as an eyes closed visualization to deepen the experience.

If you are a more experienced ACT clinician and feel ready to stretch your wings with metaphors, then the following suggestions may help: keep your clients interests in mind and the process of defusion and what it’s all about – if your client is working in a retail clothing store for example, or is interested in fashion, you help them to visualize themselves walking amongst racks of clothing, picking one item up at a time, looking at it, and putting it back on the rack. You can then shift this to having them pick up an item, that perhaps has words written on it, moving from less to more evocative, and imagine themselves noticing the words, and returning the hanger to the rack, remembering who and what matters, and walking in that direction, while the clothes just stay on the rack.  It helps to keep in mind that because all the processes overlap, many metaphors, if not all of them, connect to each of the processes in some way, so you may be doing more defusion than you think.

Question 5

In your experience, what are some engaging mindfulness activities for adolescents?

Sheri Turrell · Accepted Answer

I usually meet with adolescents in the after-school hours, when they are exhausted from sitting and learning – so I gravitate to mindfulness activities that are experiential in nature and will engage their unique interests. Keeping in mind, asking what is showing up in the moment or if they are aware of what they just said or did is mindfulness-based and builds up present moment awareness. To build the skill more explicitly, I often start with five senses experience, moving internally to breath and body if needed and when appropriate. A few of my favorites include: listening to music you don’t like (lots of judgments are likely to show up, which is great for practicing noticing, returning focus to the music, without judgment, and hearing what is there – and it’s how I discovered I actually like Dolly Parton);  playing with soap bubbles and trying to notice the colours in the bubbles and the sound they make when they pop is a huge hit, provided you have space for bubbles and don’t mind soap getting all over the place; mindful stretching and balancing (again, judgments may abound) are also engaging and playful.

As teens develop their skills in noticing what is present, purposeful distractions add a new challenge.  For example, having them engage in mindfulness of sound while showing flashcards with judgments they have identified written on the card adds an ‘in vivo’ opportunity to notice and name what showed up, and return focus to whatever the anchor is supposed to be.

Question 6

Hello - do you have some ideas for doing values work with adolescents via telehealth? Thanks

Sheri Turrell · Accepted Answer

The telehealth platform, while not without its’ benefits, has impacted the way I like to explore values. Typically, I like to give clients a set of values cards, and ask them to ‘sort any way that makes sense to you.” I used to ask clients to sort the values into piles of ‘yes’ and ‘no’ according to whether the qualities mattered to them and go from there. However, I find giving adolescents the opportunity to sort values in a way that suits them is far more meaningful and enlightening. I have had clients who created piles of values based on “here’s what matters to me” and “here’s what I think others want me to be,” and “here’s what I think is supposed to matter to me, but it doesn’t,” just to give a few examples. This opens up a range of possibilities to explore and differentiate their self-as-content from their values and alerts me to potential pitfalls when exploring values-based behavior change.  With telehealth, I’ve resorted to providing printed pages of values and sharing my screen with them, so we can both access the values list.  Some adolescents are able to sort from the list, as I described above, and I write down how they categorize and place values in various ‘piles,” which I later send to them via email.

Depending on your telehealth platform, you may be able to have your adolescent client ‘play’ with different values by showing up on screen and engaging with you while they embody some qualities they identified. Asking questions such as “How will the “responsible” you show up?” verses the ‘irresponsible” version of themselves, or the “present and aware” you verses the distracted you?  Because they may be able to see themselves on the screen, this may add to their ability to ‘track’ behavior and notice how and when values are showing up. For some adolescents, the telehealth platform changes the intimacy and vulnerability such that they are more able to engage in this way and try on different values and ways of enacting those values.  I’ve had some success in asking teens to give a ‘thumbs up’ using icons in my online platform (ZOOM) when they catch themselves embodying their values and acting consistently, and doing so does not seem to interrupt the flow of the session unless we want to pause and reflect on the moment.

Question 7

What level of parental involvement do you ideally want for both individual and group ACT interventions with adolescents?

Sheri Turrell · Accepted Answer

I have been thinking about this for many years and trying out different configurations when I can. I still have not been able to bring my ‘ideal” to fruition – still hoping!  Will share my current ‘ideal’ dream – perhaps some of you will be fortunate enough to have the infrastructure / resources / staff to make this happen and let me know how it goes.

My current “dream” is to run groups for teens while parents are engaged in a concurrent parent group. My hopes for the parent group are twofold, that parents learn to work with their own unwanted thoughts and feelings, and that they learn the skills to support their teen. Often when a teen is struggling with experiential avoidance, I find that at least one parent is struggling as well. I would run a parent group in which parents are learning how to notice, name, and make room for their own unwanted thoughts and feelings, and then engage in behavior that is values driven, especially when their teen is overwhelmed by emotions. My co-author and colleague, Mary Bell and I have run this sort of parent group in a brief format, with parents who are struggling to support a teen who is using substances – wish we had more resources to run the group for a longer duration and with the teens in their own concurrent ACT based group, but that was not possible for us.  The parent group, however, was one of the most heartwarming and rewarding experiences of my professional life! I would also want to include in the parent group, the opportunity for parents to practice what they have learned, with their teen. I find incorporating elements from emotion focused therapy is very helpful when working with parents especially if they need some help with empathy and emotion coaching.

With individual work, it varies and definitely depends on the reason for referral and family dynamics, just to name a few factors. Many teens want therapy to be a private relationship and don’t want parental involvement, while others do want a more family-based approach.  For those who want their privacy, if that is clinically warranted, I will involve parents at the beginning, getting to know them as people so I have a broader and deeper understanding of the context in which my client lives their daily life and how emotions are experienced by all concerned.  Because I value interpersonal relationships and connection, I want to include parents as early as possible, and as often as needed, with flexibility.  It does help to have parents present for the consent and formulation / explanation of treatment approach however, so they can support your clinical efforts.  If parents brought their teen to work with you in the hopes of ‘getting grid of their anxiety,” and you are engaging the teen with ACT, uninformed parents may feel blindsided and mistrustful of your work. While my flexible “ideal” may work well for the families I serve, it does not work well if someone wants a ‘one size fits all” answer – trust your clinical judgment.

Given the inclination of many adolescents to keep their therapeutic relationship private, my co-authors, Mary Bell, Christopher McCurry, and our colleague Erin Lipsitt, are currently creating a video series to complment our teen self-help book (The Mindfulness and Acceptance Workbook for Teen Anxiety), that walks parents through the premise of ACT and how to work with their own thoughts and feelings so they can make values based behavior changes as they support their teen. We are hoping to have it available online by fall 2020 and the videos will be accessible on our YouTube channel, Mindfulness and Acceptance for Teen Anxiety, https://youtu.be/XuIxLF0KtuM.

Question 8

Are there any ACT apps that you would recommend for adolescents?

Sheri Turrell · Accepted Answer

None so far, but that’s because I don’t know of any, not because I don’t like any that I have found.  Many of my clients benefit from non-ACT based meditation apps to support their practice in present moment awareness. I often find myself recording audio directly into my clients’ cell phone (when we were meeting in person) or using SoundCloud to record instructions / visualization that a client found helpful, which gives them a very personalized audio tool that really does not take very long for me to record, upload and send to them.

Question 9

What if your teen client's values and goals directly clash with the expectations of their parents and family?

Sheri Turrell · Accepted Answer

Not an easy situation.  In such cases, it is important to fully understand the struggle in terms of values and behavior, which often get confused. This may be an example of what area of life, what role, is important to parents / family verses the adolescent. Often, I find when there is a ‘clash” it’s actually more a lack of awareness of personal values and an inability to communicate what matters to other family members.  Parents for example, may have lost touch with their connection to the type of parent they want to be and what that might look like. In their haste to make things ‘better,’ they may fuse with assumptions and judgments about their teen and forget to be curious and open to hearing about their teens’ experiences, values, and desires. The reverse may also be true, where teens may be either out of touch with their values and / or not communicating them well, rendering their motivations a mystery to others, which opens up space for assumptions. I find it helpful to keep the developmental tasks of adolescence in mind, as this can slip off the radar of even very experienced clinicians.

Clashes are undoubtedly occurring within a context of the adolescents’ efforts to forge an identity, establish some separation from parents and become increasingly independent. This is often difficult for the teen and parents for various reasons, and a curious clinician can help to explore and identify the underlying issues. The majority of the time, I find that parents and teens are actually on the same page about wanting the teen to grow up into some version of a responsible, self-sufficient adult who can make a positive contribution to society.  If you can find a way to open this up and build a bridge between parents and their teen, the ultimate goals may be the same, with values used to guide each family member along the journey which ultimately, requires collaboration, communication, and understanding.

Using a somewhat simple yet frequently occurring example, is the teen engaging in what seems like ‘excessive screen time” (easy to do in present pandemic) which parents feel is contrary to their expectations of what the teen should be doing with their time. Helping parents see their teen for who they really are, in the present moment and appreciate their teens’ values and goals, goes a long way to mutual understanding and growth.  What is ‘excessive” during a pandemic when all interpersonal contact has been online for many people? Is the ‘screen time” having adverse consequences that anyone can see or hear, or are parents reacting to worries or rules in their own minds about what ‘should’ be happening?  From an ACT perspective, bringing in whatever you can (i.e., collaborative problem solving, role playing,  psychoeducation about the adolescent phase of development) to improve conflict resolution, understanding, and communication for your clients would be part of the process of committed action, which gives us lots of options.

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