Question 1

What are some exercises/activities you find particularly effective to help youth identify their values?

Sheri Turrell · Accepted Answer

When I started to facilitate ACT based groups with teens, I was relieved when we arrived at the values session, believing it would be so much easier than the rest – I was wrong!  I find adolescence a great time of life for values exploration as this is when youth start to think about who they are and what matters to them, with a passion I wish we adults could hang onto at times! That said, their focus on peer acceptance and tendency to get hooked into comparisons and judgments, makes it very hard for some to disentangle values from rules.

Regardless of how your teen clients are able to identify values, I do think a lot of follow up is needed to keep the spotlight on the context and the consequences, in terms of goals, interpersonal relationships, and how they feel about themselves.  I have worked with many teens who value ‘being caring’ yet struggle to discern when, where, and with whom, this is a helpful quality to bring to any given moment. Being ‘caring,’ while it sounds lovely, may be detrimental when acted upon with an abusive other, or if it means not setting boundaries and being passive.  Helping them explore the impact of their choices will help them to track when this is workable and when it is not. I put purposeful attention on the long term impact as teens tend to be very driven by short term relief that avoidance offers.

Many teens arrive to therapy with a strong sense of ‘not good enough’ firmly established and I often hear that identifying values feels like ‘saying something nice about myself.” Given that this is not consistent with their self as content, they will resist choosing what matters and who they want to be. I try to focus on what is unfolding in the present moment between us, and the qualities the teen may be embodying, and I gently inquire as to whether or not my guess is correct.  
A few other ways I have found helpful are online values sorting programs or giving a list of potential values – seeing them written down seems to offer some defusion and distanced perspective taking and frees teens up to choose. I recently started to ask them to picture themselves as a baby (as an eyes closed visualization), lying in their crib, (which engenders some degree of compassion), and offer them the chance to imagine standing beside that younger ‘baby self’ – I then ask, “if you could give five (a randomly chosen number) qualities to that baby, that would guide them through life, what would you give them?” This has loosened up even the most avoidant teens and has not failed me yet!

There are also some ‘canned” ACTD metaphors (i.e., your 80th birthday party) that work well, with a slight adjustment to make them more developmentally appropriate, such as asking “if it was your birthday (specify age if a special birthday is approaching), or high school graduation” and “people are making speeches, what would you hope they would say about you,” or ”If you could control what other said about you in a snapchat (pick any social media platform) post, what would you hope they would say?”

There are of course, ‘traps’ to be on the lookout for when exploring values, which I was not adequately prepared for when I started this work!   Values in Therapy by Jenna LeJeune and Jason Luoma is an excellent book that is worth investing in for a deeper understanding of values work. Double checking with teens that what they hope for are actual qualities that matter to them is important, as I often hear qualities they ‘lack’ and that have gotten them into trouble, such as teens with ADHD identifying ‘being organized and focused” as values. When I explore with them, there is no passion, no affect, and no vitality to the answer. Asking them to imagine that they have all the approval of everyone in the world and then asking, ‘what would matter then?” can be a very powerful question to pose and appeals to their sense of novelty and sensation seeking which they can bring to this imagining.

Question 2

Do you ACT any differently with teenagers than with adults?

Sheri Turrell · Accepted Answer

Yes, and no – how’s that for a non-committal answer? Yes in that I may use the same metaphors such as ‘tug of war” that I do with adults. No, in that I will engage teens in an experiential version of metaphors and eyes closed visualizations whenever possible – which is why I have a rope in my office and am always prepared to play ‘tug of war.” Given that adolescent metacognitive skills are not as well developed as adults’ generally speaking, I find the experiential component gives them a lot to draw upon while trying to make behavioral changes.

There are so many changes going on over the adolescent years, cognitively, physically, and emotionally, just to name a few, that I like to provide a balance of structure and freedom –which varies from one teen to another.  I like to give my teen clients an opportunity to be independent and creative, finding their own ways to practice mindfulness, identify what would be helpful to practice between sessions, and set up their own home practice, for example. I also tend to avoid giving them paper / pencil charts and things to fill out, as many tell me they ‘get enough of that at school.” Some will decide to keep track of things in their phone while others refuse altogether and that is fine for me. I just ask them to try things out over the week and let them decide what to try, knowing that I will ask them what they noticed over the week when they return.

Supporting identity formation is also important while ‘skilling up” (a great Russ Harris term) the ACT processes, and this is where an intense focus on values and an exploration of all that is possible, can becoming enlivening and creative as we help our teen clients benefit from their developmentally normative novelty seeking and burgeoning independence.

I find I am more likely to keep my clients’ personal interests in mind when working with teens so that I can help them incorporate this into metaphors and experiential ‘experiments.” Keeping current with adolescent pop culture is helpful in this same regard. For fear of writing way too much, I’ll just add one last point, which is that I do keep my ACT ears open for fusion with comparisons. Given the importance of the peer group and sheer panic that can result from not being part of ones’ group, comparing to others can be rampant during the adolescent period and I work explicitly to help them track moments of comparison and how they react, and how that works out for them, over the long term – scaffolding their natural tendency to focus on the short term consequences of behavior.

Question 3

Can ACT help teenagers with eating disorders? If yes, how?

Sheri Turrell · Accepted Answer

So glad this question came up, as working with teens with disordered eating / eating disorders has been a passion of mine since the beginning of my career.  It is important to remember that even though many therapists consider ACT their main modality of treatment, we don’t all practice it the same way and the ‘how to’ can vary from clinician to clinician. I want to encourage everyone reading this to make ACT their own, integrating it with other modalities as appropriate and as suits your style and that of your client.

For me, I integrate ACT with my extensive psychoanalysis training and find this a very helpful way to think about my clients with disordered eating. I will try to keep this simple and ACT focused, yet do recommend Body States, edited by Jean Petrucelli, if you are not familiar and are interested in the relational psychoanalytic perspectives of disordered eating. When I read that book, it really highlighted for me that the disordered eating is the metaphor, and in ACT, metaphors are readily incorporated, so the two ways of working are very easily integrated.

Seeing the eating disorder as the metaphor has heightened my awareness of boundaries, affect attunement, empathy, identity, and assertiveness, all of which may be facilitated via the eating disorder symptoms.  For example, when teens are binge eating or purging, what is it, metaphorically, that they are trying to consume in vast quantities, and then trying to spit out?  
Going back to the underpinnings of ACT, functional contextualism, I like to get a detailed account of when the eating behavior occurs, in what context, as well as the antecedents and consequences of the behavior.  This helps me ascertain the function although it can often be a laborious and long process if the teen feels that their eating disorder “is always there,” and can’t discriminate antecedents. Identifying antecedents includes thoughts and feelings, in addition to the situation, and can alert us to the function of the behavior in terms of avoiding thoughts and feelings, or self-soothing, for example. I focus on consequences from an interpersonal perspective, inquiring about interpersonal / attachment needs, wants, and desires, and whether or not those needs are met via the eating disorder – often, they are, which makes the eating disorder very reinforcing.  We can use this knowledge to offer new contingencies in the therapeutic session, gradually moving clients towards more and more psychological flexibility, starting whet the client is at.

As part of any ACT assessment, I am also assessing the clients’ ability to be in the present moment, shift perspectives, share unwanted thoughts and feelings, and get in touch with who / what matters. With my teen clients with eating disorders, what I typically find is that my clients live life outside of the present moment, equate their sense of self with body shape and weight, are unaware of physical sensations, cannot put a name to feelings, and have little idea of who and what matters beyond their eating disorder. As you likely already know, this is not easy work. ACT may not make the work any easier or faster, yet I do find it effective in helping teens live more of the life they want, and in reducing reliance on eating behaviors to meet their needs.
Providing an in-depth ‘how to’ is beyond the scope of this forum, however, I shall outline a few things that I have found helpful with each of the ACT processes as pertains to working with teens with eating disorders.

I often begin teaching mindfulness skills using the five senses, staying external to the body and working closer to internal experience as the client can tolerate. For some who are very focused on their abdomen for example, mindfulness of the breath may flood them with thoughts about body and being fat and may simply be too evocative – which would override any sense of willingness that you may be trying to build.  “In session” present moment awareness will be essential to build up as a skill, both for the therapist (helps to make guesses about clients’ feelings) and for the client.
Given my emphasis on the eating disorder as the metaphor, and the developmental tasks of adolescence, working on self as context has become more of a focus for me even with simple interventions like noticing when your client voices a preference or opinion, and reinforcing that expression, perhaps asking them to repeat it from the perspective of “I.” For a more detailed description of the ‘self’ and relational frame theory, applicable to working with teens with eating disorders, I highly recommend A Contextual Behavioral Guide to the Self by Louise McHugh, Ian Stewart, and Priscilla Almada.  My only caution with this book is that I’ve had to read it over several times because it is so comprehensive, and it’s been time well spent!

While you may be tempted to try to defuse clients from statements such as “I feel fat,” I have learned along the way that first exploring the eating disorder ‘part’ of them in terms of what it allows them to do, or to experience, and how that might connect to values, can be very important. Perhaps eating disorders are ego syntonic because they line up with values in some way and allow the teen to live according to qualities that matter?   I remember the first client I gave a deck of values cards to who had an eating disorder, and instead of asking her to sort according to what was and was not important, I just asked her to ‘sort.” She put several cards into one pile and then told me “that’s what matters to my eating disorder.” She had values such as determined and connected in that pile. This further clarified the function of her eating symptoms and gave us an opportunity to explore other ways for her to try to meet the same needs, other ways of living the same values, without using the eating disorder.  From this point onwards, we rarely focused on her eating disorder, with the exception of me occasionally checking in as to the frequency of some of her more life-threatening behaviors.

You may find Acceptance and Commitment Therapy for Eating Disorders by Emily Sandoz, Kelly Wilson and Troy Dufrene helpful in your work with teens who struggle with eating.  As I mentioned above, ACT won’t necessarily make the journey faster or easier and should be done in conjunction with medical consultation as per your usual practice. That said, I do find it a very rewarding way to work with teens who have eating struggles.  ACT opens up space for a focus that includes so much more than eating behavior (i.e., what they ate, how much, when, how many times they purged per week, etc) – which I admittedly, find very boring – I want to know the person who is hidden underneath all of this suffering.

Question 4

How do you work with teens who have been forced to come along to therapy by their parents, and they don't want to be there, and they have zero interest in doing ACT?

Sheri Turrell · Accepted Answer

If a teen has been forced to therapy and has little interest in doing ACT, I’m not likely going to try and ‘do ACT,” not in an obvious way, or right away. I can, however, bring my ACT consistent clinician stance into the room: engaging with curiosity, empathy, using distancing language to reduce shame and blame, listening for, and reinforcing, values and values-based behavior, without engaging in a power struggle.  I don’t work with mandated clients, so I can’t speak to that extreme of ‘forced.”

Best case scenario, the teen sticks around long enough for me to explore with them, their thoughts and feelings around being forced to attend and gives me a chance to get to know something about them outside of the reason for referral. This may reveal some values and important areas of their life and give me a ‘side door’ through which to form an alliance with the teen and increase the likelihood that they will return.  Is there a reasonable possibility that parents will support my working together with the teen on something the teen wants to work on, “since you are stuck with me, how can we use this time to your advantage?”

Alternatively, I may work with parents and teen to find some common ground as a focus of the work.   Would the teen be willing to engage if the work was family based, if that’s appropriate, where the focus shifts to what each family member can do to make things better?

When I have encountered teens who are highly resistant to engaging in therapy, it’s often the case that they are either seeing themselves as the ‘problem’ that needs to be ‘fixed,” and feeling the shame and anger that comes along with this, or they are adamant that parents need therapeutic support, not them (and they are often correct).  Exploring perceptions, values, and avoidance strategies amongst family members may become part of the work at the assessment phase, with either the teen, parents, or both.

Worst case scenario, if the teen is really not interested, I don’t want to try to force them, because I don’t believe I really can, and because I believe in therapy as a collaborative process that is strongly rooted in the relationship that develops between therapist and client.  Embodying my values of respect, dignity, authenticity and honesty in how I treat others, I would let the teen and parents know that therapy is not ‘workable’ in the present moment. I would leave the door open for the teen to return should they desire (which I hope they would, if their initial experience has not been too aversive), and / or offer alternative modalities of therapy or refer elsewhere if they are really not interested in ACT, yet do want some help for something. I would also offer to find parents some support if that is the more appropriate option.

Question 5

How do you find it best to structure sessions when practicing ACT with adolescents

Sheri Turrell · Accepted Answer

I am admittedly, not very structured, and so my sessions tend to be very flexible and that may be one of the reasons I work well with ACT, or it works well with me!  I do offer more structure for teens who need it, and less for those who do not, so go with your clinical judgment and what works best for you and your clients. That said, I do like to keep my eye on values and goals, and intermediate steps that can be taken along the way towards the larger goal. I use the acronym LLAMA, outlined in ACT for Adolescents, A Clinician Guide, to assess where they are at in terms of the ACT processes, and build up skills as needed. I ask teens what they want to practice between sessions - some will offer up a very pre-planned skills practice or exposure while others prefer to try and ‘sprinkle values into the day” without a specific plan. If the latter approach does not seem to be meeting their needs, I would suggest shifting to the former. Regardless, I do suggest they try to preplan when they will engage in committed action as I find those who make a more explicit plan are more likely to follow through.

Upon return the next week, as we explore what unfolded, I am keeping my ear out for what might have gotten in their way of committed action, whether it be fusion, experiential avoidance, lack of contact with present moment, or lack of distancing and perspective taking.  The nice thing about the ACT processes is that they all overlap (see Hexaflex with interconnecting lines), so engaging teens in an experiential exercise to discern their observing self, for example, will touch upon all the processes and build the skills.  I may use some metaphors, visualizations or experiential exercises that target one process more than the others (it may be the exercise, or the way I process it that touches on a particular process) if the teen and I agree that this is what got in their way of being successful.

When teens are successful in engaging in committed action, I like to pause and really explore that with them so they can make sense of how they did what they did, and take ownership of their successes. Then we work collaboratively to identify next steps in an ongoing way.

Question 6

Hello.   Please suggest a book on this topic.

Sheri Turrell · Accepted Answer

I would suggest books by myself and Mary Bell, ACT for Adolescents, A Clinician Guide, as well as the Mindfulness and Acceptance Workbook for Teen Anxiety, co-authored by Christopher McCurry. Patricia Zurita Ona has written an excellent self-help book, The ACT Workbook for teens with OCD.  For a more general overview of ACT, I would highly recommend anything by Russ Harris, not just because ASK is his project, but because his writing is accessible and memorable.  I also recommend Mindfulness and Acceptance for Gender and Sexual Minorities, edited by Matthew Skinta and Aisling Curtin. If you come from a more traditional CBT background, you may find A CBT Practitioner’s Guide to ACT by Ciarrochi and Bailey helpful to bridge the gap, I know I did when I began learning ACT. Stoddard and Afari provide a compilation of fabulous metaphors in The Big Book of ACT Metaphors. I hope to soon offer a book review section on my training site, sheriturrell.ca, so stay tuned!

Question 7

how to deal with the repeated bad performance in online exam by a 21 year old male due to excessive anxiety. This person is reluctant to have counselling session...through suggestion how can i help?

Sheri Turrell · Accepted Answer

If anxiety is getting in the way of academic performance, and assuming such pursuits matter to this young man, and he is reluctant to attend therapy, I am left thinking that he is highly, highly, highly avoidant of his own feelings and this will take time and patience. Engaging in therapy is exposure to all the stuff inside we try to run from, the faster we are running, the harder it will be to stop and engage in the work. Perhaps he would benefit from a conversation about what therapy will look like and some discussion of his role in the process, that he is an active participant and can decide when things feel like too much for him to tolerate, and how you would respond if this happens. If dealing with this in person / online is too much for him, perhaps a self-help book would be a way for him to get started – I would of course, recommend the Mindfulness and Acceptance Workbook for Teen Anxiety (Turrell, McCurry & Bell) – it would be appropriate for his age.  I am left wondering if perhaps he has some conflicted feelings about school or his program or the course he is struggling with – as that may explain some of his hesitation to face his anxiety. If this last idea is confusing, it’s coming from my training as a psychoanalyst, which I find can complement my work with ACT – explaining further may get me into trouble as I will want to write a book and that’s not what I’ve been ASKed to do (pun intended).

Question 8

How can teenagers be helped to see that they can do something about their issues rather than blame it on their circumstances or others and feel helpless about it?

Sheri Turrell · Accepted Answer

Working with teens who have a role to play in their own struggles yet insist on putting responsibility elsewhere can be very frustrating for therapists.  If we are not maintaining our present moment awareness in such moments, we can get caught up inside our own judgments and behave in ways that may be experienced by our teen client as aggressive or shaming.  Having to take responsibility for ones struggles and making changes can be very daunting and bring intense shame, guilt and regret. This is just one of many circumstances in which a functional analysis can be helpful to support teens in uncovering their contribution to events in their life without piling on more blame and shame. Normalizing their behavior as avoidance, for example, is understandable and many ACT texts outline ways to explain how humans are ‘hard wired’ to try to fix what they don’t like, outside and inside, so trying to avoid unwanted thoughts and feelings is sensical and normal, we all do it at some point.  Teens in particular are wired to opt for short term relief as opposed to considering the long-term impact of behavior and normalizing this can go a long way to helping them take some responsibility without adding shame in the process. Feelings of helplessness need to be explored in terms of function and workability. Working to help the teen identify their own values, as well as what they can and cannot control will undoubtedly lead to behavior change.

Ultimately, I believe a strong therapeutic relationship, developed over time, will be essential to help such teens face themselves.  Blaming others and feeling helpless are examples of experiential avoidance, and these behaviors are serving a function – likely protecting the teen from feelings and thoughts that evoke vulnerability  – and it will take a strong and safe relationship to give them a context in which they can be with their vulnerability, and share it.

Question 9

How do 'usual' ACT interventions apply to teenagers and young people - do you reinvent / change the intervention in any particular ways?  I know a lot of young people who would absolutely roll their eyes at some of the exercises.  Do they just have to try it to believe in it?

Sheri Turrell · Accepted Answer

I find ACT to be tremendously fun and engaging with adolescents and have not actually had anyone resist too much. While there may be scepticism at first, they have all tried it with me. That said, I do a very ‘soft’ sell, I don’t insist, I ‘invite’ them to try experiential things such as playing ‘tug of war’ with a rope in my office, and if they don’t get anything out of a metaphor or experiential exercise, I don’t push it or try to convince them.  Once we have finished the assessment phase and explored the effectiveness of the teens’ avoidance behavior and the consequences of trying to avoid and control what you can’t really avoid and control (i.e., thoughts and feelings), the opportunity to try something very different is often met with relief and curiosity. From there, I think it’s a matter of tailoring your approach to suit your client.  Keeping developmental tasks such as identity formation, separation and increasing independence in mind, along with cognitive changes such as abstract thinking, perspective taking and metacognitive ability, gives me the ‘structure’ I need in considering how to proceed. Metaphors and experiential exercises followed by genuine inquiry into their experience encourages their development and growth.

In order to practice ACT well, I wholeheartedly believe that therapists must embody the philosophy and the underlying processes, trying them out for themselves in their day to day lives.  I would never ask a client to engage in a metaphor or an experiential exercise or visualization that I have not worked through myself. If we are genuinely and openly practicing ACT relative to our own thoughts and feelings, “believing” will not be an issue. For clinicians who have not tried to engage with their own values and make space for their own unwanted thoughts and feelings, I’d suggest they don’t practice ACT with someone else until they do!

Question 10

I have students, primarily between the ages of 9/10 and up, who answer my initial question of "what's going on/" or "Why are you here?" with a "Don't know."  It is often difficult to dig and find connections and make them aware of why their parents are concerned.  Any suggestions?

Sheri Turrell · Accepted Answer

These responses can certainly be challenging obstacles to moving forward with a young child and family. Functional contextualism comes to mind and would lead me to be very curious about the function and context of ‘I don’t know,” what is the child trying to communicate?   If they are trying to communicate an actual lack of knowledge or clarity, asking parents to explain their concerns to their child might suffice, and gives the clinician a window into the family dynamics. I would observe the child’s reaction to the parents’ explanation and try to gauge how they are feeling in response.  Does the child listen, smile, open their eyes wide and express the joy or relief that comes with clarity, do they look confused or angry, or do they put their head down or hide behind their hair, possibly overwhelmed with shame or guilt?

The parents’ explanation itself is part of the context in which the behavior of “I don’t know” is taking place. What information do the parents provide? What is the emotional quality underlying what the parents are sharing? When kids struggle with intense emotions, parents often arrive to the therapist exhausted and frustrated, hoping that the therapist can ‘fix’ their child / teen, and offer up a long list of things the child is doing ‘wrong’ that are ‘causing problems.”  Are parents feeling anxious or helpless in the face of the challenges? When this happens, kids pick up on that and want to avoid the fear and anxiety that comes with knowing a parent can’t help them, that they are “too much” for their parents, which leaves kids feeling very unsafe.  If this is the case, “I don’t know,’ may be a way to avoid their fear, hoping therapy will come to an end and they can avoid their own reality.  Summing it up, ‘watching the room’ is key – it’s a behavior analysis unfolding in present moment.

Question 11

Can you talk about the use of ACT with adolescents who have experienced "stubborn", chronic suicidal ideation that has been difficult to shake - even after participating in therapy (CBT, etc.)?  Any examples?  Thanks!

Sheri Turrell · Accepted Answer

I have worked with many such adolescents, each of whom struggle with chronic suicidal ideation for very unique reasons. My best answer is, it depends, meaning the first order of business is to understand the antecedents and function of the ideation and doing a behavioral analysis can help with this. I also suggest a semi structured diagnostic assessment to ensure you don’t miss something like major depressive disorder, borderline personality disorder, early psychosis or a trauma history.  Because ACT is a transdiagnostic therapy, the issue of diagnosis may be less relevant and sometimes even frowned upon, however, there are some people for whom knowing what to call their struggle is impactful in reducing shame, blame, guilt, and adverse reactions from those around them.   
 
Generally speaking, I would want to explore what is meant by ‘ideation,” and the antecedents and function of the ideation. Is the ideation representative of an actual intention, is it an obsession that is serving to help the teen avoid other unwanted thoughts and feelings, is it a way to draw in caring others, is it a way to express trauma, thoughts, or feelings that the client does not have words for, or is the idea giving the teen a way to imagine lashing out or punishing someone they are angry with, just to name a few possibilities.

If an analysis of antecedents, behavior and consequences reveals, for example, that the ideation is a way to draw caregivers closer and fulfill attachment needs, engaging the adolescent in exploration of short- and long-term costs and benefits may be illuminating and build motivation to change. That said, if this is what is going on, it may mean that other, healthier ways of engaging in relationships have not been, or are not currently, available to the young person and this may become your focus. If the adolescent has not experienced feeling cared for and connected to others, my therapeutic focus becomes our relationship, and helping the young person notice when they are feeling this way with me, and to make room for those feelings and choose their next behavior based on values. This can be very difficult work and it can be easy to forget that feeling cared for can be highly aversive if it is unfamiliar. For teens for whom this is the case, the therapeutic relationship can serve as exposure to difficult thoughts and feelings, for which we can help them use all of the ACT processes to support them in the moment that is unfolding, after we help them develop the skills.  Before engaging in exposure tasks, I do like to build up each of the processes and often use the acronym LLAMA to give adolescents a structure to use when needed (found in ACT for Adolescents).

If the ideation is an expression of anger that can not otherwise be expressed, that would lead to a different focus in therapy in which helping the adolescent to notice, name, and make room for emotions and physical sensations would be of central importance. At some point, parents or caregivers may need to be involved directly or with support of their own. I often find in such circumstances that parents are struggling to provide empathy and / or demonstrate emotional attunement and acceptance of the teen, which is leading to a lack of safer, healthier alternatives.
From an ACT stance, if the ideation is meeting a need (either through positive or negative reinforcement) normalizing the ideation and the need may be helpful, in terms of what the adolescent hopes it will help them achieve and the context in which this is occurring. You may want to explore the possibility that values are being expressed somehow in the ideation or the behavior that follows. My guess is that the ideation is ‘stubborn’ because it is not well understood, yet.

Question 12

I've been seeing teens who present with social anxiety symptoms that stem from their internal conflict in disclosing their sexual identity. They worry that their family and friends will not accept them, which could be true. Which ACT principles/strategies should I focus on first?

Sheri Turrell · Accepted Answer

I’m really glad you asked this question. I strongly encourage all clinicians working with adolescents to ask about gender and sexual orientation, as appropriate, so that teens don’t have to hide who they are, or who they are becoming, because we are blinded by our own biases and assumptions about who they are.

Given the overlap between the processes, a clear distinction may or may not be needed.  However, to give a bit more of a ‘linear’ idea, I tend to focus first on present moment awareness and building up “observing self” skills, so the adolescent can take a more present and distanced ‘look’ at those around them and be open to what they find, which may be that those around them will be unaccepting, or it may not.  Helping clients differentiate what their mind is telling them from what is actually happening around them can be very important when working with individuals who dread social rejection, and this would be no different. The more aware we are of the present moment, whether it be pleasant or unpleasant, the better able we are to cope with what unfolds.

At some point, I would introduce values and help this client explore the values that are part of each side of their conflicted inclinations about disclosing.  Because adolescence brings with it a developmentally normal tendency to engage in acts of protest, as well as acts of identity exploration, I would want to explore the function of their disclosure in terms of their timing and to whom they are thinking of disclosing – with a consideration of workability.   In this present moment, within the contest of these relationships, what is disclosing in the service of? I would suggest an emphasis on self-as-content, exploring the narrative they hold of themselves which may or may not include internalized homophobia for example. If your client decides to disclose, you could explore the possibility of a hierarchy, asking who would be the easiest to talk to first, who would be the most likely to be accepting, or who is safest.

Of course, as you work through all of this, unwanted feelings and thoughts may emerge, and you may need to pause and engage in defusion and allowing of internal experience before proceeding.  As you mention in your question, their fears of how others may react could be true, in which case trying to defuse may be experienced as very invalidating so caution is warranted.  And I would absolutely engage from a place of compassion and encourage self-compassion in this client.

Each of the ACT processes applies to the therapist too. We need to watch for our own fusion and avoidance and bring our values to bear when working with individuals who are different from ourselves in terms of sexual identity, as well as gender identity, culture, and power.  As you bring your own values into the relationship with your client, you will hopefully give them a safe space in which to explore the possibilities and to feel accepted, which will bode well in supporting them along this journey. Ensuring they have supports in place will help them to feel less alone and isolated, should their loved ones not respond as we would hope. What I have given is a brief overview, for a more detailed guide, I would highly recommend “Mindfulness and Acceptance for Gender and Sexual Minorities,” edited by Matthew Skinta and Aisling Curtin.

Question 13

Why do teenagers get depressed so frequently?

Sheri Turrell · Accepted Answer

This is a very important topic as depression impacts a significant proportion of the adolescent population (around 13 % according to World Health Organization, 2019). Functional contextualism, the philosophy underlying ACT, reminds us that both the function of behavior and the context in which behavior occurs are crucial to understanding the person we are working with. The developmental phase of ‘adolescence” is itself, a context – characterized by a desire for more autonomy, pressure to fit in with peers, increased freedom and access to technology, and exploration of identity, including sexual and gender identity.  Depending on how developmental factors interact with other contextual factors, such as economic status, education, culture, exposure to violence, trauma, gender and sexual identity, to name a few, some teens will be more at risk than others.

As the adolescent brain develops, teens become increasingly capable of abstract thinking and perspective taking.  While this has its’ benefits, it can feel like our natural human tendency to compare ourselves to others has just gone on steroids, along with the risk of being rejected from our peer group, which for some teens, feels tantamount to being utterly alone in the world.  Have you ever noticed comparing yourself to those who are less successful, less sociable, less attractive, less muscular, less of anything? Chances are, you compare yourself to those who appear ‘better’ in some way, and so do teens. Given their reliance on their peer group, this sets the stage for behavior aimed at being ‘good enough’ so they can stay in the group.  Believing you don’t compare favourably can lead to greater efforts at self-improvement, or to feelings of helplessness and hopelessness.  Just thinking about comparing poorly and being rejected can lead to feelings of loss and sadness, in the absence of actual rejection (please explore texts on the theory underlying ACT, Relational Frame Theory, if this intrigues you). Teens who respond to such thoughts by isolating themselves may set up a ‘self-fulfilling prophecy’ by pulling away from others and removing themselves from their peer group. I’m quite certain I could write a lot more on this topic, however, shall opt for brevity and hope there is something clinically useful in what I chose to include.

Question 14

What are some good ACT worksheets and resources for adolescents?

Sheri Turrell · Accepted Answer

You will often find worksheets and links for audio resources included in ACT texts and on the website for the Association for Contextual Behavioral Science (https://contextualscience.org), although some may need to be adapted for teens.  Mary Bell and I did include audio links in our first publication, ACT for Adolescents, however, we did not include worksheets, likely as a result of not realizing what a good idea it would have been, at the time, and because we often created worksheets spontaneously, as needed, to suit our client(s) at the time.  To be honest, we used very few worksheets in our ACT teen groups as the majority of teens did not want anything that even vaguely resembled schoolwork. Instead, we offered them ‘experiments” to try such as different mindfulness practices (Listening to music you don’t like is one of my favorites – I learned I actually do like Dolly Parton) and let them decide how to record their practice and what they noticed.

When clients have needed a worksheet, I create them by editing existing versions to suit my clients’ purposes. Even an initial general ‘monitoring’ sheet can be edited easily to include the following ACT consistent headings: situation, unwanted thoughts, unwanted feelings, behavior to get away from thoughts and feelings; short term costs and benefits, and long-term costs and benefits.  I recently created a worksheet to prepare a client for exposure work, with the following headings;  “what can I do when unwanted thoughts show up” (same with feelings)  so they can list whatever metaphors or experiential exercises we have done that have resonated with them, and a column for ‘important things I can do when these thoughts and feelings show up” so they have a ‘menu’ to choose from ahead of time (Thank you to Patricia Zurita Ona for this idea), and a column for short term and long term costs and benefits, some of which are already known to them, others are consequences they are testing out.

If you are looking for resources to support therapy, “The Mindfulness and Acceptance Workbook for Teen Anxiety,” written by Mary Bell, Christopher McCurry and myself, includes audio links and take teens step by step, through the ACT processes and can easily be used as a ‘workbook’ by teens as part of therapy or on its’ own.

Russ Harris is a prolific creator not only of wonderful books, but worksheets, that can be easily adapted to suit your needs, at https://www.actmindfully.com.au.

Question 15

How to set goals with an adolescent that is taken to therapy by someone else?

Sheri Turrell · Accepted Answer

This really brings to the foreground, the importance of assessment, formulation and informed consent. I don’t work with people who are mandated to therapy for any reason, so I can’t speak to that circumstance. It’s not uncommon however, for parents to insist that their adolescent attend therapy to ‘fix’ the teen, perhaps with the hopes of eliminating unwanted emotions or behaviors that the parents are finding difficult to manage but are not the top priority for the adolescent. I would take my time in the assessment phase and try to flush out each person’s primary concern for the adolescent and try to find some overlap as a way to gain cooperation.  Even if the adolescent did not want to attend therapy, is there the possibility that they may want to see changes in their life and will engage with me? Ultimately, if the assessment reveals that ACT is an appropriate model of therapy for the adolescent and what they are struggling with, I would explain the model to the adolescent and their caregivers, along with an explanation of how I work with my patients, and leave it for them to decide. Some will agree to give the adolescent their space to work on what they want to work on, other caregivers will need support of their own, or joint sessions with adolescent and caregivers, and some will decline. Keeping my own values in mind as a therapist and as a human, guides my behavior– coupled with my own boundary that I will not treat someone who does not want to engage in therapy with me.

Question 16

What are the advantages and disadvantages of ACT with individuals versus groups of adolescents?

Sheri Turrell · Accepted Answer

Group based ACT has been one of the most rewarding experiences of my professional life.  When I began working with ACT, I would methodically plan out the group content in advance and try very hard to stick to my plan. However, as I got more comfortable and experienced with the model, I quickly let go of my plans (this approach is not for everyone, it works for me) and opted for more spontaneity and creativity. This also meant I had to follow my discomfort into the unknown, which was accompanied by excitement, heartbreak, vulnerability, and compassion.  When moments unfold within a group of adolescents as we support them to let go of their narrative of not good enough and the shame that comes with this, and to explore their values and what truly matters, it can be transformative. What resulted has been some of the most meaningful and emotionally moving moments for the adolescents.  The normative ‘function’ of being in a group is not to be underestimated, as members experience, firsthand, what it is to be accepted, valued, and part of a group. Giving them a safe space to explore their self as content/narratives and let go of unworkable patterns of behavior, often as it unfolds in the group itself, can help adolescents carry forward very meaningful changes. The main disadvantage I have found is that groups can require a lot of facilitator time behind the scenes, debriefing and planning, as no two groups are ever the same and you will get personalities that are a challenge for facilitators, as would be the case when working in other modalities. Individual therapy, on the other hand, does allow for a more customized approach, which is beneficial if an adolescents’ struggles are not appropriate for a group setting or perhaps an adolescent is not where other group members are in terms of basic emotion regulation skills such as identifying how they feel.

Overall, I prefer group-based ACT when working with adolescents. When Mary Bell and I wrote our first book, ACT for Adolescents, we were thrilled to include a section at the end of each chapter for adapting the content to group-based work –finding the group format to be a wonderful opportunity to be creative and authentically connected to young people.  Although we provide a suggested sequence and content for the sessions in our book, our groups differed from one to the next.  While all of our groups were ACT consistent, we tailored the content to suit the participants, which many told us created a very unique and useful experience for them.

Although we provide a suggested sequence and content for the sessions in our book, our groups differed from one to the next.  While all of our groups were ACT consistent, we tailored the content to suit the participants, which many told us created a very unique and useful experience for them.

Question 17

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 18

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 19

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 20

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 21

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 22

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 23

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 24

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.

Question 25

How do you help adolescents who have harsh and critical parents?

Sheri Turrell · Accepted Answer

When caregivers communicate via negativity and criticism, what comes to mind is Baumrind’s classification of authoritarian parenting, characterized by high expectations, low responsiveness, and very little tolerance for mistakes.  It’s not difficult to imagine that children who grow up with this as their predominant parenting context will internalize the intolerance and harshness, incorporating it into their narrative of who they are by the time they are adolescents.  While this sort of growing up environment can have different outcomes for different people, I will speak to what I find is most commonly reported by my clients. In ACT terms, this would impact their narrative or self-as-content, presenting as self-loathing and a ‘story’ that they are never good enough, as well as fusion with harsh and critical thoughts (i.e., judgments and self-loathing) and avoidance of the emotions (i.e., shame, anger, anxiety) that come along with mistakes or the fear of making mistakes.  Often, I see teens striving for perfection in an effort to avoid criticism.  Life can start to narrow such that their time and effort goes into avoiding mistakes, keeping others soothed so they are not critical, and hiding emotions, at the expense of living a values-based, fulfilling life.  
Attention to each of the processes underlying ACT have a role to play in helping to support teens who grow up in this sort of environment.  When the situation is complex, I often find myself going back to the middle pillar of the processes (present moment and self as context) in order to ground myself and my client and to start building the skills necessary to help them step back from their critical sense of self and explore what is going on in more detail. Helping teens learn to get present and notice when their own harshness is showing up is an essential first step, as is being able to step back and observe what is happening. Infusing the work with self-compassion will be very important throughout.

As you move to the left pillar (acceptance and defusion), there will undoubtedly be very difficult thoughts and feelings that are showing up for your client.  I would keep alert for shame and anger, as the teen may have learned to hide these to the point they don’t even recognize when they show up anymore.   Tracking what shows up inside as well as what they do in response to their own inner world (i.e., thoughts and feelings) will be important, as they may engage in behaviors that are meant to soothe others in order to avoid harshness, sometimes at their own expense.  Many teens I have worked with go to great efforts to avoid criticism from others by speaking in a very derogatory way about themselves, in an effort to ‘criticize myself first so others don’t do it to me because that hurts less.”  Helping your client track what they do in response to their own judgments or anticipation of judgment from others will be very important, identifying both the short term and long-term benefits and losses (risks) with an emphasis on the interpersonal consequences of their behavior.

Values can be difficult for teens to identify if they are used to criticism. I often hear teens say, “but that’s like a complement” as though they are allergic to saying something positive about themselves. If thinking of who they want to be in a way that matters is very new for your client, they may struggle a great deal at this point, as we humans opt for coherence of our narrative, we don’t like things that contradict, even when it’s painful. When this happens, I have found it helpful to ask them to identify others whom they admire, and the qualities they admire, and would like to emulate in their own life. This creates some distance between the teen and possible values and allows them to step closer to values slowly and gently, without being overwhelmed and resorting to avoidance.  Helping the teen to identify values congruent behavior in session will be important with an emphasis not just on overt behavior, but also the qualities they embody within their behavior, and helping move them towards choice in terms of what matters.

One final area to consider is the teen in relation to their caregivers. I like to explore what the teen does in response to harsh / critical moments with parents – are they able to assert themselves, would that be safe? Is family work needed? Is parenting work needed? ACT can provide a wonderful structure to parenting and family work, with an emphasis on values-based behavior changes and using tracking to expand each persons’ perspective relative to their relationship and the impact they are having on one another.