Most parents arrive at the idea of therapy late, and often sideways. Something has gone wrong; grades have fallen through the floor, a bedroom door has slammed shut and stayed that way, a school nurse has rung with worrying news. By the time parents pick up the phone to me they have usually spent months telling themselves it’s ‘just a phase’. And here’s the thing: sometimes it is. Teenagers are supposed to be moody, secretive and catastrophically bad at loading the dishwasher; all this is annoying for both them and you but also ‘developmentally appropriate’. The trouble is that the markers of ‘normal’ adolescent misery and the beginnings of something more serious can look identical from your standpoint in the kitchen.
I spent well over a decade working with teenagers in a secondary school setting, and I still see this demographic in my private practice. What follows is what I wish every parent knew before they needed it: that good therapy, when it’s really needed, is well worth the investment, and how to tell a good therapist from one who will waste your money and, worse, your child’s trust and goodwill.
Why therapy helps
The fact is that adolescence is when much mental illness begins; over half of all lifetime psychiatric disorders have started by the age of 14;¹ according to the NHS, roughly one in five children and young people now has a probable mental disorder.² Personally I think that’s probably overstating the case, but it’s still a statistic worth taking seriously and certainly suggests that waiting to see whether your angst-ridden teen will ‘grow out of it’ may be a risky gamble.
The good news is that there is evidence that therapy can help; a meta-analysis of 447 trials spanning five decades found that psychological therapy for young people produces meaningful, durable benefits;³ the effects are not miraculous, but they are real. And NICE (and I am well aware we don’t all have nice things to say about NICE but it’s a serious institution nevertheless) recommends psychological therapy, not medication, as the first-line treatment for mild depression in young people.⁴
Timing matters too. The adolescent brain is unusually plastic in comparison to that of adults; habits of thought and ‘ways of coping’ laid down now tend to stick. Teach a fifteen-year-old how to sit with discomfort rather than drink it, snort it, starve it or scroll it away, and you have given them a skill they will keep forever. Of course you can do all this later (after all, if you couldn’t, why would one ever treat adults?), but it takes a bit longer and, just as importantly, there is likely to be more baggage and collateral damage later on that a teenager treated in a timely manner may never accrue.
There is something else just as important: teenagers will often say to a stranger what they cannot say to their parents. This is not a failure of parenting; after all, separating from you is the developmental job of adolescence (‘individuation’ if you want the technical term). A therapist is an adult who is not their parent, not their teacher and not ‘grading them on performance’; that gives this relationship something special. I have also found that when the real problem is trauma, ‘big T or small’, treating this directly often allows the depression and anxiety sitting below it to fall away of its own accord.
What to look for in a therapist
Registration. It may alarm you to discover that in the UK, ‘therapist’, ‘counsellor’ and ‘psychotherapist’ are not ‘protected titles’; this means that anyone can use any of these after a weekend course, or even no course at all. Check that the person is on a register accredited by the Professional Standards Authority, such as the BACP, UKCP, BABCP (for CBT) or the Association of Child Psychotherapists. Clinical and counselling psychologists must be registered with the HCPC. If you ask someone with whom they are accredited and they seem somewhat vague, I’d suggest you are very much less vague about ending the conversation.
Experience with adolescents. Teenagers are not small adults. Ask how many young people they currently see, and what training they have had in working with them. Anyone working with under-18s should also hold an enhanced DBS check and be able to explain their safeguarding procedures without a glacial pause to ask Google for their answer.
The right approach for the problem. Now this is tricky. There is evidence that different difficulties seem suited to different modalities, and to some extent they are. For example, CBT with exposure work seems the treatment of choice for anxiety and OCD; trauma-focused CBT or EMDR for post-traumatic stress; and family-based treatment for anorexia.⁵ A good therapist will tell you what they intend to do and why; a poor one will tell you they are ‘integrative’ without explaining what that means or how this approach is likely to benefit your particular child.
Fit. Having just said why models matter in treating specific presenting problems, just as important is the ‘fit’. For many teenagers who are just feeling rotten, the ‘model’ matters less than the ‘therapeutic alliance’ they strike up with their would-be therapist. The quality of the relationship between therapist and young person is one of the most consistent predictors of whether therapy works.⁶ Let your teenager meet them and give it three sessions or so before deciding. Their verdict counts more than yours; after all, you are not the one who has to sit in the room and bear the darkest recesses of your soul. In my experience, a lot of teenagers do not want gentle nodding from a woolly counsellor with comfortable shoes and no map of the teenage territory; they want someone who does not flinch, does not patronise and can on occasion make them laugh just when they feel their cosmos is collapsing.
Confidentiality, red flags and practicalities
Parents often find confidentiality the hardest part. You know that at least some of what is said relates to your relationship and the life you have tried so hard to create for your child. However, you need to be able to cope with this. Your teenager needs to know that what they say will not be relayed, verbatim, to you; without that, they will tell the therapist exactly what they tell you, that is to say, nothing of note. A young person who understands their treatment and the limits of confidentiality can consent to it in their own right. A good therapist will explain at the outset what stays private and what does not; if there is a serious risk to your child’s safety, you will be told. Anything else, you will not.
Be wary of a therapist who:
- promises a quick fix, or a cure in six sessions
- offers you a weekly rundown on what your child has said in confidence
- shuts you out entirely, and most importantly with no agreement about how risk will be communicated
- cannot tell you what the plan is, or how progress will be reviewed
- takes sides; therapy is not a tribunal, and a therapist who recruits your child against you (or you against your child) is doing harm whatever else they do.
On a practical note, start with your GP and your child’s school. NHS CAMHS is free but waiting lists are l o n g, and thresholds are therefore by necessity high; many schools have counsellors who can see a young person in the meantime and in many cases, this is all that is needed. Counselling Directory is a good place to start if you can afford to pay privately, and many will be happy to do a free intro chat online. Private fees vary widely, so ask applicants upfront what these are, along with the cancellation policy, which must be communicated to the child. A short initial consultation, ideally with your teenager present for at least part of it, will tell you more than any website, however fancy.
A final word
Asking for help on your child’s behalf is not an admission that you have failed; it is one of the more competent things a parent of a child in distress can do. Your teenager may well roll their eyes, refuse the first appointment and insist they are ‘fine’, which we all know is an acronym for ‘Fucked Up, Insecure, Neurotic and Emotional’. Take them anyway.
Some of the young people I have worked with spent their first session glaring at me in silence with an air of quiet malice: arms folded, hood up, phone face down on the table like a loaded weapon they were prepared to use at the first sign of trouble. I have learnt not to take this personally. Silence in a first session is rarely indifference; far more often it is a test. They want to know whether I will fill the void with platitudes, whether I will be shocked, whether I will report straight back to their parents, and whether I am simply one more adult with an agenda. And yet many of them later told me it had been an absolute game-changer. It was the one hour in the week when they did not have to ‘perform’ being okay, the one room where nobody was disappointed in them, and the place where the pressure that had been building, quietly and dangerously, could finally be released. What no self-respecting teenager would say, but is no less true, is that once the initial pressure has been released, the actual work begins and the real magic of psychotherapy can begin to exert its effect.
References
1. Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R. & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6).
2. NHS England (2023). Mental Health of Children and Young People in England, 2023: Wave 4 follow up to the 2017 survey.
3. Weisz, J. R., Kuppens, S., Ng, M. Y., Eckshtain, D., Ugueto, A. M., Vaughn-Coaxum, R., et al. (2017). What five decades of research tells us about the effects of youth psychological therapy: a multilevel meta-analysis and implications for science and practice. American Psychologist, 72(2).
4. NICE (2019). Depression in children and young people: identification and management (NG134).
5. NICE (2017). Eating disorders: recognition and treatment (NG69).
6. Shirk, S. R. & Karver, M. (2003). Prediction of treatment outcome from relationship variables in child and adolescent therapy: a meta-analytic review. Journal of Consulting and Clinical Psychology, 71(3); Karver, M. S., De Nadai, A. S., Monahan, M. & Shirk, S. R. (2018). Meta-analysis of the prospective relation between alliance and outcome in child and adolescent psychotherapy. Psychotherapy, 55(4).
