In order to further examine the relationship between therapeutic program staff and young adults (see our previous article in the Winter 2024 issue of Insights), we explore three cases.

Tony Issenmann, Director of Family Programs at Blue Ridge Therapeutic Wilderness, discusses his staff’s interaction with a family that initially and unsuccessfully tried to use structure and even pressure to push their son toward “success.” John Tobias, founder of Red Cedar Transitions, describes the importance of accepting messiness in working with a complex young adult to establish his independent life. Chris Blankenship, Assistant Clinical Director and Senior Therapist, Open Sky Wilderness Therapy, describes the importance of allowing a client to evolve through their own messiness to reach a state of self-understanding and be able to approach the world with confidence.

Following are the three case studies. Names and some details have been altered to protect the clients’ identities.

Tony Issenmann, PhD, LMFT

Blue Ridge Therapeutic Wilderness

There is often tension between our emotional and intellectual understanding of an experience. What makes sense intellectually does not always resonate emotionally. The developmental stage of young adulthood is no different. While there is a desire for structure, routine, and a clear path toward a successful future orientation, the day-to-day experience is full of messiness. We understand the need for structure, control, and routine, and yet almost no one would describe adolescence and young adulthood as a neat and tidy developmental process. As with many other areas of life, this developmental stage is most successfully navigated when both experiences are accepted and tolerated.

Young adulthood is further complicated when considering that it is rarely experienced in isolation. Parents have their own desires for their children. And, while most parents can intellectually identify the reality that development is messy, most do not have the ability to tolerate being connected with their child during this messiness. This creates an interplay between the parental process and the young adult process. While most of the focus has been on the young adult, my experience has been that under typical developmental circumstances, the parent’s ability to tolerate higher levels of emotional distress, or messiness, is directly correlated with the young adult’s developmental trajectory.

This dynamic was present with the Rogers family. Daniel (19 years old) and his parents, Sarah and Matt, sought coaching for their adult son who “lacked the motivation and drive to complete school or to keep a job.” Daniel was open to coaching and stated his main goal was independence from his parents.

Like many parents (and programs), Sarah and Matt focused on providing structure as a way to help Daniel navigate the young adult developmental stage that, as an extension of adolescence, is full of identity exploration. The structure itself can have a limiting effect on the necessary exploration process. When not properly checked, the parental, or program, perspective can focus more on facilitating an approach that is tidy rather than one that leads to authentic exploration. Why might this be? I suggest it is not because parents or programs truly believe that tidiness is superior to authentic exploration, but rather because messiness is uncomfortable.

While Matt and Sarah did not name “messiness” as the main frustration they had with Daniel, when identifying their goals, they described wanting him to “go to college,” or “keep a job and not bounce around from interest to interest.” They described a sense of anxiety and fear that he would not learn to become successful. When projecting forward, they could only imagine scenarios of dependence. Their past efforts to “help” were based in providing structure: schedules, boundaries, timelines, and ultimatums. In their mind, these efforts were intended to guide Daniel to a successful and stable future. They had very limited insight about the role their own anxiety played.

When there is more room to explore because parents have a greater frustration tolerance, growth is more natural and authentic. This involves getting it wrong—which is often messy.

I do not believe Matt and Sarah are alone in their approach. It has been my observation that the underlying purpose of the structure parents wish to impose on their young adult child has more to do with the parents’ inability to manage emotions than their child’s absolute need for structure. Young adults often do need structure, and they want it. But they are also looking for independence. Structure imposed from the outside, especially from parents at this developmental stage, is often met with resistance. At best, this approach results in compliance-based success. At worst, it results in a refusal to mature. Both are reaction states to the parental unit. When there is more room to explore because parents have a greater frustration tolerance, growth is more natural and authentic. This involves getting it wrong—which is often messy. But in getting it wrong, the young adult learns over time to get it right. So, perhaps the greatest gift a parent can offer their young adult child is not structure, but rather a commitment to their own emotional growth (and perhaps access to a coach or therapist with whom the child can work as they experience all the messiness that accompanies true exploration).

This does not mean that parents need to accept anything and everything the young adult child wishes to do or explore. Guardrails are still required when behaviors are life-threatening. However, many parents see what is equivalent to an emotional or relational broken wrist but perceive it to be an emotional broken neck. It is the parental responsibility to learn to distinguish the two.

The focus of coaching with Matt and Sarah revolved around emotional awareness, increasing their distress tolerance and value-based boundaries. Daniel and I worked on setting clear goals, taking practical steps toward exploring his independence with intention, and staying connected to his parents. Over time, his parents showed a significant increase in their ability to tolerate Daniel’s exploration, and his efforts became less reactive.

This scenario is consistent among many families I’ve supported. I have found that the greatest success comes when parents work with a coach to increase their capacity to tolerate the emotional distress they experience, while the young adult child is supported as they independently work on hitting their next developmental milestones. Without support, it is natural to focus on solutions that are short-term and only related to symptom alleviation. However, with the support of a coach, parents and young adults can work toward systemic solutions that yield long-term developmental success.

John Tobias, Founder

Red Cedar Transitions

A 23-year-old male came to Red Cedar Transitions, an Asheville transitional living program for young adults. He had a long history of treatment, including two years elsewhere and wilderness therapy. He was adopted at age seven from another country and diagnosed with neurodiversity and extreme ADHD—meeting all criteria including inattention, difficulty staying on track, seeking stimuli, and extreme executive functioning challenges. (Keeping with his medications and appointments, however, he did succeed in going to work—arriving at 6 a.m., getting there on his own oftentimes by bicycle.)

Red Cedar is a program in which participants live on their own and have mentors averaging 12-15 hours a week and therapy with staff clinicians. The therapeutic work for this participant included interpersonal training and social pragmatics—developed to help him build awareness for how it is for others to be in relationship with him.

His goals in coming to the program were to build interpersonal awareness and get a job. He had held a job at a golf course, which he kept successfully until he had conflicts with coworkers and was fired following a physical altercation. While there, he had also ruined some equipment by not paying attention and using the wrong gas. Since then, he had held two other jobs—one for six to seven months—but he never got his driver’s license, as one employer had requested, and had more conflicts. He is currently working in a store.

We at Red Cedar consider him a success; he is in the world and learning from experience. His social training includes feedback from coworkers and bosses. He has demonstrated great resilience, never giving up. He is still working on growth with his interpersonal skills, as he would like to have friends and intimate relationships.

Executive function support includes helping him with cleanliness and orderliness. Mentors also work with him on learning social cues. Interpersonal work in therapy focuses on impulse control and mindfulness so he is not a slave to his emotions. He remains motivated as he continues to experience both negative and positive consequences of his behavior. We expect him to remain at Red Cedar for up to five years.

In a tighter container, he would lose motivation. Here, he gets to experience and learn to recognize healthy boundaries—he does not see staff as friends and has lost friends due to his inability to notice, understand, and respond to social cues. He has learned though mindfulness to see that his feelings will pass, and that these emotions are normal; a feeling or internal experience is not an enemy, but rather something to work with. Not allowing ourselves to experience feelings is the genesis of pathologizing—leading to anxiety about anxiety, panic about panic. Practice and repetition allow him to develop enhanced cognitive and psychological flexibility. 

Chris Blankenship, LCSW

Open Sky Wilderness Therapy

Emily arrived at treatment by way of a small, conservative town in the American south. She was a 19-year-old, cisgender female who had just finished an up-and-down freshman year at a small college. She enjoyed tennis and reading, and had a history of problematic behavior that included self-harm, fighting with friends and family, and risky sexual encounters. She came to treatment willingly and was eager to learn how to better engage in the world.

Emily was diagnosed with autism spectrum disorder, level 1, ADHD, depression, and anxiety prior to her enrollment in treatment—diagnoses that were quickly confirmed. Emily had black-and-white thinking patterns, struggled with disruptions to her routine, and was consistently behind in most social interactions. It was easy to connect the dots between those autism symptoms and some of the externalizing behaviors she had been exhibiting during her freshman year. These issues formed the backbone of our initial treatment plan.

Emily formed strong bonds with her peers and was comfortable in the milieu by her third week. In her fourth week of treatment, she started our therapy session with an abrupt and surprising declaration. Emily wanted to be a man. She was ready to start a physical transition that very day and wanted to talk about hormone treatment and scheduling top surgery. Emily suddenly threw a huge wrench into our previously straightforward treatment plan. 

Even though gender fluidity is considerably more common for people on the autism spectrum, it was not at all expected for Emily. She grew up in a place where transitioning was all but unheard of. Her church was steadfastly against it, as were her parents. Emily had never once given an indication that she saw herself as a man—she had always leaned toward more stereotypically feminine pursuits, dressed very femininely, and seemingly embraced the idea of womanhood. Having worked with many people in the first stages of transition, I knew that all of that was understandable and that it was important to follow Emily’s lead, no matter how potentially “messy” it may be with her and her family.   

Executive function support includes helping him with cleanliness and orderliness. Mentors also work with him on learning social cues. Interpersonal work in therapy focuses on impulse control and mindfulness so he is not a slave to his emotions.

Emily’s abrupt disclosure was messy for several reasons. Emily did not want her parents to know and did not think they would approve. Emily wanted to go by a new name and use he/him pronouns with all peers and staff without changing her therapeutic records. Emily wanted to start using a chest binder and wear all male clothing. I didn’t blink in my support. I embraced the new pronouns and led a group where Emily introduced himself as John to his peers. I got all new clothing for John and requested that they be disbursed at no charge to avoid a bill for all new clothing. I purchased a binder for John myself, for the same reason. I instructed all staff to use male pronouns, and changed all internal documentation to reflect the change, while keeping external documentation as it was to support John’s desire for privacy.

John spent the next three weeks navigating life as a man. He processed the difficulty of being misgendered and people using his dead name. John talked about the discomfort of the binder and the odd fit of his new clothes. John asked less and less about medical transition and seemed uninterested when I brought the information on hormone treatment that he had asked for.

By the fourth week as John, he completely broke down. He reported feeling more depressed than before and more anxious around people, and he had started to engage in self-harm for the first time since being in treatment. He looked at me in therapy and said, “I thought that being a man would make it go away.” “Make what go away?” I inquired. In the hours that followed, John shared for the first time in his life about being sexually assaulted as a child. John felt weak in the eyes of men and was hypervigilant about being attacked again. John hoped that being a man would allow a semblance of safety, but it hadn’t. Instead, it had caused confusion and deceit.

A few days later, John asked if she could go back to being called Emily, using female pronouns, and wearing female clothing. We sat down with her peers and Emily shared about being assaulted and about her fear of being a woman in the world. She apologized and was met with more kindness and support than I could have ever hoped for. In the weeks that followed, she talked openly with her parents about her gender “transition,” and the reasons behind it. She told them about being assaulted, the impact that it had on her, and the ways that her problematic behavior connected to the trauma. We spent the remainder of Emily’s stay working on her autism symptoms, depression, anxiety, and most importantly, her newly identified post-traumatic stress.

Emily came into treatment with years of fear built up inside of her and having done everything in her power to protect herself from that fear. Being in a safe treatment environment allowed her to attempt one last thing to make her fear go away, but she soon found that it too was ineffective. Emily needed to replicate “messy” patterns of avoidance, and withholding from her parents, to learn that her old behaviors weren’t going to work. While my initial inclination was to question Emily’s ideas about transitioning, I knew that it was important to attune to her and initially support her desires. Emily’s messy divergence into gender identity treatment helped her to feel safe and cared for—it allowed her to finally admit what she was running from and to get the structure and treatment that she actually needed.

Today, Emily still goes by Emily. She is finishing college, in a long-term relationship, and has a strong connection with her parents. She still relishes beating guys on the tennis court—not because she’s afraid of them—but because she loves herself.

Compiled by Cynthia Cohen, MSPH, IECA (CO)