When the child describes a stressful situation, find out how that makes the child feel. These children often respond “Fine,” “Okay,” shrug their shoulders, or say, “I don’t know.” The toolboxes you acquired in Goals 1 and 2, together with the COMFORT techniques (Fig. 7.1), and the dialogues presented below will help you create an environment in which the child can comfortably explore and verbalize emotions associated with stressors.

This 16-year-old adolescent [E] has been in therapy for approximately 9 months. At initial diagnosis, her PNES symptoms were occurring daily and involved full-body convulsions. Three different regional epilepsy centers misdiagnosed and treated E for epilepsy. The fourth epilepsy center diagnosed PNES, and her family accepted this diagnosis. Her episodes resolved after eight individual therapy sessions. Her stressors, identified at the onset of therapy, included advanced placement classes that required more work than the teen felt she could manage, a busy traveling hockey schedule, bullying by a group of girls in her class, and what was described as the “typical” frustration teens feel about their relationship with their mother.

E presented as an attractive, quiet, and rather unconcerned teen. She easily expressed irritation with her family members for being overly concerned about her symptoms. She also felt frustration because the bullies in her class were making her life “challenging.” Although she showed little happiness or excitement about her academic and sports accomplishments, she spoke of them openly. E seemed to be comfortable and relatively confident at the outset of therapy. It became clear during the first several months of therapy that she was quite self-conscious and guarded about discussing her true feelings. It was difficult to help her express intensity in her emotions. When she described situations, everything was “fine” and “normal.” Over time it became clear that this was not an accurate description of her life at home and at school. The therapist was aware of more than “typical” teenage difficulties between mother and daughter and the mother’s very critical stance. The dialogue below demonstrates how not to probe for stress-related emotions. The blue bubbles comment on the therapist’s techniques and the yellow bubbles on E’s responses.

Therapist: How are you? How has your week been?

E [without much excitement]: Pretty good. Umm, I haven’t had any episodes, so only 2 months until I can drive again.

Therapist: You must be really happy about that. You have enjoyed driving in the past, right?

E: Well, I guess I haven’t been able to do much of it, because these episodes were always happening. It will be nice to be able to get away though.

Therapist: Yes, you mean to be able to go places that you’d like to go more on your own?

E [rolling her eyes]: Just to get out of my house.

Therapist: Getting out of the house and being with friends without needing to be driven around will be really nice.

E: And I’ll get to go out with my boyfriend again without my parents needing to drive us everywhere.

Therapist: That will probably feel very good.

E: Yeah.

Therapist: So, what kinds of things do you like to do when you get to be on your own?

E: I like to be with friends. I prefer being out of my house, so anything that gets me out of the house.

Therapist: Why don’t you like being at your house?

E: I don’t know, it’s boring.

Therapist: Just not a lot to do there?

E: Not really. And my brother is really annoying.

Therapist: Yeah, little brothers can be pretty annoying.

E: He just won’t leave me alone.

Therapist: So, getting out of the house would be nice and being with friends and your boyfriend. Now that your episodes are well controlled, are you planning on going back to the hockey team?

E: Probably.

Therapist: We talked last week about goals that you want to try to accomplish including managing your schedule a bit so that you did not feel like you couldn’t have a social life. So, have you thought any more about how we can approach that goal? Which things that you are doing do you feel like you could put on hold?

E: Well, since I’m not driving a lot of the stuff after school is already put on hold because my parents won’t pick me up late, so I end up being stuck in my house all the time.

Therapist: Oh, well, maybe that is a good thing. Because it’s kind of forcing you to slow down a bit and have a little more free time and not be so overscheduled?

E: But it’s boring and then I’m stuck at home all the time.