James was a depressed and lethargic 13-year-old boy who’d almost given up when I first met him. During the time I treated him, he went through some death-defying experiences, two psychiatric hospitalizations, and a tough court hearing, as well as a therapeutic turning point in which he discovered something that gave his life meaning. Although it’s been a long time since we first spoke, I remember that first hour vividly; I can still see him shuffling slowly, reluctantly, into my office. He kept one earplug in, the other draped around his neck, blaring Metallica, a band that the disenfranchised boys on my caseload loved so much I could recognize it despite the tinny sound coming from one distant earbud.
James barely acknowledged me during his first visit, acting like he was on a forced death march as he entered my sunny office. He sat as far from me as he could manage on the couch, angling his body so none of him was pointing in my direction. Crumpled over, he began picking at the shredded bottom cuff of his jeans and flicking little threads onto my floor. Disengaged and annoying, I thought, feeling instantly anxious—along with a deep and heavy sense of how hurt he must be feeling to greet me in this sad, distancing way.
I slowed my own pace down, trying to get some control over my energy and nerves. Be less overwhelming, I told myself. I asked a few questions, pausing and breathing into the spaces between, and noted with relief that James didn’t shut me out completely, although he ventured only terse responses that were perhaps as much as he could muster. About 20 minutes in, I gently shared my own experience of sitting with him there, tentatively wondering aloud about his guardedness and acknowledging how much all of this must suck—including, I imagined, being in therapy with some nosy, middle-aged, hippie lady like me. I said I could understand if he didn’t want to be doing this. I told him that I’d take some responsibility for making it more fun for him, since he was pretty much mandated to be here—which also probably sucked.
James didn’t respond to my query with words, but he glanced up at me, dark, startled eyes filling with tears, before looking away even more fiercely than before. I knew he was lonely and frightened, and I had an inkling about some of the reasons why. At that point, I also understood that he was fragile as a teacup; I wouldn’t expect to engage him in “real therapy” for many weeks to come. First, we had to find a safe way to be together in the room. That day we began to play Rummy 5,000—an epic version of the traditional card game, requiring multiple therapy sessions to complete and, not incidentally, moving James’s body, mind, and focus gradually in my direction.
I saw James for more than three years. For the duration, his father was in prison for multiple serious offenses, and they had no contact. James’s opiate-addicted mother came and went, sometimes in jail, sometimes trying hard to get clean, often unavailable, and ultimately a tragic disappointment. Initially, James could visit her when he wanted to, or when she was interested in seeing him; at one point, before losing custody permanently and moving far away, she joined us for a few sessions. It was helpful for James’s healing that I saw both her remnant love for him and her heartbreaking limitations.
James lived mostly with his grandmother, who’d gotten temporary guardianship of him the year before. When she was exhausted or unwell, he’d stay with his aunt and uncle an hour away. This wasn’t a perfect arrangement, but it offered more stability than he’d had previously in his life. He was struggling academically for the second time in the seventh grade and, because he was sleeping so poorly at night, he snoozed through many days in school, making it impossible to keep up. The overwhelming combination of his chaotic family life, a reading disability, the move to a new junior high school, and his relentless depression had taken quite a toll on his motivation. But without a safe relationship, I couldn’t help him with any of that.
In recent years, scholars studying interpersonal neurobiology (IPNB), adolescent development, and relationships of all kinds have arrived at similar conclusions regarding the importance of attachment bonds across the lifespan and the crucial role attachment plays in psychotherapy. Current thinking about psychological growth and healing emphasizes human interdependence and connection, rather than separation and individuation, even during adolescence. It’s now widely agreed that the self develops in the context of relationships; the compelling existential truth—particularly vital for anyone working with teens to consider—is that a coherent identity emerges only in connection with others. These dynamic models of psychological well-being recognize that authentic caring relationships provide the keys to optimal development, and nothing else will do. The conclusion from more than a half-century of research on the importance of human attachment is clear—love is good.
Developmental–relational theory (DRT) provides the evidence-based rationale—drawing from attachment research, the study of contemporary adolescence, and IPNB—for the value of secure love in therapy with traumatized teens like James. It offers an integrative framework for why and how to pay steady, benevolent attention to someone who may never before have had anyone’s steady, benevolent attention. In its emphasis on right-hemisphere attachment and feelings, this approach reflects a set of values that are distinct from more cognitive-behavioral approaches; in its reliance on the slow, hard work of corrective relational experiences, it also distinguishes itself from other, more technique-driven and solution-focused models.
With traumatized adolescent clients, it’s emotion that gradually changes emotion—not rational explanation or interpretation, not snazzy techniques or “fake it till you make it” exhortations. Indeed, while I offer many suggestions for “things to do” in therapy, I’m under no misapprehension that these strategies constitute “techniques” much beyond their utility in forming, maintaining, and repairing the strongest possible therapeutic alliance.
Because we’re adults working with kids, DRT does not, strictly speaking, strive for the more symmetrical power arrangement that’s generally emphasized in contemporary relational work with adults. Yes, we want to be collaborative, to co-create a therapy we do with and not to our young clients. However, we must be willing and able at times to step out from behind our neutral stance and really show up as concerned adults do. It seems to me that, for so many of these kids, the real ADD is adult-deficit disorder; their struggles in life largely stemming from the adverse developmental impact of adult inattention.
In fact, what we therapists have to offer our young clients, more than anything, is our well-regulated, fully developed, two-sided adult brain, with its mature capacity for awareness, perspective, appraisal, curiosity, and forgiveness on full display. We make and sustain connections, we repair inevitable ruptures, we provide the safe haven and secure base. In DRT, we’re both the mechanism of change and the intervention. Because we are the adults in the room, we are responsible for what happens in treatment.
Connection and Authentic Emotion
DRT keeps us attuning and reattuning to the adolescent in the moment because only through new healing experiences can the teen’s right brain learn to fire and rewire for safety and intimacy. Here are a few fundamental strategies to accomplish this.
Keep It in the Room. Whenever possible, bring the conversation into the present. In this work, we privilege the relational-emotional experiences in the moment over all other topics. As much as possible, the real-time connection between therapist and adolescent takes precedence over the other relational experiences in their lives—indeed, over most other kind of stories they’re telling about what’s happening outside in the “real world.” We make that focus explicit, bringing it back into the moment. We note, “People made you mad today; am I making you mad?”; “It seems you’re expecting me not to understand this since your teacher didn’t. I imagine that’s pretty frustrating right now”; “I’m feeling confused; are you?”; “My stomach just clenched a little hearing that”; “What happened right now when you laughed at that?”; “You seem pretty fidgety today; can I help?”; “I’m with you”; “It is scary”; “We’re not connecting well right now, and I want to do better”; “That is hilarious; tell me more!”; “I’m so moved that you’re able to tell me this”; “Can we sit here together, feet on the ground together?”; “I’m feeling a little worried about you, is it okay if I say so?”; “I think I just missed the boat on that one, I’m so sorry; can we try again?”
Repair Quickly. All therapists—no matter how well trained, how deeply present and compassionate, or how skilled—miss a lot. It’s simply impossible to pay attention to and “get” another person all of the time. Fortunately, rupture and conflict are not only inevitable, but also crucial to development in therapy. This isn’t to say you should intentionally show up late, or contrive some issue so you can resolve it. No need for that: you will screw up sometimes, without even trying. The important treatment element here, however, is to acknowledge when you realize you’re not in sync, even if it’s minutes or possibly weeks later. Don’t hesitate to try and try again, no matter how trivial the lapse might seem to you.
A few years ago, I worked with a young man whom I once addressed by his younger brother’s name. (Years later, I’m still defending myself in my head: seriously, their names rhymed, like Jon and Don do). He winced when I misspoke, so I could tell that this error really affected him, but I let it slide—along with our connection for most of the rest of the session.
In my semiaware mind, I thought, People make mistakes; this one is small. But for this teen, my mistake and my disregard were still hurtful, perhaps tying into a lifetime of feeling unseen and unimportant. With just a few minutes left to go, I started to repair, and asked about the moment of rupture, also apologizing for not apologizing sooner. He remained a little grumpy, but came back the next week to try with me again, which he might not otherwise have done. And I worked harder to notice the next time he showed me that we weren’t in sync.
The truth is that misattunement is simply inevitable. But we can take some solace from the work of Ed Tronick and his colleagues, who minutely observed interactions between infants and their mothers. This research demonstrates that even the best parents get it wrong a lot: on the first try, they can miss the baby’s signals a staggering 70 percent of the time—and still end up with securely attached kids. As with therapy, the interesting part isn’t the misattunement; it’s what happens next. Tronick’s research demonstrated that the infant’s emotional regulation was actually enhanced by ruptures that were followed by repairs. Babies with this experience develop greater mastery of their dysregulated states and an increased sense of safety and security in relationships. Within that dance of attunement, these early missteps and corrections generalized to other relationships, too. And of course, sustained intimacy is only possible for people who are capable of resolving inevitable conflict.
But the traumatized teens we treat usually have long histories of rupture without repair. I may have been the first adult who ever apologized to them. They have precious little tolerance for the hard work of trying to make a relationship better. One of the common outcomes of developmental trauma for adolescents is a microscopically short fuse for rejection, disappointment, failure, or emotional abandonment. They physically experience a call for whatever secondary strategies they’ve developed to regulate in the face of this too-familiar sense of disconnection, perhaps most notably the flight response that advises their bodies to “Run fast, and don’t look back.” This means that the effort to reconnect after a rupture, no matter how small and seemingly inconsequential, is 100 percent ours to make. Resolving conflict and reattuning are fundamental to this work, so we absolutely need to face disconnection when we feel or know it happened.
We say, “I shouldn’t have interrupted you”; “I’m really struggling here, and I can tell I’m not getting it at all”; “I’m so grateful you’re willing to keep trying to tell me what’s going on”; “I was a kid a long time ago, so I need to have things explained to me that would make it easier if I knew.” We find the courage to apologize—“I’m so sorry, please forgive me”—and then we try to fix it any way we can. We get better doing this in a general way, and it gets easier to admit mistakes as time goes on. Still, there’s a specific strategy to learn for reattunement with each adolescent. Just like the mothers in Tronick’s research, we’ll have to figure it out through trial and error as we go along together in that particular intersubjective dance.
Be the Adult. The therapeutic relationship here is both real and transferential. Thus DRT with traumatized adolescents requires that we make sense of who we are to the teen, both as our authentic adult selves and as stand-ins for all the other adults they’ve ever known or needed. Devaluing our importance to them as caring adults might be humble or efficient, or fit theoretically into more manualized paradigms that “anyone could do.” It might somehow get us off the hook—write off a therapy that goes less well than we wanted, or say goodbye without pain, and forget them more easily. Still, this stance really reflects a kind of childism; we can too readily reduce ourselves to the role of technician, or interventionist, and keep the work from getting “too personal.” But these teens aren’t going to get generically healthier in therapy, as if there were any such thing as “generic health”; they’re going to grow up to become more like us. They’ll learn about love, repair, problem-solving, and what regulation feels like from how we do these things—from how we live in the world, and from being in this specific, unique relationship between a vulnerable child and a caring adult.
And so it makes no sense to be neutral with the same equanimity with which we’re trained to treat adults. Yes, our adolescent clients are sharing deeply personal information with us, and we know how fast we lose contact when we start judging and preaching. But they’re also telling us stuff so that we’ll react to it. We have an obligation of sorts to share our experience of being with them—from the unique vantage point of perceiving them with our adult senses.
We describe our experience of them, to help them. We might want to say, “I’m feeling really worried about you right now because you’re not being safe”; “I’m very proud of you. Did you know that?”; “I’m a little anxious about telling you the answer is ‘No’ because I imagine you’ll be very disappointed”; “It’s been a long time since I was your age, but maybe my experience with bullying might be helpful”; “It’s your choice, and I wasn’t invited to that party so I won’t be there, but can I tell you what I think might happen if you go?”; “I’ll care about you just the same whatever you decide, but I wonder if I might suggest something that could help?”; “Of course it’s true, as you say, that the world has changed a lot since dinosaurs roamed the earth, back when I was 16, but I’ve learned a lot about broken hearts in all that time, and I still believe that having your heart broken never stopped being excruciatingly painful”; “I remember what happened the last time, so I wonder if I could make a prediction here”; “I know it feels terrible now, but I’m pretty hopeful that it won’t always hurt this much”; “You are one of the bravest kids I’ve ever met.”
Be Kind. Sometimes when I supervise graduate students, I see them getting tangled in theory and in their own heartfelt desire to say or do the perfect, healing thing. These neocortical distractions pull them up into their own heads and out of relationship. They may take on an officious, helpful tone, or the deliberate mannerisms of someone trying to sound like a grown-up or, worse, a therapist. My eager students offer psychoeducation and interpretation, or they ask for information about tangential elements of a complex narrative, just to keep the conversation going along the surface. They’re thoughtful and hardworking; none of this effort is particularly harmful. But I want them to get out of their heads and into the room when they start feeling disoriented or preoccupied about what to say next, too. So I suggest this to them: “If you don’t know what to say or do, just be kind. You can even ask yourself, ‘What would a friend need?’”
Therapists are under a lot of pressure to do something transformative in every session, to fix whatever in the room seems broken, to make it better fast. Sometimes this desire stems from expectations of supervisors or insurance companies, or simply from compassion for desperate parents or frighteningly dysregulated teens. Before you try to do anything else, though, frontload empathy and validation; indeed, empathy and validation may be all that are needed in this moment. It never hurts to be kind. And no matter what we do next, first we must make the limbic connection that lets our adolescent clients know that we get how hard this is for them, and that we respect that. If it were easy to fix, they’d have done that already. If you don’t know what to do, listen fully—allow yourself to feel for and with them. Be kind. For these kids, that’s an intervention.
Go Deep into the Small Details. Adolescents live in the small details of their lives. In many ways, all of us do. But the teen who doesn’t yet have formal operational thought is learning very directly through her daily experiences. Real events, when shared so they’re practically relived in the therapy room, provide the adolescent with the opportunity to be both the subject and the object of her own story; she gets to see, hear, and feel what happened to her in the recounting, and to experience herself as interesting, and worthy of your interest. In this way, a detailed account of a seemingly small event expands and takes shape with the support of an affectively engaged and curious therapist. This kind of sharing of experience also helps it make emotional and logical sense.
See what happens when you stop trying to “do deep work” and instead explore actual events in as much minute detail as the teen can handle. There’s meaning everywhere, even in the lunchroom at school or on the hair-soaking walk along a rainy street to your office. We get so confused by content and by whose agenda we need to serve in a given hour. My advice is usually to go with the flow; don’t be worried if you’re “just” talking about another fight with another ex–best friend. If that’s what’s most readily available, see what happens when you go all the way in, with your heart and mind fully engaged.
Be Playful. Trauma therapy is, much too often, serious business. When we think about “doing trauma work,” we may assume—incorrectly—that it shouldn’t be fun or playful. Remember, these aren’t adults we’re dealing with, and our young clients probably didn’t get much time to “just be kids” before they hit adolescence, making them less resilient now. Neglect and abuse not only interfere with secure attachment, but also with the behavioral system of exploration and play.
Without a secure base, the capacity to play gets compromised; traumatized children can’t manage the wide range of arousal states or the level of undefended absorption that play requires. The unpredictability and novelty of play may be too evocative of the unpredictability and danger of earlier traumatic experiences. Furthermore, it might be that some of our adolescent clients don’t play because they’ve come to associate positive affect with vulnerability to ridicule, disapproval, disdain, or even punishment. All affective states, including the ones that we might associate with a fun time, have their perils for these adolescents.
In DRT, then, don’t just pay attention to the trauma story and attachment-related issues; look for opportunities to engage more playfully, too. These may be just micro “now moments” where eyes meet and knowing smiles are exchanged, moments that offer the possibility for more expansive, enjoyable times, too. Linger on a guffaw, laugh at yourself (but never at the teen, unless you’re laughing together and he clearly gets his own joke), expand on something that seems ironic, comical, or just mildly amusing. Notice when the connection feels lighter, or something tough has been accomplished; relief can feel good, too. Laughter is an attachment-based affect, and it can be good therapy to share such joy.
For adolescents who struggle to see the good time in traditional talk therapy, and are rigidly defended against playful movement or banter, I often like to include play-based activities that involve turn-taking or mutual focus, particularly ones that can get a tiny bit messy, or give me the chance to be amused with what’s happening. I’m not above blowing bubbles, balancing peacock feathers, shooting Nerf baskets, playing catch, or doing a jigsaw puzzle if it might be fun, regulating, and connective to do so. In the past couple of years, I’ve also helped make original board games from a kit; one girl I worked with even rebuilt the board game “Guess Who” using pictures of kids from school, telling me all about these classmates as we constructed it.
You don’t have to play or goof around with your adolescent clients, of course, and many don’t want to, but you can. While therapy with traumatized teens is often really hard, sad, wrenching work, it needs to be more than that, too, so they can live fuller, happier, more integrated lives when we’re done. And don’t forget: we’re successful when our clients feel co-regulated at the end of a therapy hour, any way we help get them there.
I had to hospitalize James on two occasions. Truth be told, I had my eye on him from the start because, a month into our work, he’d punched a wall so hard that he broke his hand. Then, that first spring, he was often covered in bruises and scrapes that he attributed to simple carelessness while practicing tricks on his skateboard. He’d had at least one concussion that I knew about.
I worry in a particular way about traumatized kids who have this kind of trouble keeping themselves safe: there’s always the likelihood that they might be engaging in dangerous, unconscious reenactments. I came to believe James had a self-destructive streak that developed in response to feeling so unsafe in his home when he was small. He still had trouble keeping his body safe.
About six months into our work, James had, once again, been doing skateboard stunts, and deliberately catapulted himself off a bridge into a deep, cold river. Although, amazingly, he suffered only minor injuries, he wasn’t clear with me about what he’d hoped would happen. When I asked about suicidal intent, James just shrugged and said softly, “Who cares?” I did, of course, and got him an inpatient bed that day. He stayed just a week, though, since he was able to spin the incident as a knuckleheaded teenage act, and convince staff that I’d misunderstood him.
The second hospitalization, about a year later, was more serious. His grandmother, sensing he was more depressed than usual, had checked up on him before bedtime and discovered to her horror that he’d been busy constructing a noose. She quickly brought him to the emergency room. This incident, a more unambiguous suicidal mission, led to a month-long stay in the psych unit.
The precipitating events were clear. A few days earlier, James had taken the brave and unusual step of calling Child Protective Services about his own mother. She’d been using drugs that day—he was certain—and a couple of scary men had been at her apartment when he got there, maybe one of them was her dealer or a boyfriend; he hadn’t met them before. James didn’t feel safe and, to my understanding, he wanted her to get help, and maybe go back to having supervised visits. James had told me about his call to the child-protection hotline; he emphasized that he’d made the call anonymously. In telling me, James reassured himself that he’d done the right thing, although he was so anxious recalling the experience that he practically whispered.
I expressed my admiration, thinking that the call had been a valiant bit of self-advocacy. I was concerned by what might follow this turn of events after our session, but he seemed angry and fretful, not suicidal. And he was standing up for himself for the first time. In hindsight, perhaps I should’ve been more worried; in many years of practice, I can’t recall another time that a teenager reported his own mother to social services. I readily grasped that there might be fallout he hadn’t considered, including more jail time for his mother, but I failed to predict what did happen next.
After leaving my office, James evidently felt increasingly guilty, and he ultimately decided he had to call his mother to tell her he’d been the one to dial the hotline. He’d tried to apologize to her, saying he loved her and wanted her to stop taking drugs. But she’d raged at him as never before, bringing up all the things he most dreaded hearing: he’d ruined her life, she never wanted to see him again, he was just like his psychopath father. Not surprisingly, this nightmarish phone call precipitated a new level of despair for James, and he decided the only way to escape his misery was to hang himself.
The following week, I went to see James on the inpatient unit. Fortuitously, I happened to get there on an afternoon when a couple of therapy dogs were also in the community room. I got to see a side of James that he’d never revealed to me. He was remarkably relaxed, affectionate, and happy down on the floor, rolling around with a golden retriever and talking in a loving, goofy way to the dog. Here was this miserable, isolated boy who had planned to kill himself, and who struggled so hard to connect with other humans, in deep limbic engagement with an animal. I took note and filed away this observation for our next session at my office.
In the interim, and with his grandmother’s consent, I contacted a veterinarian friend of mine, Dr. Z., with a proposition. If I could persuade James to give it a try, would Dr. Z. take on the experiment of “hiring” an assistant who loved animals and needed to be of use? He agreed, and a plan was hatched. When James and I met after his discharge, he was diffident about the offer, but he didn’t exactly refuse. His grandmother set up a few after-school visits at the veterinary clinic to give it a try.
James came to therapy a week later, after spending his first two afternoons shadowing Dr. Z. around the clinic. I immediately noticed that his shoes were now tied, and that he had a different sort of bouncy energy in his gait. This usually taciturn, sorrowful boy proceeded to spend the next hour telling me (in nauseating detail, truth be told, although I only half-complained) about helping to spay a Bernese mountain dog, and tending to the shaved and stitched cat who’d evidently been the loser in a neighborhood fight. While my intervention here wasn’t some kind of magical cure, James now evinced, for the first time, a trace of passion and purpose beyond mere survival. And, there and then, he began to get some traction in his life. Happily, too, Dr. Z. became another important member of James’s team of reliable, nurturing adults.
My delight in finding a way to connect with James is important to describe. The stakes are high with high-risk kids, and we’re often less helpful than we hope. Had James gone though the cycle of self-destructive behavior, overt suicidality, and hospitalization another few times, I think he would’ve become increasingly difficult to reach. But even now, years later, as I write about this astonishing young man, I find myself smiling a little. By the time we decided to take a break, James had left school and was working toward his GED. He’d gotten a job as a dog groomer in a big pet store at the mall, and he’d even started amassing his own loyal clientele. I’m proud of that young man. And so here’s the thing about DRT: it’s the kind of therapy that, when we’re really connecting deeply with a teen, makes us stronger, too.
Adapted from the book Treating Trauma in Adolescents: Development, Attachment, and the Therapeutic Relationship by Martha B. Straus. Copyright (c) 2017 The Guilford Press. Published by Guilford Press. All rights reserved.
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CategoriesIn the Therapy Room Clinical Practice & Guidance Anxiety & Depression Families Kids & Teens Mind, Body, Brain Trauma
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