Jenna is waiting for me, perched on the edge of her seat outside my office. The moment I open my door, she springs out of the chair. Though it’s just a few feet to my sofa, she can’t wait to cross the threshold before she bursts into a tirade. Today, she works herself into a high-pitched lather about the mean woman at the DMV who wouldn’t accept her documentation to get a learner’s permit. As with many of the tougher adolescents I treat, Jenna’s defiance and woundedness go hand in hand. I sit back, nodding and clucking supportively. Until she gets the story out in full, there’s no bigger role for me.
My work is still hard, though. I have to be as fully present and attentive as I can, letting go of my anxiety about her, a tendency toward judgment, and some informed skepticism about her version of events. If I respond too soon, or too fully, or ask a question that suggests, even in the slightest way, that I’m not all in, she’s furious with me. ”Just listen to me and don’t interrupt,” she demands.
Most weeks start this way: someone—a so-called friend, an employer, her boyfriend, a parent—has done something to thwart her, and she’s undone by it, preoccupied with unbearable injustice. She fills our time together with embellished fantasy scenarios of harsh retribution. About the DMV bureaucrat who suddenly needed additional forms of ID, Jenna fumes, “I’ll curb-stomp that bitch if I see her in town and leave her bleeding.” By now, I know it’s just bravado; that’s how bad she feels.
Sometimes I get tangled up in a convoluted story and completely miss Jenna’s intended point. Then I’m the one letting her down. Although I don’t screw up on purpose—no need for that!—these small but significant and recurring ruptures are essential to our work. Despite my aversion to conflict in my personal life, I take in her searing glare head on, knowing my work is strongest when I’m fully engaged with her disappointment in me—when I feel wretched, too.
The metaphor I keep in mind at these times comes from driving on icy Vermont roads at night. When my car starts to slide, I know I have to turn into the skid, even when it’s scary to do so. With Jenna, when I get it wrong, we practice on our own slippery hill. I apologize for being confused; I might beg her to slow down to accommodate my aging brain. I commiserate about how hard it can be explaining yourself to people, and thank her for trying again. I feel her mounting irritation, my anxious defensiveness, and I think, Aha! Here’s the hook. Here’s the unbearable way it is for her in relationships. How do I unhook or at least go down trying?
Although patience isn’t her strong suit, Jenna is beginning to know, in her heart, that I’ll do what I can to fix things between us. My job is to feel calm with her. It’s not a matter of just teaching her isolated coping skills. If she can be mad at me, she can also come to feel, in real time, what it’s like to let go of smaller injustices. Practicing that with her loving but befuddled therapist is as safe as it gets. And her nascent acts of forgiveness are thrilling to me; they mean we can get back onto the road with more traction, together.
By the end of the hour, even when we begin with her raging and sobbing, Jenna usually leaves more cheerful. She’s much less reactive than when she entered, and best of all, we’re more in sync. When I’m able to be present in this way, my cooler, more regulated brain lowers the emotional temperature of her hot head. Over the year or so that we’ve been meeting regularly, she’s allowed me to comfort her more and more, using me more effectively for soothing. This is the wonder of what I call Time In.
Essential to the reflective practice of Time In is an intentional relationship with an adult who really shows up—self-aware, engaged, and compassionate. For me, and for most people I know, these vital qualities aren’t automatic: they have to be developed and practiced. To play our part, we must first foster our own capacity to self-regulate before we can demand it of a terrified or furious teen. Thus, we need to be aware of our own attachment styles and of theirs. We may sometimes have difficulty believing we can be important to a defiant teen, but this uncertainty often reflects our own history of insecure love and desire for self-protection. Attachment is a two-way street: it’s not just about them.
Our default use of Time Out and all the cognitive emphasis on teaching self-soothing and problem-solving skills miss the point with these most vulnerable kids. For them, Time Out often doesn’t work: the problem persists, the behavior resumes, the teen gets more agitated and resentful. Down the road, if they have the capacity to be comforted and know what comforting feels like, they can learn to self-soothe. But first these kids have to learn to rely on others to feel better. For a child to develop, parents need to “loan” the infant—and then the child, the adolescent, and the emerging adult—their adult regulatory system. But most complexly traumatized teens have missed out on this opportunity when they were little, and so a major goal of therapy is to backfill this absolutely essential experience. For these kids, it’s a gigantic leap to allow someone to provide comfort to them. They don’t trust others to be reliable, nor do they believe they merit such care. Their behavior puts to the test the most important question: will you be there for me when I need you? When we send them away as punishment, or chide them for being irrational, or get upset because we can’t tolerate what they’re doing, our answer to that question is no.
Jason is a 16-year-old high school freshman who’s endured unfathomable horror in his short life, certainly much more than he can reasonably cope with. Consequently, he’s in trouble everywhere he goes. Since he’s in survival mode most of the time, he has little energy for academics. He was held back twice before being expelled from his regular public school for truancy and fighting. Now he’s in a new special school for behaviorally challenging kids, and it isn’t going well.
I meet Jason about a week into his tumultuous transition to the new program when I arrive for my monthly consultation there. The principal tells me Jason’s giving them a hard time. He’s spending a large portion of every day separated from the class, hammering on the Time Out room walls, and spewing profanity. In fact, I hear him screaming from down the hall about someone being “a fucking retard.” I’m not sure if he’s berating himself or someone else, but he’s putting all he’s got into his fury, as if his life depends on it.
I don’t like this Time Out room, not one bit, and eventually, a few months later, I manage to persuade the administration to get rid of it. But today, Jason is in there, throwing himself at the walls. Peering through the little porthole in the door, I’m instantly surprised and heartbroken. After hearing about his excesses, I expected him to be bigger and meaner-looking, but through the slot, I see a terrified, wiry little guy in outgrown clothes, red faced and sweating, flinging his body about, wild-eyed with fear. Nothing more than my intuition tells me I’ll be safe in there, but I go with it. I open the door and slip into the room. Immediately, I sit down on the floor with my arms around my knees. I want him to know simply “I’m here”—and that’s what I say, even though he has no idea who I am.
Jason’s rage is dissociative. To calm down, he needs to attune to someone’s steady breathing, to sense a patient and kind presence, to be reassured by the occasional sound of a gentle voice. I keep breathing steadily and audibly, my gaze softened, not staring at him, not threatening, my expression as compassionate as I can hold it. Soon he’s sitting dazed across from me. His ragged breath becomes more regular, his vacant eyes focus back into the scowling present. The tension in the room begins to ebb. When I can tell he’s feeling a little better, I suggest that maybe I’ll just hang out with him today. He nods in quick agreement, and we leave together for lunch moments later.
By the afternoon, the staff has questions for me. What did you do in there? Why did you cross our school policy by going into the isolation room? I attend the next faculty meeting and share my thinking about Jason. I tell them that screaming yourself into exhaustion isn’t the same as learning to self-soothe. I explain that traumatized and dissociative children can’t begin to regulate themselves until they know what it feels like to be calm, and they can learn what that is only when they’re around regulated adults. In other words, when we’re reactive to an escalating child or teen, we feed the fire. When we find ways to stay calmly attuned and connected, we help quench it. Parents of infants have always known this, and now we have neuroscience and evolutionary biology to explain why. Co-regulation isn’t just for babies: it’s for everyone, especially traumatized adolescents and their red-hot brains.
Releasing the Hook
For adolescents to become more securely attached in general, they need to learn to attach to us, specifically. This means that their healing, the way they develop a sense of connectedness in the world, the way their brains will change—it all hinges on their becoming more like us. It might seem obvious that we therapists should be more securely attached than our clients, but they don’t teach us that in grad school, and we can write hundreds of treatment plans without giving our own attachment styles a second thought. To do this kind of practice, we need to have awareness, not just of the adolescent’s internal working models, but of our own.
Personally, I’ve spent a lot of my life worrying about what people think of me and working strenuously, even obsessively at times, to keep them happy. When conflicts arise, my first reaction is to rush in and crush it down into a tidy “it’s all good now, right?” package. I used to think I intervened in this way to be therapeutic, but now I realize this reaction was for my sake: I needed people—adolescent clients, their families, even my own daughters—to calm down so I could too. I first became aware of this pattern when I became increasingly agitated when one of my daughters was going through a rough patch. “It’s not her job to make you less anxious,” my therapist said.
I think of this now when I work with clients like Jenna, who demand I be fully present and centered but can be so activating for me. Indeed, our reactions to our clients have deep roots in our own attachment histories, and our capacity to remain attuned to them largely depends on our own self-awareness. We can’t get unhooked from their self-defeating relational patterns until we recognize we’re bringing some of our own stuff into the room as well. It’s our own immediate reaction that informs the hook—the point where their worries and expectations about relationships grab hold of our own. As therapists, we work to bring this reaction into conscious awareness and enter into more careful reflection—some mindful, compassionate reframe that can bring us closer together. Only then can we release the hook and become capable of offering something better and different from what our initial reaction would have produced. With our toughest cases, the chief obstacles to doing this kind of work are the Big Four Hooks: helplessness, failure, dissociation, and rejection.
When it comes to working with developmental trauma, helplessness is a familiar visitor for many therapists. Sometimes in the middle of a difficult session, I have a strange feeling of disorientation, thinking, Yikes! These people need professional help. Oh, no! They’ve come to me for this! When I share this sensation at workshops, even though I’m not kidding, it always gets a huge guffaw of recognition.
In this line of work, we’ve all had moments of helplessness. It’s important to realize how our feeling of helplessness mirrors the client’s experience. Simply put, we’re wired to comfort and be comforted, and we feel miserable when our capacity for either seems out of reach. This sensation goes deeper than our professional sense of competence, though that’s invariably in the mix, too. It reaches to the core of our attachment fears—our earliest, preverbal need to be protected—as happened when I met Samantha and her mother for the first time.
Samantha was a self-harmer, carving words and symbols into her arms and legs. When I asked what brought her in, she shrugged, then pulled up the sleeve of her sweatshirt, revealing block letters etched into her forearm: “Life Sucks.” Her depressed mother sat nearby, sinking deeper into her chair as the interview progressed and she listlessly commented on how dysfunctional the family had been for generations. The school had said Samantha needed therapy, but her mother wasn’t sure it would be worth the effort. Since Samantha’s father lived in another country, her mother thought maybe Samantha should just go live with him, while grimly noting, “Of course, he’s a drunk and doesn’t want her.”
For several years, Samantha had been cutting herself, drinking to black out, and having episodes of destructive rage. From what I could gather in the first session, she’d witnessed furious conflict between her parents as a young child. Given the severity of her father’s violent alcoholism, she was mostly relieved to be safe from him. Quite aware that her mother found her exhausting, she was nevertheless hurt and confused her when her mother threatened to send her to live abroad with him. Yet she didn’t want to come to therapy, and told me so directly. So here’s where the hook came for me, and here’s how my process of reaction and reflection unfolded.
Samantha’s hook. You can’t help me. You don’t know how bad my life was, and still is. I have to take care of myself in any way I can. I’m not going to let you take these strategies away—they’re all I’ve got. So my mother’s right: this will be a big fat waste of time.
My reaction. Yes, you’re so right! This is much too difficult for me. Maybe your family needs a bigger menu of services, or someone better trained. Your poor mother! But why isn’t she taking better care of you? The suffering in this room is suffocating!
My reflection. Wait a minute. I’m feeling bad for this kid and this poor, sad, overwhelmed mom. I’m scared I can’t help them, but I haven’t really tried yet. They’re here, right?
My response. “I’m just beginning to see and feel how hard life has been for both of you,” I said to them. “I can’t promise miracles overnight, but I’d like to try and help you both feel better. You’ve felt alone for a long time, and being alone makes everything worse. I don’t claim to have a quick fix, but let’s meet for four weeks, and then you can decide whether to sign on for more therapy.”
This kind of work doesn’t lend itself to dramatic transformation or miracle cures, but essential to beginning the process of connection is the capacity to recognize the initial hook and discover in oneself a state of calm and receptivity. Samantha and her mother did return for the contracted sessions, and then a few more times here and there over the next few months. It was hard for them to sustain engagement when they were feeling better, but they continued to contact me when in crisis. As tenuous as our connection was, it only emerged when I overcame my initial impulse to push them away and protect myself, bringing greater compassion into the room.
When working with kids who are battling the cruel legacy of developmental trauma, a lot is at stake for them. We all know this, but what we may not recognize is what’s at stake for us as well: our reputations, our sense of professional identity, and our self-esteem. In addition to helplessness, the experience of impending failure can have tentacles in our earliest relationships—and it’s the same for the traumatized teens I see, who often expect their relationships to fail. Still, it doesn’t feel good to anyone when a relationship falters, and we therapists need to be aware of what’s happening, not only for our young clients, but for us, to be able to work through it. That was certainly the case with 13-year-old Ian, who came to therapy cheerfully, seemingly eager for a captive audience. Whenever he entered my office, he plopped down on the couch, took off his shoes and glasses, and adjusted the pillow behind him. Having settled in, he adroitly swatted away any agenda I might have, preferring to tell me long, elaborate stories, mostly about video games. There were metaphors to be had there and work to be done, particularly regarding his obvious avoidant attachment style, but I just couldn’t seem to figure out how to connect with him around the video games he used to retreat from human contact.
I thought that if I joined him in talking about the things he loved the most, we could find a path to walk on together. But even when I tried—really tried—to follow his train of thought, my mind fogged over. I couldn’t grasp his world. I asked my gaming friends for tips, went online with Ian to see for myself his magical eye–hand coordination, put my whole heart into comprehending what happens inside his special world. This mattered to him; he mattered to me. I thought I should be capable of wrapping my head around Metal Gear Solid. (Is that what it was called? I can’t even remember the name of the game.)
Even writing this, I feel the utter futility well up in me again. I wasn’t bored with Ian exactly: I was always actively listening, but there didn’t seem to be a place in my brain for the information I needed to connect with him. Eventually, he eyed me with a wilting combination of disappointment and scorn, pronouncing, “No offense or anything, but talking to you is like talking to drywall.”
In some ways, of course, this was a small failure, not really that big a deal. True, no one had ever compared me to drywall before, and it stung—remember, I don’t like it when people are unhappy with me. Also, I tend react to this sort of rupture with humor, perhaps as a way to manage my sense of doom. But here I needed to let it hurt, so I could know what to do next. To get unhooked, I had to let this experience of failure really get to me.
Ian’s hook. I’ve had deeply disappointing relationships with neglectful, unreliable adults, and I’ve found a way to help myself feel better. I’m sharing it with you because there’s nothing else in my life that matters as much, and it’s cool. But you’re just like all the other lousy grown-ups: you don’t have a clue about who I am. Maybe you should just be quiet and let me forget you’re here.
My reaction. What he’s showing me is so boring I want to scream. This kid is torturing me, and it’s working. I want to make him talk to me about something else, to feel other feelings, to get this relationship going. But why do this at all? I hate it when people make me feel incompetent. Should I just nod like a bobble-head shrink, or refer him to a guy therapist who can understand him? Adolescent males are just mysterious. Why is this so hard for me?
My reflection. I seem to have a lot of feelings about failing with this boy who’s had so much failure in his own life. Isn’t it interesting that he’s talking about something that he understands better than I ever will? I need to reconnect with him, now that I have a better sense of what it’s like for him in the rest of his life. How can I do that?
My response. “This must be really frustrating for you. You’re really expert at this game and trying so hard to explain it to me,” I said. “I want to do better than drywall, and I think I can. How about we start over, and you show me an easier game? Can you try to teach me how to play the easiest game there is? Sometimes people learn better when they practice with an expert.”
This is a little embarrassing, but—thanks to my excellent instructor—I’m now quite adept at a cute game called Frogger, which Ian’s 5-year-old sister liked. I can also grasp enough basics of his most beloved Minecraft to see how it really does tie into real-life experiences. Through concerted effort, I’ve risen above the drywall level of attunement. These days, we actually laugh together.
Staying attuned to another human being can be hard work, and slippage is inevitable. I do better with highly anxious teens like Jenna, because the fire hose of emotion usually keeps me wide awake. The disengaged, slower-processing kids are more challenging for me. Indeed, when I’m being less mindful, their disconnecting strategies work all too well. At times, we may share only the physical space of the room, and nothing else. But it shouldn’t be their job to show me a good time and keep me awake. So even in cases like Lucinda’s, I have to be especially mindful of the hooks and how to move the therapy forward.
Lucinda was an avoidant-style teen I treated for four years, until she was 16. She’d been adopted out of long-term foster care and had been living with her “forever family” for only two years when we first met. Right away, with her arms crossed and a full scowl, I knew she’d be a tough customer. She didn’t hide her disdain for me. I was her seventh therapist, and she was just 12. At first, I made a little small talk, offered to play a game, asked a couple of questions about how she was doing in her life, all while she glared, wordlessly, at me. Sometimes, in the first few minutes, she’d briefly answer a question or two before clamming up and sitting like a stone sphinx for the eternity that was the therapy hour. During this time, I debated whether to keep pushing in one direction or another, to end the session, to ask her about what was happening in the moment, or to wait her out with a benign expression on my face while my mind left the room.
But Lucinda had a much vaster array of dissociative strategies than I. Once, early on, she seemed to fall soundly asleep in the session, and I couldn’t rouse her. She was still breathing, thank God, but completely immobile. Embarrassed, I had to get her laughing dad to come in and wake her up.
Lucinda’s hook. I don’t trust you. Your so-called therapy is mind-numbingly boring and I don’t see the point in your questions. Do you know how many people have let me down when I got close to them? No, you don’t—even I can’t remember them all. So I’ll do whatever it takes to keep you from hurting me. Leave me alone! Oh, you won’t go away? Okay, I will. I’ll even fall asleep.
My reaction. What a dull hour this is! I can barely stay awake myself. She doesn’t want to talk to me. Maybe she’s right: therapy isn’t for her. But why does she have to be so obnoxious about it? I’m a nice person, so why won’t she give me a chance? Maybe she thinks I’m a sham. Goodness, my sandals are too tight today. What should I have for dinner?
My reflection. Imagine living in the world believing no one is there for you. Her dissociation is her gift to me: now I know a little more how frightened and overwhelmed she must feel. How do I make her simply feel welcome here instead of retreating into my own trance state? How can I get her to engage with me so she can feel better in my office and maybe learn, in time, to begin to rely on me a little bit?
My response. Using as few words as possible, I showed Lucinda a new 500-piece jigsaw puzzle of horses grazing. (I knew from her mother she was a horse lover.) I suggested we might do it together over the next few weeks. She shrugged noncommittally, but took it from me. Going over to the table, she dumped out the box, not bothering to glance at me a second time. But she came back the next week, if only to do the puzzle. When we were side-by-side at the table, I breathed myself into trusting the process, and my adult limbic brain, to bring her into relationship with me over time.
A few weeks in, while we were still doing the puzzle, more amiably, bit-by-bit, she suddenly turned to me and wondered, “So when are you going to ask me important questions?”
I grinned at her and asked, “Like what?”
She gave me the eye-roll I came to know well in subsequent years and replied, “Duh, like about being adopted!”
The lives of traumatized adolescents are full of narratives of loss. What’s maybe less obvious is that, depending on our own attachment stories, we’re also vulnerable to some of these same preverbal fears. When a session ends poorly, we may worry about “losing the case”—and often, the feeling of loss goes deeper than that. For us and these kids, hooks that stem from rejection can happen suddenly, especially when things seem to be going well.
This happened for Pete, a bright graduate student I supervised a few years ago in his treatment of Maria, a 14-year-old girl who’d been the victim of incest and hideous psychological abuse. Pete was a thoughtful, intellectualized young man, who’d grown up with alcoholic parents and had learned from them how to be vigilant and careful. His attunement gave him an advantage; he readily noticed subtle changes in his clients’ mood and affect. The mistake that followed was mostly mine: I’d forgotten to tell him not to let it get too good when it came to Maria, a labile and needy girl, who seemed to relish every moment of Pete’s attention, and with whom he was doing fine work.
Several months in, after a particularly intense session—in which Pete reported they laughed and cried and felt closer than ever—Maria disappeared. For the next three weeks, she refused to return, telling her foster mother that she didn’t like him anymore, and was “done, done, done!” with him. He came to supervision afraid he’d blown the case, but, at core, he felt rejected by someone he cared for. Here’s how I helped him process it and figure out how to respond.
Maria’s hook. You’re the only man I’ve ever met who might be safe to get close to. But then again you might not be. If I let down my guard, you’ll hurt me. That was waaay too intense for me, waaay too fast. Did I see tears in your eyes, too? I have an impact on you? Now I’m completely terrified. Before you betray me, I’m out of here.
Pete’s reaction. What about my hard work? What about my internship hours? What about my supervision? So I do everything right, and you don’t come back? I thought you should have a female therapist, a more seasoned therapist, a trauma specialist, but no one listened to me.
Pete’s reflection in supervision. So therapy can get “too good” for someone who believes that the people who are supposed to protect you will eventually harm you. I was really disappointed, and I admit that it hurt when Maria blew me off these past few weeks. But it does make sense, now that I sit with her mind in my own. I guess I need to apologize and really persevere to get her back in. I want to repair this so we can try again.
Pete’s response. Peter made two phone calls to her, wrote a letter of apology, and sent two encouraging text messages. Then Maria returned, a little warier, but immensely relieved that he hadn’t given up. Pete promised to check in with her when they talked about harder topics to be sure the pace and intensity felt safe. He apologized again for moving faster than she could handle.
Maria hadn’t been able to set limits in the home where she’d been abused, and certainly, no one had ever apologized for harming her. Here, new possibilities for connection emerged from rupture and its repair.
Traumatized and oppositional adolescents tend to have a narrow bandwidth of expressiveness, generally on the defiant and hostile end of the spectrum. Living with hypervigilance and a fiery nervous system, they can be sent over the edge by seemingly small provocations. The real goal of treatment is to help them feel at home with a broader range of life’s emotional challenges, especially those really big feelings like joy, sorrow, terror, and rage. To this end, treatment can be playful and raucous, silent (be it stony, pensive, amiable, dissociative, or seething), chaotic, loud and wild, heartbreaking, hand-wringing, and everything in between. In this work, the therapist needs to follow the affect, even if it’s often tucked out of sight, just beneath the anger, or behind blank-eyed disengagement. And our best guide is usually our own reactivity, examined carefully and transformed into the most corrective experience of authentic relationship that we can provide.
Over time, this approach has a secondary, but equally important effect: it builds the courage and staying power our young clients need to handle their easily triggered frustration and discouragement. Jenna flunks her permit test, gets fired from work, crashes her car. Jason gets beat up at school, repeats grades, and doesn’t have friends. Lucinda struggles to make it through a day at school without retreating into a dissociative fog. Samantha believes she’s “too much” for her mother. For these kids, and many like them, surviving each day often comes down to an act of guts and willpower. But even as I encourage them to become grittier, better insulated, and more resilient, I also know they need my compassion and the encouragement to face the helplessness, failure, and rejection they must inevitably face in life.
Traumatized teens don’t make it easy, but they can’t do it without us. And we’ll have to cultivate our best, most self-reflective selves to help them if they’re going to make it.
Photo © Science Photo Library / Corbis
Martha Straus, PhD, a professor in the Department of Clinical Psychology at Antioch University New England, is the author of No-Talk Therapy for Children and Adolescents, Adolescent Girls in Crisis, and Treating Traumatized Adolescents: Development, Attachment, and the Therapeutic Relationship.