While working as a classroom aide at a therapeutic day school, I was called to assist in a crisis incident involving 14-year-old Nicky, whom I knew well and who’d long ago been labeled with a dreaded diagnosis—oppositional defiant disorder (ODD). He’d just thrown a desk, stormed into the hall, and threatened to leave the building. I arrived to find him backed into a corner with his arms crossed and head down, snarling and swearing at the three male staff members standing near him.
“You don’t need to f-ing be here,” I remember him saying when he saw me.
“Hey! You don’t talk to Kate like that,” one of the staffers said sternly, clearly agitated with Nicky’s behavior toward me.
I put up my hand to my colleague and shook my head slightly as if to say, “Thank you, but don’t worry about it.” Then I motioned for the three staffers to back up a few feet, and crouched down to the floor between them and Nicky. With my gaze toward the floor, I remained quiet. Within a few minutes, Nicky slid his back down the wall and started to cry, a signal he was starting to recover. It wasn’t long before he allowed me to sit next to him, talk through what had happened, and get his day back on track.
At his previous school, Nicky had been one of “those” kids—you know, the ones whose faces are twisted into an ever-present scowl or smirk as they spew verbal venom at adults and peers alike. The ones whose defiance against rules, social norms, and authority—and their propensity to lie, talk back, and act out—had gotten them kicked out of more classrooms than anyone can count. The ones who are academically regressed and emotionally immature, and have few, if any, friends. You know, “those” kids—the ones who are often difficult to like.
And I love them. In fact, after almost 20 years of working with hundreds of teens and tweens across numerous settings, they’re the ones I remember. There was Tim, a seven-year-old boy in residential treatment, who was built like a tank and routinely attacked staff members. Alyssa, a sixth-grade girl, who dressed like she was 18 and spewed creative combinations of cuss words that would make your head spin. Dylan, an 11-year-old boy who could upend all the classroom desks and tables and start tearing down posters in under a minute before you knew what was happening. The list goes on—each with his or her own list of diagnoses, IEP goals, and treatment plans. And each one deeply, deeply wounded.
It’s these clients who have kept my passion for this work alive. Sure, they were snarly and unpleasant, smart-alecky and argumentative, even aggressive at times—but beneath those tough exteriors were some of the most intelligent, compassionate, resourceful, hilarious, and creative kids I’ve ever met.
Of course, seeing past their unlikeable behavior wasn’t always easy. Sadly, these wounded young people are innately skilled at repelling others, and they have a knack for making “unconditional positive regard” seem like an impossible feat.
Early in my career, I came across a powerful remark in What Do You Do with a Child Like This? by school psychologist Larry Tobin, an observation that fundamentally shifted the way I work with these young people: “Emotionally disturbed kids are distinguished by their regrettable ability to elicit from others exactly the opposite of what they really need.” It was so simple—and so true! The child who lies about their accomplishments needs someone who believes in them. The teen who rejects caring people needs more care and connection, not less. The girl who emulates hypersexualized celebrities needs appropriate attention for her innate qualities, not shame-filled comments about her appearance. My rule of thumb became Kate, whatever your gut reaction is, do the opposite.
Finding a Way In
ODD and similar (unhelpful) diagnoses are, at their core, relational in nature, meaning these clients are likelier to cooperate with adults with whom they have a connection. In other words, the best laid “behavior management” plan doesn’t mean much without a relationship to anchor it.
And there’s the rub: building a relationship with a heavily armored, developmentally regressed, profoundly sad young adolescent is no small feat. They don’t exactly let you in the front door. They can’t. They’ve been too hurt, neglected, or abused by important adults who were supposed to care and keep them safe. Any desire they may have to connect with someone is equally matched by a profound instinct to fiercely protect that desire.
This is where many talented therapists get stuck. Knowing the importance of the relationship is one thing; knowing how to build that relationship with someone who wants nothing to do with you is another—and it’s where the art of the work comes in.
Connecting with these adolescents asks us to stop banging on the locked front door and instead find another way—a side door, a window, a chimney—to make some kind of connection. What follows is a short compilation of “side door” principles and approaches I’ve used as guideposts for connecting with a client like this.
Show up as yourself. For good reason, these kids’ authenticity radar is finely tuned—and your first audition will be short. Hang in there, keep trying, but don’t shoot yourself in the foot by being anyone other than yourself. Inauthentic translates to untrustworthy in their world, so feigning emotion or enthusiasm won’t get you very far. For this reason, I recommend scheduling these clients at a time of day when you feel most centered.
Don’t take it personally. Dishing out verbal disrespect, ghosting your session, or engaging in endless other therapy-interfering behaviors isn’t about you. These behaviors are practiced methods for keeping people at a distance. What better way to push someone away than to show your worst side? Stay in it with them and decide carefully whether and how to respond to these behaviors. Some can roll off your back, others should be discussed, and most don’t need to be addressed in the moment. There will almost always be an opportunity to circle back, and when you do, acknowledgment, curiosity, and underwhelm make a good combination. It’s usually best to address patterns of behavior, not one-offs.
Let them know they’re wanted. The mere presence of many of these kids is ignored, avoided, or dreaded by most people, usually because of their unlikeable behavior. Imagine getting the sense or outright message that you’re unwelcome everywhere you go. An authentic “I’m so glad you decided to come today” or “Hey all right, you’re here!” can go a long way.
Don’t underestimate the depth of their pain. You’ve only seen a fraction of their suffering. As a supervisor once said to me about a young man who was depressed and known for giving out verbal lashings, “If that’s what he’s showing on the outside, imagine what it’s like on the inside.” I haven’t looked at kids in emotional pain the same way since.
Bring your calm to their chaos. Regulation starts with the adult in the room. Whether it’s from day-to-day life or past trauma, or both, these kids have nervous systems that are in a perpetual state of fight or flight. When you are calm and centered, your body sends a message of safety to theirs. Using a soft tone of voice, intentional breathing, music, and movement are all ways you can lower the stress response and soothe their “wired” bodies.
In a crisis, less is more. When an adolescent is escalated, it’s our instinct to want to help them talk it through. What we fail to recognize is that the “use your words” window closed long before the point of crisis. In the heat of the moment, it’s best to keep the words to a minimum and shift to nonverbal communication, like avoiding direct eye contact, giving some space, intentional breathing, and turning your body away just slightly.
Learn to identify pink flags. Crisis situations are often the result of cues for support that were missed along the way, or what I call “pink flags.” Pink flags are the subtle signs or tells that something is brewing—and every client has them. For example, I don’t recall the specifics of what led to Nicky’s desk-throwing incident that day, but he likely felt ignored or belittled in some way. His go-to pink flags were to disengage from the class, put his head down, tap his pencil, and mutter under his breath. Left to smolder unattended, these signals quickly escalated to bigger, more overt behavior that screamed, “I need more support!” Getting to know pink flags (and helping your clients know theirs) is an invaluable skill.
Allow them to teach you something—anything! Be vulnerable in that process. One of my best sessions occurred when a withdrawn teen girl taught me to crochet. She was so compassionate and patient as I self-consciously fumbled with the hook and yarn. In allowing her to be the teacher and expert, I saw a confidence in her I’d never seen before. Therapy gold!
Understand that you’re a seed-planter. We all want to experience that Good Will Hunting moment with our clients—and maybe you’ll have one or two—but it’s far more probable that your work will come to fruition long after your clients have left your care. You simply don’t know how or what they’ll remember about you, and sometimes your best hope is to stand out in their lives as an adult who “gets it” and cares.
Create a therapeutic space your inner tween would want to visit. Remember, you’re likely not their first nor last therapist. They know the drill. Sometimes it helps to have something novel in your office that might pique their interest. This could include a mini-basketball hoop, an optical illusion poster, pictures of your pet, hot tea, a bean-bag chair, an essential oil diffuser, unique fidgets, or, one of my favorites, a half-done, ongoing jigsaw puzzle (350–500 pieces) that any client can work on at any time. It’s a great activity, which doesn’t demand eye contact and inherently communicates that many kids come for therapy.
Redefine what successful treatment looks like. Success with these kids won’t look the way it does with the rest of your caseload. What feels like minimal progress is just that: progress. Take it. Celebrate it. Sometimes the highlight will be that a client came to your office for five minutes, or that, for the first time, she was destructive with objects but not aggressive toward people. Jump in there with your motivational interviewing skills and ask how she was able to show such restraint—evoke that change talk wherever you can while also praising positive choices, no matter how small they may seem.
Know that you’ll make mistakes. I still remember a time when I hurt an older teen’s feelings with an ill-timed sarcastic comment that I thought would be funny. It was 18 years ago, and I can still picture the hurt in his eyes as he confronted me about it. (Good for him!) Don’t be afraid to apologize when you make a move like that. Model the repair process and follow through on doing better next time. Remember, these are developmentally young children in bigger bodies. Side note: sarcasm—specifically, the kind that bites—has no place in this work.
Don’t lose sight of your why. Stay close to the reason you continue to show up each day. This is difficult work! Often in a moment of self-doubt (Am I just spinning my wheels here? Would he be better off with another therapist?), my why comes flooding back into view. It could be that for the first time, a client comes by my school-based office just to say hi. Or a private client asks when she can come back. I recommend keeping a “bad day folder,” which for me is where I keep all the notes, drawings, and art projects that my clients have made for me, along with encouraging messages and positive reviews from colleagues, supervisors, and families with whom I’ve worked. When I’m having a bad day and start doubting why I do this work, I open the folder to find reminders of everything that keeps me going.
PHOTO © ISTOCK / RUBEN RAMOS
CategoriesIssues & Developments Clinical Practice & Guidance In the Therapy Room Clinical Skills & Experience Kids & Teens
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