Advice: Supporting a Teen in Immense Pain...

Dear Dr. Bobinet,

We've been having escalating problems with my teenage stepdaughter. I noticed a marked change when she was 12 and in the 6th grade. Mostly the attitude, which at the time we felt was very normal. But it quickly degenerated into her compulsive lying. In 7th grade she was known as the school tramp and began spreading false rumors about her father. She would say that he always beat her. This ended up with my stepdaughter and her mother lying to the police and my husband going to court. Of course she wanted to be at her mothers' where there were no rules. We found out in the middle of 8th grade that she had sex with an 18 yr old. We think the ex-boyfriend of her best friends' older sister. We talked to the police and I believe that investigation is still going on. But she has lied to the police and refuses to give up the name of this boy. We thought it would be best to get her away from these friends and her alcoholic mother, (my husband has full custody), so we sent her out East to be with her Auntie.

This did not work. In fact her behavior is more out of control than ever. She's drinking, smoking pot, has had multiple sexual partners (she just turned 14 in March) and finally ran away. We found her and she is back, but now we are wondering what to do with her. She has so much rage, is so devious we don't know how to break through that. She has actually said she'd rather be in foster care than live with us, would rather die. How do we help this girl?

Thanks,
Kim (name has been changed)

Dear Kim,

Your situation touches my heart and I want to assure you that there are things you can do to get a positive response.

Your stepdaughter is using negative behavior to control the adults in her life. She is able to do this because an adult (her mother) in her circle is showing adolescent-like behavior by enabling and rewarding the negative choices of her daughter. Her mother keeps "letting the horse out of the pen"-so to speak (FYI: I grew up with horses). As we shared, your stepdaughter is in a great deal of pain.

Your stepdaughter has already proven that when adults try to control her, she is willing to take dangerous risks (like running away) in order to seize control and scare the adults into not holding her accountable. She also uses hurtful language to try and take control of you and your husband by suggesting that death and living with strangers are better than living with you.

Since she is in the first half of adolescence, her acting out is even more dramatic than she will be as an older teen. She can be supported in two ways.

First, the escape route out of being held accountable must be closed in order to create an environment where she can heal.

An obvious (though expensive) choice that many parents use is removal of their teen to a remote therapeutic camp. I have known both success and failure stories of these camps, so my advice is to take an hour with your husband and thoroughly profile your daughter. Look at the world through her eyes and ask, "what kind of experience would build her up?" You must identify ahead of time what level of accountability and firmness would be right for your daughter. What kind of setting and therapists would get through to her in a way she would open up to? Do this BEFORE you look for a specific camp. You can get input from referrals online. I recommend against "boot camps" and harsh treatments. It should also incorporate the family. As an article in Mother Jones, October 2007 states, " The most effective treatments for troubled teenagers have these things in common: They use family-based therapies; they treat adolescents with empathy, dignity, and respect; and, except for very short periods of emergency stabilization, they keep teens at home."

As a complement to profiling her, it is worth profiling your selves. In what ways have you held onto fears, anger, hurt, or judgment that affects your interactions with her? This is a family dynamic--of which you have control over exactly half of it. You and your husband must prioritize taking care of your selves so that you have extra energy and most importantly, clarity, to handle this.

She has more energy than you according to this calculation: rage x age. To match this and redirect her with support, you MUST be as healthy as possible. Because her issue is emotional, it is easy to overlook how demanding that is on others (i.e. you). But imagine if she was undergoing major surgery to remove a life-threatening tumor--how much demand on parents does that have? I know it is tempting to focus only on her, but trust me on this one.

Another way to close the escape route is to (at least attempt) reaching out to the adult who is not holding accountability and ask for their participation in not harboring the teen when they runaway. This may not be possible under the circumstances, but I like to ask families to exhaust all possibilities, especially if they assume that person will not cooperate due to their past behavior patterns. Surprisingly, even the most “unhealthy” people can have moments of helping, if given the opportunity. Sometimes people will react from their best self if you build them up and make it safe by reducing your preconceptions. Even if they do what you predicted, they must be invited to help.

There are other ways to close the escape route--such as taking a long drive (which is short-lived, but effective if you can arrange it) or doing a project together. (This usually gives the teen a captive adult audience without the penetrating stares that teens try to avoid) Someone (likely) has to change the pace, change the environment, and invest more time for her at this time. As much as possible, business as usual has to stop (except for the true responsibilities), so that we can really get to know what is going on. Worrying about it while you go about daily life does not work. Worry is not preparation.

Finally, if things escalate and you feel you must regain physical control of your stepdaughter's safety from her being a risk to herself, legal means such as the police or medical means such as a 5150 (involuntary psychiatric hold) may be needed.

A second way to support your stepdaughter is to build her up--give her some hooks to help her to want to stay despite her urge to run away from the pain.

You must get BUY-IN. Whether or not you utilize a therapeutic camp resource, you will need to find some way into her heart. This is not as "hokey" as it sounds.

I can guarantee you that inside of her, there is a girl who wants to stop behaving like this. That part of her waits for someone to "get her" and to stop judging her. When teens generate that much bad behavior, they often feel unlovable. The lying is a symptom of her immense fear of non-acceptance and judgment. It also may indicate a coping mechanism to escape her pain. She may act like she doesn't care, and back it up with cruel and insensitive behavior. But, trust me, in over 20 years of working with angry, rebellious, "I don't care" teens--I have yet to find one of them who does not secretly "want out" of the insanity of their pain. Target that part of her--build it up to be stronger than her self-sabotage.

The circle surrounding her appears thin in places. Her biological mother is not holding her end, and the auntie needed to have more supports to hold accountability around your stepdaughter. The second way to support her is to build this up and make it appealing to the part of her that wants out of her pain.

She needs a therapeutic relationship that is strong enough to hold her. You mentioned she was able to lie her way around a therapist. She sounds smart and cunning--quite a strength, but being applied negatively. There are many good therapists. However, for a smart girl in this much pain, you will need to find a GREAT therapist. If your stepdaughter is not in immediate life-threatening danger, it is worth doing research on finding a couple of great leads. Of course, this is only relevant if you have some way to get her into therapy.

How do you get her buy-in to do therapy? Again, you must build up the part of her that wants out. You can launch a campaign to build her up. Getting messaging into teens without their blocking includes short but sweet texts, email, written notes, sending a message through a friend, etc. You can tell her, "you are not alone", "I am here for you", "I feel sad that you are suffering", "I believe in you", "You are loved". Absolutely NO judgmental statements. Speak from compassion for her hurt; speak from your own hurt. If you get a chance to talk with her, ask her open-ended questions and do NOT have an obvious agenda. Also, do not indicate that you are afraid for her...it really freaks teens out if you mirror to them that you think they may not survive (because they fear their failure, too).

If you can get her into therapy, I also recommend joining a good Dialectical Behavior Therapy group, to bolster her supports and offer a curriculum to reconnect you as a family. Additionally, mindfulness based therapy groups for teens in your area, if available, would help her build skills. Either way, she needs more people involved with her. This will require reaching out.

The substance use is of concern. I cannot tell how addicted she is from afar, but all of what I have said becomes harder in the face of a full blown addiction and the altered mental states which suppress the part of her that wants out. The fact that she started at such an early age makes her more at risk of developing a full addiction. There are profiling tools online (http://www.intervention.com/defns.html), and follow-up evaluation with a therapist is critical after you get buy-in.

If I could draw a diagram of all of this advice, it would look like this: fill-in the broken part of the circle of support and accountability around her with a mix of family & positive friends (whomever you can enlist), therapist/ therapeutic camp, girls group therapy, substance treatment resources (if needed), and emergency supports (legal, medical) if she “breaks out”. In the center, you would put the incentives to make it as attractive as possible to stay in the circle: messages of support/empathy, removal of judgment and blame, honest sharing, building her up, and anything else she is attracted to.

This is an invitation and opportunity for you and your husband to advance in your emotional literacy within yourselves and in support of your stepdaughter. Time management is sure to be challenging as you balance your own self-care (and the care of your partnership) with designing and trying interventions for her. My heart is with you wholly. Please let me know as you proceed.

With support,
Dr. B

Lord of the Flies: When Teens Attack and Why?

You may have seen the disturbing story this week about the six girls and two boys in Florida who recorded a graphic video of beating up another girl for “trash talking” on myspace.com. Another video from a cell phone, just released yesterday, shows a student beating a teacher in class in Baltimore. I can only imagine that most adults who see these stories feel outraged—and perhaps even fear. Adults naturally want to know how this kind of violence could happen and how it can be stopped. Here is my explanation.

Long ago, I was forced to read a book called, The Lord of the Flies, for my eighth grade English class. I hated it. I probably did not even notice the brilliant writing and storytelling skills because the story itself was so creepy. In the book, a group of plane-wrecked boys with no surviving adult deteriorate into anarchy and eventual mob-like violence as they gang up on a weaker boy. I likely hated it because it was too close to the real life teen attack behaviors I had seen at 13.

Throughout my teens, I found I had a knack for breaking up arguments and fights. It was a strange but natural gift—not one that adults noticed or praised like athletic ability or artistic talent. But on a Friday night, when the teens around me had had too much to drink and their drama started, that gift was gold. I broke-up many guy fights by placing myself in the center. The girls’ fights were trickier—they required more fast talking to dismantle the “ticking bomb” of girl emotions—but I managed those as well. I made it through high school without a scratch.

So, why is an almost 40-year old boring you with stories of high school? Because it has everything to do with why some boys, girls, teachers, or counselors get attacked and why some NEVER do. I dare to say that the whisperers NEVER get attacked.

I have taught and counseled in juvenile detention and adult prisons for over a decade. Most of the young men in my classes and sessions have been repeat, violent offenders. Some have been sex offenders. I have been indoors in a locked room doing group work. I have been outdoors overnight with a group far away from the detention camp staff. I have neutralized emerging fights and dismantled small riots. I have assisted prisoners who were standing for peace amidst a larger scale riot. In the community, I have experienced the same thing. As a smaller woman working with much larger men, I have used whispering to stay safe and make peace.

So, why do teens attack? As far as I can tell, they most often attack when cornered and they attack when they see weakness and insecurity.

When cornered or challenged toe to toe by an adult who is using their authority to overpower a teen, sometimes the teen will attack. Such an event happened to a friend who is a teacher. The teacher made a demand that the student leave the classroom due to negative behavior. The student left, but returned a minute later to “get something from my desk”. This was an obvious move of defiance to the teacher, who commanded the student to leave again. The student left and the teacher decided to keep him from returning by blocking the classroom door, squaring it off with his own body. Of course, the heavier student saw this as a challenge and violently pushed the teacher aside to get back in. At one detention facility, I saw a repeated version of this by a guard who continually ordered the teens around. Most of the time, the teens complied. But every now and then, one of them would have just received tragic news or felt angry for another reason. This guard got punched out regularly. However, another guard, whom I regard as a true whisperer with teens, had never had an incident in over 30 years on the job. The second guard commanded respect because he first gave it—so he worked WITH instead of AGAINST teens.

The second reason I believe most teens attack involves their reaction to weakness and insecurity. Teens, particularly angry teens, despise weakness and insecurity in others because it brings up their own similar feelings. Perhaps they are “hating” on their inner child and all that it represents as a way to push into adulthood. If they grew up in a family of child abuse, this is amplified as they play out the beat down of the child—by beating up the person who reminds them of being weak like a child. Certain body postures of cringing and cowering have such a strong broadcast of being “prey”, they may actually invite attack from teens.

I recently had the privilege of speaking to several Aikido masters in Santa Rosa, California and Boston, Georgia. Since Aikido is the martial art best known for neutralizing attack, I find it highly applicable to the teen whispering techniques. In an interview, one of the masters, Anthony Bell, says that in Aikido you meet the strength of the attack, blend with it, and keep focused on doing as little harm as possible to the attacker. This is also in line with a saying from one of my Native American mentors and a whisperer, Rick Williams, who told me that “respect is the first law of Native Peoples”.

I do not believe today’s adults have been trained in the skills of neutralizing attack from teens—and that is probably why most people want to throw young people in jail or offer more severe forms of punishment thinking “that’ll teach them!”. But, as they say, an eye for an eye results in a lot of blindness. I am convinced, through my own experience and the success of those who use peaceful methods, that most teen attacks can be prevented and calmed if adults know how.

Take Care of Your Self--REALLY!

Most of what I see when adults struggle with teens involves the lack of or inappropriate self-care of the adult. Whether you are a professional or a parent of teens, you MUST care for yourself in order to be a healthy guide for teens. Because of their volatility, teens are a sharp mirror that reflect back to you aspects of yourself in which you are not healthy or solid. But, most adults dismiss the need to take care of their self. They either feel it is self-indulgent or unnecessary—often until they are brought to their knees through stress or crises.

I get all kinds of push back for advocating self-care, so let me unpack this a bit. I want to define what self-care is, and more importantly, what it is not.

What SELF-CARE is:

Self-care increases your mental and emotional stability. It offers clarity to your interactions with teens. Specifically, self-care is a practice, or a group of practices, that offers healing and power within. I like to breakdown self-care practices into three categories: BEFORE, DURING, and AFTER.

BEFORE practices are those that help you to be more calm and slow to anger at your baseline. The most potent of these, according to research, has been mindfulness meditation. Meditation carries the advantage of refined self-observation that allows one to see the arising of emotion as it is happening. This kind of inner awareness works powerfully to avert conflict. Additionally, therapeutic counseling can help to resolve issues from childhood that come into play with teens as they often remind us of our own youthful experiences. Other practices such as proper nutrition, sleep, and exercise also set the stage for emotional calm.

DURING practices help you to reassess and neutralize your emotional triggers in the heat of the moment. On both sides of my family, we had a long history of sudden explosive yelling. In order for me to change this experience for the teens I serve and parent, I have had to work hard on DURING practices. The most important DURING practice is to stay focused on your breath. It gives you some space from your mind—which wants to run with emotion. Another practice is to direct your attention. In a moment of being triggered, focus your attention on your body’s response and try to identify the self-talk that is catalyzing your emotions. Saying to yourself, “she doesn’t appreciate me,” or “he is trying to manipulate me—he can’t do that!”, fuels your emotions, leading to trouble with teens. Instead, get good at watching your emotions rise, notice what you tell yourself, and then practice a reverse message. Using reverse messages like, “maybe they do not mean to do harm” or “Is my judgment about them really true?”, can create some space for reassessing your options in the middle of a heated interaction. Finally, the classic cognitive behavioral practices, such as counting to 10 or taking a time out, are helpful.

AFTER practices help you to "metabolize" the stress of managing your teen's strong emotions. Most adults ignore the after effects of unsatisfactory interactions with teens. More importantly, they are missing a great opportunity to learn lessons for bettering the future. There is a saying, “if nothing changes, nothing changes”. To avoid this trap, use AFTER practices that count—those that will import insights into your consciousness, from the unconscious patterns your brain has tracked for you. AFTER practices include journaling, processing verbally with another adult or support group, and silent time alone in contemplation. AFTER practices that return the body to baseline are also important. These may include being in Nature, stretching, drinking water, getting rest, or otherwise decompressing.

What SELF-CARE is NOT!!!

Without judging anything as “bad”, it is important to point out that some coping mechanisms have been miscategorized as self-care. The main reason for excluding these practices as self-care is that their benefits are short-lived and do not contribute to mental stability or clarity for BEFORE, DURING, or AFTER use. Such examples include so-called “retail therapy”, stress eating, and self-indulgent pampering. You are the best judge on whether something you do offers lasting self-care or momentary escape. A good question to guide you and reveal your inner motives is to ask yourself, “why am I doing this practice?”

IN CONCLUSION:
I want you to have a rich, rewarding life, replete with positive relationships with teens. But, how can you achieve this without investing in your self? Despite all of the temptations to neglect yourself or even self-indulge, may you find a way to take your SELF-CARE seriously.

The Science and Theory of Suicide: Relief for Those Affected

For too long, loved ones of those who commit suicide have blamed their selves for not doing something to prevent it. Likewise, some people blame the person who commits suicide, labeling them selfish, weak, or unable to ask for help. Fortunately, recent scientific evidence offers us a healthier, more truthful way to understand suicide.

In my medical training, I was taught that suicide is a tragic outcome of a REAL medical illness. So, why would we blame ANYONE? Maybe if we don’t know what causes it, we feel someone has to be responsible. Maybe because the illness is happening within the brain, we expect the person to have some control over it.

We don’t blame people for getting cancer. We know that some cancers cause symptoms that let doctors catch the tumor early—and immediate treatment helps these patients survive. Other cancers, unfortunately, show no symptoms until they have spread so much that it’s already too late. But, even when doctors find very advanced tumors, they don’t blame their self or their patient—and neither do the loved ones.

Recent research has shown differences in brain activity of depressed patients who are suicidal and those who are not. Evidence also shows differences in the brains of depressed compared to non-depressed people.

There are at least two areas that differ in people who feel suicidal. An area controlling impulsivity in the front of the brain shows less activity than in non-suicidal people. This may mean these people are more likely to be impulsive and act on their feelings. Because this area rapidly changes during adolescence, it may not prevent teens from impulsively acting on suicidal feelings.

Another area of difference in the brains of people who feel suicidal is the emotional center. This area is more active and may act like an amplifier to negative emotions—making them seem overwhelming and insurmountable.

People who are depressed also have an increase in what is called “rumination”, also located at the front of the brain. Rumination is a group of thoughts or self-talk that repeats over and over and doesn’t stop. It is just like a “tumor”, except made up of negative thoughts that create feelings of hopelessness and sadness. In this state, people can become “blind” to seeing any way out. They also tend to isolate away from help. And it takes a lot to get through to someone who is fully in this state.

It is proven that intervening with suicidal people can save their lives if someone catches it early. But catching it early is tricky. Just like with cancer, not all ruminations about suicide happen gradually enough or announce their presence with classic “symptoms” (like the person telling you they are thinking about it or that they have a plan).

In fact, suicidal rumination can emerge so rapidly that it can shock everyone who knew the person. The result of sudden, unexpected suicides is a circle or community left in utter shock; unable to backtrack why it happened. And in that black hole of understanding how the disease takes lives, arises the self-blame.

But, after we lose someone to suicide, we must remember that no one was to blame. No one could have done anything but what they did. The suicidal brain manufactured a cluster of thoughts that then produced a crushing level of emotion that, then crystallized into hopelessness for that person. Their brain, skipping on this one message, led them to believe that taking their life was the only option.

It was not their fault.
And it was not yours.
______________________________________________________________________________________________________________________
The author has worked with adolescents for over 20 years, many of whom endured severe trauma and grief. Dr. Bobinet received her M.D. from UCSF School of Medicine and currently attends Harvard School of Public Health in healthcare management. She has studied human development and neuroscience for the past decade.

Research findings summarized from Monkul ES et al, Fronto-limbic brain structures in suicidal and non-suicidal female patients with major depressive disorder. Mol Psychiatry. 2007 Apr;12(4):360-6. Epub 2006 Dec 5.

Letting Life Teach Teens

Often, as adults, we want to spare teenagers the frustration, disappointment, and pain of life. Because adults can track consequences, we can foresee the approaching heartbreak, failing grade, or rejection, descending upon our beloved teen like a hawk on prey. Naturally, our heart feels so much empathy that we feel the urge to save them. But, in doing so, adults commit all kinds of violations against nature.

Teens need to feel the sting of failure. They do not, however; need to experience the burn of punishment. What is the difference?

Failure teaches, punishment confuses. Failure happens as a direct consequence—like throwing a ball hard against a wall and having it hit you in the head on the rebound. By contrast, punishment comes with a “spin” on it—you hit someone else when you threw the ball and they threw it back even harder to express their anger.

Here is a lighthearted true example of letting the consequences of life teach young people what to do and what not to do:

I was driving with my daughters, who started to roll the power windows up and down in the backseat for entertainment. I asked them to stop. When they were younger, this would have been enough.

To rebel against my request, they started to play a game with me. One of them would roll their window down just slightly and the other would follow suit. They wanted me to get them in trouble and seeing who could get me angry first. I didn’t bite.

“Ladies, I asked you to stop playing with the windows,” I reminded them.
“It isn’t hurting anything!” protested my oldest, and most lawyer-like, daughter.
“The windows could break if you keep playing with them. Please stop,” I spoke more sternly.

I had upped the ante. They chose to up it further and continued to move the windows—this time even more subtly. In the middle of their testing behavior, I had an insight. I waited until they had both rolled the windows up to start over on their window game. I then engaged the “window lock” button on my driver console without telling them and casually observed them in the rearview mirror.

Sure enough, a few seconds later, my eldest clicked her button. A small flash of shock crossed her face and she motioned to her sister. My other daughter tried her window, adopted the same shocked appearance mixed with a little fear, and mouthed some words that looked like “uh oh” from my position. Then, justice happened.

Not to be crude, but in medical school we were taught that people pass gas around 14 times per day. On this day, with the windows “broken”, my daughter (shall we say) “cut one”. Laughter burst through their pursed lips as they faced an impossible dilemma. Should they tell mom that they broke the windows and get fresh air? Or do they sit in the foul smell that one of them created and not tell mom she was right? I struggled to contain my laughter and asked them repeatedly, “What’s so funny, ladies?”

After letting them suffer for a few minutes, I called my friend on my Bluetooth. Still driving, I started to tell her about how the girls were playing with the windows and how I wanted them to stop and how they didn’t and so…I put on the windows lock.

“MOM!!!” screamed the girls with smiling protests. I got them. Better yet, I let them run up against consequences instead of running up against me. And, it didn’t hurt them. And do you think they will forget that lesson any time soon?

WHISPERING TIP: Allowing small failures are not always so pleasant. I have had my share of what felt like sending my beloved teen friends into the chamber of doom. But having done it hundreds of times, I can vouch for the value of young people experiencing an accurate consequence of their actions.

As a result, I recommend giving them the raw data sometimes. Do not be afraid to tell them if they have hurt you. This type of admission does not have to mean you are weak. More importantly, it lets them know how long their “claws” are, so they know how to use them more skillfully. From a teen’s perspective, it is like they just woke up one day and they had claws and teeth and they are trying to figure out how to use these as tools, not weapons.

WHISPERING METHODS: Small Failure, Third-Person Lecture, Humor.