james keim, msw, lcsw institute for the advancement of psychotherapy san francisco, usa october 14,...
TRANSCRIPT
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Therapy with Oppositional Children and Adolescents
James Keim, MSW, LCSWInstitute for the Advancement of Psychotherapy
San Francisco, USAOctober 14, 2014
Presentation in San Jose, CA
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Jim’s BackgroundMSW, Postgraduate Training in Family TherapyServed as Director of Training for Jay Haley and Cloe
Madanes at the Family Therapy Institute of Washington, DC
Director of the conference, Oppositional Youth, hosted at the National Institutes of Health
Co-Author of the book, The Violence of Men, and author of a dozen book chapters on therapy issues
Fulbright Specialist Roster Candidate, Vietnam, focus on treatment of victims of human trafficking and on clinical infrastructure development
Director of the Oppositional and Conduct Clinic, Institute for the Advancement of Psychotherapy in San Francisco
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Overview of the Workshop1 – Refining the description of ODD
Creating a functional description of ODD
Contribution of information processing differences
Contribution of Neuroendocrine responses
Contribution of self-regulation issuesTemperamentAttachment 3
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Overview of the WorkshopStage One: Redefining the Problem,
dealing with BlameStage Two: refocussing on self-care and
non-repetition of what doesn’t work, individualized parent guide
Stage Three: reworking rules and consequences
Stage Four: Restoring Soothing, basis for attachment, and having the important, emotionally charged conversations
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What Justifies a Label?Any diagnosis limits our vision and imagination
It is justified for the clinician only by the degree to which it helps to avoid harm and help clients and clinicians to resolve the problem
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DSM-IV Diagnostic Criteria for ODDA. A pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, during which four (or more) of the following are present: (1) often loses temper (2) often argues with adults (3) often actively defies or refuses to comply with adults' requests or rules (4) often deliberately annoys people (5) often blames others for his or her mistakes or misbehavior (6) is often touchy or easily annoyed by others (7) is often angry and resentful (8) is often spiteful or vindictive
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DSM-IV Diagnostic CriteriaB. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.
C. The behaviors do not occur exclusively during the course of a Psychotic or Mood Disorder.
D. Criteria are not met for Conduct Disorder, and, if the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder 7
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DSM VSymptoms are now grouped into three types: 1.angry/irritable mood2.argumentative/defiant
behavior, and3. vindictiveness.
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DSM V
The exclusion criterion for conduct disorder has been removed.
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DSM Casts Too Broad a Net
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Results of Poor Diagnostic Criteria
ODD is so broad that it is the second most common pediatric mental health diagnosis
From a clinical perspective, there are probably three different mental health problems incorrectly lumped under this label
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Focusing our DiagnosisOur focus will be on the Argumentative/Defiant subdomain. Within this subdomain, we will divide them into two groups, those who have not yet received competent home and school structure and those who have and still have ODD.
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The DSM diagnosis of ODD is refined to create subcategories that suggest quite different interventions. The most challenging subdomain, one involving the concept of Justice Injury, is the focus of this workshop, as it is the variation that seems to resist standard intervention.
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CHARACTERISTICS OF THIS APPROACHWhile we approach rules and consequences in a novel, individualized way, there is ultimately a greater emphasis on individual, family, and classroom soothing and self-regulation.
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CHARACTERISTICS OF THIS APPROACHThere is a focus on information processing differences that frequently drive ODD. This includes addressing how learning differences and/or stress hormones change a child or adolescent’s perception and memory of stressful conversations.
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CHARACTERISTICS OF THIS APPROACHThe therapist’s sensitivity to the endurance and engagement of caretakers and teachers is more important than any other variable in the therapy. The intervention is designed with this as a constant, central focus, and an evidence-based approach is used to monitor the client-clinician alliance.
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Additional Diagnositic
Criteria17
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Four Requirements:
Win-Lose view of difficult conversations
Process vs. Outcome Orientation
Hard and Soft Side of HierarchyJustice Injury
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First RequirementWin-Lose or Zero Sum approaches to difficult conversations with authority figures
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Second RequirementProcess vs Outcome Orientation
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Oppositional youth tend to believe that they are the “winners” of a confrontation with an authority figure to the degree that they inappropriately:
1.Chooses the content and direction of the conflict
2.Chooses the timing of the conflict
3.Chooses the emotional tone of the conflict
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Third Requirement: Imbalance in Hard & Soft Side of Hierarchy
Hard SideWho Makes the RulesWho Defines the
PunishmentsWho Carries Out the
PunishmentsWho Tells Whom What to DoWho has Final Responsibility
for Making Others Feel Safe and Provided for in the Environment
Soft SideWho Soothes WhomWho Provides Reassurance
to WhomWho Protects WhomWho Has Responsibility for
Expressing Love, Affection, and Empathy
Who is the Provider of Good Things and Good Times
Who Usually Determines the Mood of the Situation
Who Has the Responsibility to Listen to Whom
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Justice InjuryThere is a pervasive, heart-felt sense that one is often the victim of unjust treatment at the hands of others (usually authority figures) who deny the unfair treatment.
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Justice InjuryThis sense of being treated unjustly is the source of the child’s most passionate, confrontational, and problematic behavior. There is a resulting unwillingness, for the sake of dignity, to “bend” to normal consequences.
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Justice InjuryThe associated trauma with this
unfair treatment is so severe that it regularly evokes a fight-or-flight neuroendocrine response during difficult conversations with authority figures. During difficult conversations with authority figures, and sometimes at the mere expectation such a discussion, this fight or flight response is evoked. 24
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Trauma, Fight or Flight Responses, and ODD
Temperament, Information Processing Differences, and Neuroendocrine Contributions to ODD
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Critical Communication Concepts
Parallel and Sum CommunicationHow information processing problems impact understanding
Good and Bad communication matches at home and school
How stress hormones increase information processing deficits
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A tale of two hormones
Trauma responses andAdrenalinHistamines
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Parenting Styles Structure
Authoritarian AuthoritativeWarm
Neglectful Authority Averse
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AllianceCommon Factors Research Factors for Positive Outcome
RelationshipGoals and TopicsApproach/Method
Feedback
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F.A.C.E.FACE
F – FamiliarityA – AcceptanceC – CompetencyE - Empathy
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Clues for RapportThe parent is telling you how bad the child is
Parent may not feel heard or validated in how difficult this is
Parent may feel blamedParent trying to defend self in the session
against the child’s statementsMay not feel you value them, know they’re
tryingTeen is quiet
Not working on what’s most important to teen
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Common First SessionPacing of Session
All together 20 min Assessment Hopes for the therapy Enactment (occurring naturally)
Adolescent 10 min Engage Strongly align Goals and Treatment Plan
Parent 10 min Engage Strongly align Goals and Treatment Plan
All together 10 min Reframe Goals and Treatment Plan Confidentiality Give Them Hope 32
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Building Internal ResourcesParents
Endurance raceModeling Self-Soothing and Other SoothingImage of who you want to beSocial supportCoping Skills
AdolescentsCoping skillsValues and goals despite problems with family
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Increasing Flexibility Attitude of Experimentation
1 in 4 suggestions that therapist makes will work and 1 in 3 that clients make will work
How do you want to be and if that happens 1 time = success Discounting myths – silver bullet, last one standing, punishment
has to fit the crime, can’t let the kid “win” (but win when they control process), say it right
Keep log of what works and what doesn’t Write down target behaviors and goals We can’t “make” child do anything
Stepping Back Graceful Exits (tennis example) Modeling Self-Soothing and Other Soothing Modeling Taking Responsibility
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Changing the ProcessGraceful Exits When in Power Struggles
“You deserve respect, and if I stay in this conversation/argument any longer, I might be disrespectful, so I’m going to go take some time to cool off” Your taking responsibility for your feelings and actions You are not blaming the adolescent. You’re not saying, “its
because you make me so mad” or “because you’re such a jerk”
Model self-soothing “I’m going to go lay down” or read a book, take a walk, etc.
Model other soothing Parent goes to other parent and lies head on shoulder or in
lap
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Assessing and Utilizing Other Systems
Larger SystemsGrandparents, aunts, uncle, godparentsSchoolNeighborhood/CommunityOther Providers – pediatrician, tutors, mentorSiblings
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Parenting By MoodParents often use rules and consequences,
but they are not predictable, but based on parent’s mood. All are attempts to motivate for improvement, but may deteriorate the relationship.Yelling (become immune)NaggingShaming (often unknowingly)Reneging on ConsequencesRules Vary When EnforcedAttempts at Guilt
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Step 3 - StructureCreate a Contract
Create a benevolent authority Create a contingency management system that
helps guides parents reactions to adolescent acing out
Based on positive reinforcement Based on if Adolescent was Doing Everything Well
to Get all Rewards/Freedoms that are Age Appropriate
Parent will treat kid as if they will succeed, rather than acting like they are a “bad kid”
Goal of the contract is to externalize the rules and consequences to less affect relationship
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Expectations Expectations
Grounded in Family Values Community Standard Clear Rules with Definitions Differentiate Normal Adolescence From
Oppositional Behavior For example, adolescent says, “I hate you”
because they were embarrassed by parent at school vs. “you are a f***ing bitch, I hate you”
Adolescent is not so interested in your life (e.g., feeling rejected) or you are giving but not asking and they are rejecting
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Creating a ContractFocused on Positive Reinforcement
6 to 1 Ratio of Positive to Negative ExplainedFocus is Reinforcing Target Behaviors Rather
than Giving Energy to Negative BehaviorsTwo Tiers of Consequences
Voluntary For example, turn off the tv, go to time out,
extra choreInvoluntary
For example, tv is taken away for 2 days, no phone for 2 days
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Creating a ContractParent Consequences
Include parent consequence for verbal abuseParent self-monitors and provides consequence
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Various Methods of ReinforcementNever take away more than 50%
Large Consequences Grounded for a Month, Lose Phone for Month
Small Consequences Grounded for a Day, Lose Phone for 2 Days
Large Consequences for Short Periods of Time No Electronics for 15 min to 1 hour
Very Small Consequences Give consequence of $5.00 and take away nickels
Rewards and Consequences Specific To Rule
Specific to Rule and Natural Consequence
Menu of Consequences42
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Various Methods for ReinforcementRemind of Rewards Rather Than Encourage
EntitlementYes, you can go to the movies because you’ve been
doing ___________ so well
6 to 1 Ratio Includes Positive InteractionsMaterial RewardsFreedomsCan work off consequences by engaging in
positive behaviorsGet 1 day off grounding for x, y, or zTime off for good behavior concept
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Pitfalls to Step 3Authority Averse or Authoritarian
Parent loves and wants to protect child and may want to protect from therapist
Learn of parent’s own experience of being parentedIf parents were too strict, may feel abusive to
set limitsIf parents were too lenient, may feel abuse to
not have strict limitsMay have identified with parents (e.g., it
worked for me as a kid, so should work for them)
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Pitfalls to Step 3Parent(‘s) energy and ability
Overworked and ExhaustedOverwhelmed by ParentingParent’s triggered (possibly past trauma)Parent’s own substance useParental guiltFear of losing the relationship
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Pitfalls Contract can become another forum for power struggles
Help parent to remember to disengage when in the process
Remind them not to try to get the adolescent to like the consequence (e.g., what do you think about that?)
Parent feels it doesn’t hurt enough
Remind them that discomfort is not the end goal, but connection between consequences and behaviors
Remind parent that the focus is relationship building
Remind parent that when the kid says, “I don’t care”, it is just to push a button
Parking tickets rather than towing the car
Parent is trying to get too much agreement or collaboration around rules and consequences, so gives authority away
Parent is paralyzed by picking the right consequence and therefore gives none
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PitfallsParent is afraid
Role play and start smallPlan for safety and worst case scenario especially
regarding the 5 Aces (Scott Sells)
Parent is fearful of losing the relationshipDiscuss that the relationship is the money in the
bank for being able to provide structure and also helps child have confidence and respect for parent
Parent may not be ready, so you may jump to Stage 4, but at the same time at least try to diminish behaviors that negatively affect the relationship
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Step 4 - RelationshipGroup Exercise
A time in your life where you were having a hard time as a teen
Could you turn to your mother? Could you turn to your father?If not, what got in the way?If you could have turned to them, would that
have helped?
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Common Reasons Adolescents Don’t Turn to Parents
Adolescent says parent is:Too busyWill “freak out”Will get overinvolvedWill be judgmentalWill use it against themIsn’t stable enough to handle itResentments
Said something very hurtful about the adolescent Divorced other parent Abused child Abandoned child
Drugs and Alcohol Trauma
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Step 4 - Relationship Treating anxiety and depression is through the attachment, turning to
parents as resources Focus is on rebuilding the attachment, allowing for the parent to
parent the child, and for the child to feel comfort, support, love, and acceptance from the parent
Consequences and rewards will not be as effective if there is no relationship
The relationship part is at step 4 because by this time, the parent has hopefully made some changes and are now a benevolent authority figure, rather than parenting by mood, so that when the child shares their pain, the parent feels confident in their current parenting abilities. The adolescent can also become vulnerable, the parent can apologize, and then not continue doing the same behaviors that hurt the relationship.
Authority also means being able to handle the hottest topics like listening to things like: The child’s trauma Coming out Wishing to reunite with biological parents (in adoptive cases) Feelings about the parent’s divorce, remarriage, etc.
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“You Can Tell Me Anything”
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Preparing the Adolescent for the Soothing of Pain/Attachment Session
Explore what gets in the way of having a good relationship with the parent
How well does your parent know you? What percent?
Imagine telling that to the parent and their fears
Imagine how that might change the adolescent’s situation
Be curious about what it would be like if could turn to parent with their pain
Ensure them that you’ll work on the parent, if they are fearful of the parent being hurtful or unchangable
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Preparing the Parent for the Attachment Session
Explain to parent that most adolescents want to talk to their parents and many can turn to their parents
Explain that their child will communicate their feelings either directly or indirectly, so this is to help them directly communicate rather than act it out
Let the parent know that you don’t blame them, you know they’re doing a good job, and even when they’re hearing from their kid that they’d not doing good, you and the parent will know the truth, so there is no need to defend or convince their child
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Preparing the Parent for the Attachment Session
Encourage the parent to think about their own parents and what got in the way of the turning towards them
Encourage them to really listen to their child and convince their child that they really want to hear what they have to say and it is safe
Encourage them to let the child know they can handle it, they won’t use it against them later, and they won’t have to take care of the parent.
Prepare the parent for how hard it is to hear their child’s pain if its caused by another and how its even harder to hear it if they were the cause.
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Nicole & Her Parents
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Listening Skills for ParentsLike a Turtle, Don’t Move Too Quick, Draw Them
OutReflectionValidation (does not mean agreement)Nonverbal (nodding, mmm, hmmm)Questions
To learn more, not leading or rhetorical questions
Giving in Imagination
Encourage parent to hold off explaining themselves until the adolescent really feels heard and understood, then can share the context, but at the same time accepting responsibility
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Helping Parents Understand Defensiveness vs. Providing Context
Food Allergy at DinnerRather than say, “hey, not my fault”, you
apologize and empathize with their pain, share your pain in causing them pain
Validating Does Not Mean AgreeingSay, “I can see how you felt so hurt and I would
feel that way too, that’s a natural way to feel when something like that would happen”, “I didn’t want to cause you pain and thought I was doing the best thing at the moment. I wish I could have done it differently to not have caused you pain” 57
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Soothing ConversationsExpected ConversationsParents don’t react to provocations or button pushing
at the time and just tag it at the moment or laterMoving in and out of conversation around the hot
topicDiscussing areas of interests or strengthsChild laying head on parents shoulder or lap and is
soothed while talkingIndirect soothing and compliments – for example,
complimenting grades, talking about grades with parents and complimenting indirectly
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Listening
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Flexibility of ModelStep 3 and Step 4 can be swapped, depending on the situation
When there is not much chance of creating structure due to systems issues or parent’s ability to set limits, but important to do Step 2 so they’re not engaging in behaviors that are damaging the relationship
In some non-oppositional cases the structure isn’t very primary, so you can apply this model and skip Step 3, although again, check for parents not behaving in ways that damage the relationship in hopes of increasing motivation, like lecture a depressed child about school success, thus leaving the child feeling shamed
When Step 3 and Step 4 aren’t working so well, revert to Step 2 to help build up parent May do EMDR with parent around their triggers DBT and CBT around moving from being reactive to being responsive Having parent start individual therapy Have parent start drug and/or alcohol treatment Doing EMDR with adolescent
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Theo Wants Acceptance
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