Therapy with Oppositional Children and Adolescents

Therapy with Oppositional Children and Adolescents James Keim, MSW, LCSW Institute for the Advancement of Psychotherapy San Francisco, USA October 14, 2014 Presentation in San Jose, CA

Jim’s Background • MSW,Postgraduate Training in Family Therapy • Served 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

Overview of the Workshop • 1 – Refining the description of ODD • Creating a functional description of ODD • Contribution of information processing differences • Contribution of Neuroendocrine responses • Contribution of self-regulation issues • Temperament • Attachment

Overview of the Workshop • Stage One: Redefining the Problem, dealing with Blame • Stage 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

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

DSM-IV Diagnostic Criteria for ODD A. 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

DSM-IV Diagnostic Criteria B. 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

DSM V Symptoms are now grouped into three types: • angry/irritable mood • argumentative/defiant behavior, and • vindictiveness.

DSM V The exclusion criterion for conduct disorder has been removed.

DSM Casts Too Broad a Net

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

Focusing our Diagnosis Our 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.

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.

CHARACTERISTICS OF THIS APPROACH • While 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.

CHARACTERISTICS OF THIS APPROACH • There 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.

CHARACTERISTICS OF THIS APPROACH • The 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.

Additional Diagnositic Criteria

Four Requirements: • Win-Lose view of difficult conversations • Process vs. Outcome Orientation • Hard and Soft Side of Hierarchy • Justice Injury

First Requirement • Win-Lose or Zero Sum approaches to difficult conversations with authority figures

Second Requirement • Process vs Outcome Orientation Oppositional youth tend to believe that they are the “winners” of a confrontation with an authority figure to the degree that they inappropriately: Chooses the content and direction of the conflict Chooses the timing of the conflict Chooses the emotional tone of the conflict

Third Requirement: Imbalance in Hard & Soft Side of Hierarchy Hard Side • Who Makes the Rules • Who Defines the Punishments • Who Carries Out the Punishments • Who Tells Whom What to Do • Who has Final Responsibility for Making Others Feel Safe and Provided for in the Environment Soft Side • Who Soothes Whom • Who Provides Reassurance to Whom • Who Protects Whom • Who 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

Justice Injury • There 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.

Justice Injury • This 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.

Justice Injury • The 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.

Trauma, Fight or Flight Responses, and ODD Temperament, Information Processing Differences, and Neuroendocrine Contributions to ODD

Critical Communication Concepts • Parallel and Sum Communication • How information processing problems impact understanding • Good and Bad communication matches at home and school • How stress hormones increase information processing deficits

A tale of two hormones • Trauma responses and • Adrenalin • Histamines

Parenting Styles Structure Authoritarian Authoritative Warm Neglectful Authority Averse

Alliance • Common Factors Research • Factors for Positive Outcome • Relationship • Goals and Topics • Approach/Method • Feedback

F.A.C.E. • FACE • F – Familiarity • A – Acceptance • C – Competency • E - Empathy

Clues for Rapport • The parent is telling you how bad the child is • Parent may not feel heard or validated in how difficult this is • Parent may feel blamed • Parent trying to defend self in the session against the child’s statements • May not feel you value them, know they’re trying • Teen is quiet • Not working on what’s most important to teen

Common First Session • Pacing 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

Building Internal Resources • Parents • Endurance race • Modeling Self-Soothing and Other Soothing • Image of who you want to be • Social support • Coping Skills • Adolescents • Coping skills • Values and goals despite problems with family

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

Changing the Process • Graceful 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 • This is controlling the timing, direction, and the mood

Assessing and Utilizing Other Systems • Larger Systems • Grandparents, aunts, uncle, godparents • School • Neighborhood/Community • Other Providers – pediatrician, tutors, mentor • Siblings

Parenting By Mood • Parents 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) • Nagging • Shaming (often unknowingly) • Reneging on Consequences • Rules Vary When Enforced • Attempts at Guilt

Step 3 - Structure Create 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

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

Creating a Contract • Focused on Positive Reinforcement • 6 to 1 Ratio of Positive to Negative Explained • Focus is Reinforcing Target Behaviors Rather than Giving Energy to Negative Behaviors • Two Tiers of Consequences • Voluntary • For example, turn off the tv, go to time out, extra chore • Involuntary • For example, tv is taken away for 2 days, no phone for 2 days

Creating a Contract • Parent Consequences • Include parent consequence for verbal abuse • Parent self-monitors and provides consequence

Various Methods of Reinforcement • Never 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 Consequences

Various Methods for Reinforcement • Remind of Rewards Rather Than Encourage Entitlement • Yes, you can go to the movies because you’ve been doing ___________ so well • 6 to 1 Ratio Includes Positive Interactions • Material Rewards • Freedoms • Can work off consequences by engaging in positive behaviors • Get 1 day off grounding for x, y, or z • Time off for good behavior concept

Pitfalls to Step 3 • Authority 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 parented • If parents were too strict, may feel abusive to set limits • If parents were too lenient, may feel abuse to not have strict limits • May have identified with parents (e.g., it worked for me as a kid, so should work for them)

Pitfalls to Step 3 • Parent(‘s) energy and ability • Overworked and Exhausted • Overwhelmed by Parenting • Parent’s triggered (possibly past trauma) • Parent’s own substance use • Parental guilt • Fear of losing the relationship

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 • Parent believes no consequence will work, so does nothing

Pitfalls • Parent is afraid • Role play and start small • Plan for safety and worst case scenario especially regarding the 5 Aces (Scott Sells) • Parent is fearful of losing the relationship • Discuss 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

Step 4 - Relationship • Group 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?

Common Reasons Adolescents Don’t Turn to Parents • Adolescent says parent is: • Too busy • Will “freak out” • Will get overinvolved • Will be judgmental • Will use it against them • Isn’t stable enough to handle it • Resentments • Said something very hurtful about the adolescent • Divorced other parent • Abused child • Abandoned child • Drugs and Alcohol • Trauma

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.

Therapy with Oppositional Children and Adolescents