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

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

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

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

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

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

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

This is controlling the timing, direction, and the mood35

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

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

Parent believes no consequence will work, so does nothing 46

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

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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