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James Keim, MSW, LCSW Institute for the Advancement of Psychotherapy San Francisco, USA October 14, 2014 Presentation in San Jose, CA 1.

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Presentation on theme: "James Keim, MSW, LCSW Institute for the Advancement of Psychotherapy San Francisco, USA October 14, 2014 Presentation in San Jose, CA 1."— Presentation transcript:

1 James Keim, MSW, LCSW Institute for the Advancement of Psychotherapy San Francisco, USA October 14, 2014 Presentation in San Jose, CA 1

2 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 2

3 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 3

4 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 4

5 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 5

6 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 6

7 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 7

8 DSM V Symptoms are now grouped into three types: 1. angry/irritable mood 2. argumentative/defiant behavior, and 3. vindictiveness. 8

9 DSM V The exclusion criterion for conduct disorder has been removed. 9

10 DSM Casts Too Broad a Net 10

11 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 11

12 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. 12

13 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. 13

14 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. 14

15 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. 15

16 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. 16

17 17

18 Four Requirements: Win-Lose view of difficult conversations Process vs. Outcome Orientation Hard and Soft Side of Hierarchy Justice Injury 18

19 First Requirement Win-Lose or Zero Sum approaches to difficult conversations with authority figures 19

20 Second Requirement Process vs Outcome Orientation 20 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

21 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 21

22 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. 22

23 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. 23

24 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. 24

25 Temperament, Information Processing Differences, and Neuroendocrine Contributions to ODD 25

26 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 26

27 A tale of two hormones Trauma responses and Adrenalin Histamines 27

28 Parenting Styles Structure Authoritarian Authoritative Warm Neglectful Authority Averse 28

29 Alliance Common Factors Research Factors for Positive Outcome Relationship Goals and Topics Approach/Method Feedback 29

30 F.A.C.E. FACE F – Familiarity A – Acceptance C – Competency E - Empathy 30

31 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 31

32 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 32

33 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 33

34 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 34

35 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 35

36 Assessing and Utilizing Other Systems Larger Systems Grandparents, aunts, uncle, godparents School Neighborhood/Community Other Providers – pediatrician, tutors, mentor Siblings 36

37 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 37

38 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 38

39 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 39

40 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 40

41 Creating a Contract Parent Consequences Include parent consequence for verbal abuse Parent self-monitors and provides consequence 41

42 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 42

43 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 43

44 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) 44

45 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 45

46 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

47 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 47

48 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? 48

49 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 49

50 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. 50

51 “You Can Tell Me Anything” 51

52 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 52

53 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 53

54 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. 54

55 Nicole & Her Parents 55

56 Listening Skills for Parents Like a Turtle, Don’t Move Too Quick, Draw Them Out Reflection Validation (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 56

57 Helping Parents Understand Defensiveness vs. Providing Context Food Allergy at Dinner Rather than say, “hey, not my fault”, you apologize and empathize with their pain, share your pain in causing them pain Validating Does Not Mean Agreeing Say, “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

58 Soothing Conversations Expected Conversations Parents don’t react to provocations or button pushing at the time and just tag it at the moment or later Moving in and out of conversation around the hot topic Discussing areas of interests or strengths Child laying head on parents shoulder or lap and is soothed while talking Indirect soothing and compliments – for example, complimenting grades, talking about grades with parents and complimenting indirectly 58

59 Listening 59

60 Flexibility of Model Step 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 60

61 Theo Wants Acceptance 61

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