Presentation on theme: "Treating Explosive Kids Part 2 The Collaborative Problem-Solving Approach Drew Burkley Psy.D. Center of Excellence Clinical Psychology Fellow"— Presentation transcript:
Treating Explosive Kids Part 2 The Collaborative Problem-Solving Approach Drew Burkley Psy.D. Center of Excellence Clinical Psychology Fellow
Authors Ross W. Greene, PhD Director of the Collaborative Problem Solving Institute Associate Professor in the Department of Psychiatry, Harvard Medical School J. Stuart Ablon, PhD Director of Think:Kids, Department of Psychiatry, Massachusetts General Hospital, Associate Professor in the Department of Psychiatry, Harvard Medical School
Location Collaborative Problem Solving Institute Department of Psychiatry of Massachusetts General Hospital
Thanks to... Gloria Jones, Psy.D. Sasha Ahmed, M.S. Scott Browning, Ph.D.
“Explosive” children and adolescents? The term “explosive” will be used in this presentation because it is a common theme among all the descriptions and diagnoses
What makes CPS different? Assumes that explosive children are poorly understood and are often poorly addressed by available therapies For close to fifty years, conceptualization and treatment of explosive children have been significantly influenced by the coercion or social interactional model. There has been a focus on patterns of parental discipline Inconsistent discipline Irritable explosive discipline Low supervision and involvement Inflexible rigid discipline
The Plans When a problem arises, there are three ways to deal with it Plan A: Imposing of parents Will Plan C: Removing Expectations Plan B: Collaborative Problem Solving.
Why Plan B? Parents often chose Plan A. Works for about 95% of children Doesn’t account for lagging skills Lagging skills, such as poor frustration tolerance, poor executive functioning, etc. may be influencing compliance Typically seen in the “explosive” children Plan B helps address skills and increase child compliance
Plan B Basics
Plans A and C do not help children learn needed skills Developmentally, children are not equipped to handle explosive episodes alone. Two types of Plan B: Proactive and Emergency Parent does thinking for the child
Surrogate Frontal Lobe Frontal lobes Executive functioning Impulse Control Planning Not fully developed until mid 20’s Caregiver becomes surrogate frontal lobe Thinks for child
Surrogate Frontal Lobe The caregiver functions as a surrogate frontal lobe by: Walking child through the situation Precipitating explosive episodes After multiple repetitions, child will increase their thinking-through ability Something Caregivers already do Teaching baseball or how to cross the street Models creativity and flexibility
Rudimentary Plan B Key Ingredients for a successful Plan B are Both parties (are at a place at which they can begin calm and rational. Ensure concerns of are clearly defined Brainstorm All Ideas considered Creative problem solving for all concerns Steps Necessary for Successful execution of Plan B Empathy (plus reassurance) “I’ve noticed you’ve had problems with X, what’s up?” Define the problem Invitation
Step 1: Empathy Empathy Information Gathering to Understand Acknowledges the concerns of the child and defines that concern Starts with “I’ve noticed” Highly specific definition is essential for successful empathy Feeling heard helps people feel understood
Step 2: Define the Problem Plan A: The concern of the adult Plan C: The concern of the child Plan B: Reconciling the concerns of the child with that of the adult To Main purpose adult get’s their concern on the table. Recognize the pathways that are interfering with the ability to the child to respond to Plan A Clearly define the concerns of the child through Empathy Clearly define the concerns of the ADULT through appropriate investigation
Step 3: The Invitation Invite the child to brainstorm. For example: Let’s think about how we can solve this problem together. Let’s see what we can figure out or do about this together. Assess the ability of the child to develop alternative solutions. Do they have the skills to generate alternative solutions? Do these solutions take both adult and child concerns into account? If not, the care giver may have to serve as the surrogate frontal lobe.
Step 3: The Invitation The burden is upon both members (child and adult) of the problem solving team to solve the problem. What matters now is that a solution is developed that is feasible and mutually satisfactory. The invitation appears to many parents to be a dissolution of their power rather than a sharing and development of responsibility with their child. The Litmus test for a good solution is that it is realistic, doable, and mutually satisfactory.
Emergency Plan B Versus Proactive Plan B Emergency Plan B De-escalation technique. Most parents and caregivers don’t realize that the problems are highly predictable Proactive Plan B Solve the problem before it occurs Teaching tool Helps child ID triggers Know for future occurences
Easy Living Through Plan B Prior to explaining Plan B to caregivers, we should: Explain the pathways that are causing issues identify the triggers (i.e., problems that have yet to be solved) that commonly precipitate explosive episodes.
Easy Living Through Plan B Two forms of Plan B: Focusing on resolving the triggers for the explosion (Problem-focused Plan B) Focusing on developing the lagging skills that are causing the explosions (Skills-focused Plan B)
Common Mistakes Forgetting to Invite the child to problem solve Skipping steps Not clearly identifying the two concerns Providing alternative solutions (two Plan A’s or a Plan A and a Plan C)
Common Mistakes As a clinician, forgetting to examine and identify ADULT pathway problems before entering this step. Caregivers trying to make Problem Solving Unilateral rather than collaborative. Caregivers trying to make Plan B a clever form of Plan A! Relying too much on Emergency Plan B and not using Proactive Plan B
Beyond the Basics
Skills Needed for Plan B Identify and articulate concerns Consider these generating alternative solutions Anticipate outcomes of potential solutions
Therapist Roles Identify lagging skills Assist family in strengthening them Facilitate therapeutic process
Therapist Roles Establish alliances with each participant Maintain neutrality Prevent discussion from spinning out of control Be vigilant to hindrances to full investment
Therapist Roles Help participants stay on track during discussions Identify any impediments to progress Address within the family system
What is the single greatest predictor of therapeutic change?
Establishing the therapeutic alliance
Establishing Alliances Therapeutic relationship is vital Communication of empathy is key Validate Convey understanding
Establishing Alliances with Adults Adults need: To be heard and understood To see the clinician as competent To see the clinician has the capacity to help relieve distress
Establishing Alliances with Children Children need to know: Things may be better this time around That the clinician does not believe that negative behaviors are intentional That the clinician views the situation as a “family problem”
Maintaining Neutrality Ensure that all participants’ concerns make it into the discussion Remaining focused Understanding Clarifying
Maintaining Neutrality RRemain focused on process vs. outcome ***HOWEVER*** SSolutions need to be“mutually satisfactory”
Taking Control of the Case Therapist Roles Mediate Assess “temperature” Remain vigilant
Taking Control of the Case Therapist Roles (cont...) Actively calculates the pace of therapy Keeps the discussion on track Remains mindful of other treatments being delivered
Pathways Extended The Therapist as a Salesperson Beginning therapy focused on child skill deficits: Maintains congruence with many parents’ expectations about the process of therapy Helps alter/reframe parent perceptions of their child’s outbursts
Pathways Extended The Therapist as a Salesperson A Good “Pitch” from original definition of the referral problem to more systemic perception. Address both child and parent skill deficits Feasible when therapeutic alliance is secure.
Pathways Extended Defining the problem Executive struggles Generating alternative solutions Disorganized/unsystematic approach Language-processing issues Emotional regulation deficits Concrete thinkers
Skills Trained with Plan B
Identifying &Articulating Concerns and Problems Language Processing Skills –Using and Practicing Adaptive Vocabulary –Using Reminders –Talking about the incident later, away from the heat of the moment. –Teach Pragmatic vocabulary with problem identification Video Clip
Considering Possible Solutions Mutual process between parent and child Some children have never been given the opportunity Repetition and exposure to adults showing this skill helps to build it in some cases In other cases a structured model can help
Reflecting on Likely Outcomes and How Feasible/Satisfactory They Are Therapist may express skepticism about solutions that may not be realistic/feasible model for the family Child may not develop a solution based on both concerns difficulty with perceptive taking
Parent’s Execution of Plan B Step 1- Empathy Calming affect Acknowledge their concern Step 2 Defining Problem Help child to take your concern into account when working toward a solution State concern in a calm, tentative manner Reminder of problems solved prior
Final Thoughts Advantages of Plan B: Training can occur in the environments in which the skills are to be utilized Collaborative in nature Child is more likely to think about a problem More likely to take ownership of the problem and the solution Teaching adaptive social functioning is built in