The Fearless Practitioner: Creative Insights & Strategies for Helping the Most Violent, Oppositional &

Avoidant Child & Adolescent Clients

Aaron Wiemeier LPC

March 13, 2015

Defining The Most Difficult Clients

• One or more of the following diagnoses: Conduct Disorder, ODD, PTSD, RAD, MDD, IED, Other Mood & Anxiety Disorder, ASD

• They have languished inside a mental health system that is ineffective at meeting their needs and has reinforced their level of distrust of adults to a significant self-protective level

• They have experienced significant secondary gain at the expense of their aggression, avoidance, deceipt etc

• 2 types: Directly Aggressive Conduct vs. Sneaky Functional Conduct (Fight or Flight)

• Highly Effective at Splitting Systems and the adults and professionals within them

Don’t’s & Do’s1) think your going to be the one to save the child or get them to change (Jeff Hall)

-Feed The Therapist Ego set up to own their effort more than they do

2) try too hard to connect with them directly especially in the beginning

3) promise you’ll be there for them either directly or indirectly

4) think that these kids are fools or are unaware (Masters of Survival!)

5) think that you are different than them

1) believe that you will make a significant difference in their lives (Seed Planter)

2) Establish safety through accountability, structure followed by hope (in 1st Session)

3) Do acknowledge that the relationship you have will be temporary (goal to learn from one another)

4) Reframe their skill at reading and controlling others

5) Acknowledge we are ALL broken!

(Mirror Team Ex:)

Bonus Don’t & Do

• Don’t think that your graduate level training will allow you to not be triggered by these kids!

• Do learn and understand what your greatest triggers are and how they relate to your own childhood trauma, issues and experiences.

14 Most Important Concepts – In order of Importance(mostly)

1) Fear: The Great Destroyer

2) Know Thyself….

3) Setting The Precedent: The Importance of The First Session

4) How You Start is Not How you End

5) Believe

6) Commitment

7) CBES is the Way to GO

8) If you Must Talk About Feelings…..

9) Drop The Agenda

10) Be a Kid Again!

11) If They Can Control You

12) Predictable Unpredictability

13) The Art of Saying NO!

14) Metaphors for Confronting Fear

Fear: The Great Destroyer

• They will use fear to control others

confront fear/anger directly (i.e. DJ and female tx assault)– Setting appropriate limits with older kids (post 10) re: violence re:

accountability and working systemically to reduce systemic enabling (i.e. tx centers) once kid is given tools and has reasonable capacity to use them

– Violence in home or school setting must be FIRST priority as no change will occur before this is dealt with

Know Thyself….

– Pos/Neg Cognitions List – Understand and reduce your own triggers

(gender considerations re: I am in danger)– DON’T BE A HIPPOCRITE –they don’t like

hypocrites!– Supervisor/Supervision is Key (style of

supervisor is Key)

Intervention: Prove To Me You are…….

Positive & Negative Cognitions List

Setting The Precedent: The Importance of The First Session

• PTSD – How severe/Eval – let them know wont work on deeper stuff until later – no digging – EMDR not appropriate right away (i.e. DJ)

• ODD/Conduct –RESPECT/reality based/how many therapist have you had before – understand they’ve heard everything your gonna say before by someone else – why should they think you are any different – are you? Can you be? Are you willing to be?

• RAD (Former Diagnosis) – confront efforts to control immediately (most clients will not actually have this diagnosis/misdiagnosed or diagnosed by their exhausted parent who probably has their own attachment issues) – Everyone has attachment “Issues”

• ADHD – impulsivity addressed/communicate need for training/life long process that starts with decision (connect with idea that they don’t want to be an angry person)

• Autism/Aspergers – normalizing

The First Session continued

• Addressing Anger in first session – Anger is a choice – giving anecdotes (i.e. shorts example) – Healing Hand in first session for younger kids (regulating tool) – set EXPECTATION that they will begin to use this but relieve pressure for ODD with parents by acknowledging they will oppose and focus on the one positive (i.e. – kids want self-control once they experience it)

• Also eval of kids defense mechanisms by seeing if kid can acknowledge anger problems in first session

• Reframe anger as fear based and note this will be repetitive and they will get annoyed (i.e. Im gonna say this to you so much that youll start to believe it) – challenging them with an intellectual approach

• Work First Then Play

• Establish Small Amount of Authority Critical - Level of Confrontation varies by level of severity of traits/diagnosis

• Tone Essential: Stern and Serious Hopeful and Encouraging

• r-e-s-p-e-c-tMeet them where they are at - if you are too passive they don't respect that - as they feel you are easily controlled and not safe - confrontation necessary to establish respect - if you are a confrontational person you can wait until later session to confront because you will have set the tone anyway - if not you need to set that in the first session (aversive arousal explanation) – DH Example where I was regulated at his aggression and he escalated until I challenged and met him at or near his aggression level verbally

How You Start is Not How You End

• Start may be confrontational - always end on hopeful belief oriented process – Create New Reality (use Anecdotes i.e. (PM re: famous person telling wont change Believe – movies Afisher – survival stories - real life stories to inspire – Nick V

• Passionate descriptions of some of what they desire to do but wont talk about – Afisher confronting birthmom

“Why did you never come for me”• As much as possible…don’t focus on behavior but on

underlying fear process…can be used in confrontational element of session

Believe

• Healing Management/Functional Skill Development (must get contract if healing to be tried with older teen (i.e. EP)

• Body and Brain Designed to Heal Neurologically!• PM example re: telling parents she would never heal

more than where she was• Japanese experiments ability to change composition of

water• Biology of Belief

To Believe or Not to Believe

“ I think I just didn’t have confidence in myself when I was younger…now Im starting to believe…now I actually- know I am talented” – TR

Committment

– Be realistic about it – say it for what it is – don’t make promises directly or indirectly that you cant keep (i.e. – female tx’s at tx center having babies and leaving)

– First Session: Acknowledge (often in question form) how many therapist and people have gone in and out of life but DO NOT try to convince them you’ll be any different – but rather acknowledge the truth about the r2 – that its temporary – that your job is to help with XYZ – and when that’s done you’ll move on – that you are not a part of their family etc.

– Adoption considerations: extraneous providers fading into background – FAMILY is central piece – normalizing systemic experience/reducing unnecessary tx stuff – connecting to community experiences

– Some kids will need a long term commitment – actions speak louder than words – attachment considerations

– You are NOT the agent of change…they are, and secondarily their family is if they are healthy enough – drop your level of importance in their life

CBES is the Way To Go

– Community Based leads to opportunity (EP stray Dog ex)

– Experiential - essential to mimic real life and reduce resistance )(TB Paintball-led to my ability to confront him during violent episode/situation “I respect you I just need some time to calm down”

– Systemic - systemic treatment critical to effective change - aligning major persons to give heathy similar message to client - reduce enablers and escape routes - influence court/ legal systems –

– Autism/aspergers – counter at MCds – local Bball courts to promote social interaction and provide real time feedback

– Movement is Key (Bball etc. – often times to end session if bigger issues dealt with)

Systemic: Extra Note

Myth: The legal system will do nothing more than make a child’s problems worse and consequences do not work

Truth: Children need healthy consequences and follow through to learn healthy role formation and base cause effect relationship as well as to establish safety

Myth: Once they get wrapped up in the legal system they will never get out

Truth: The above is only true if you as their therapist do not follow them through that system giving appropriate recommendations for increased or decreased accountability/mediate over and undereactivity by that system

Systemic: Extra Note 2

How To Be An Influence In Court

What Judges Want:-Specific clinical explanation relating to diagnosis with direct recommendations-You to seem like an expert…you basically need to wow them in about 15-30 seconds

What Judges Do Not Want:-Wishy washy uncertain theoretical clinical commentary with no clear recommendation

If you Must Talk About Feelings…..

– Make fun of the white guy in the beard “how do you feel” stereotype

– Younger kids Healing Hand…expectation and move on

– Older kids generally addressed in intellectual way but note need to have concrete ideas on how to cope with anger and that noticing where in body is a clue to help them

Drop The Agenda-

• often times we go into sessions with an agenda/plan - they are aware of that and that and it is predictable….

• what if you do something that is unpredictable (i.e. eat dinner when arrive at house – don’t go right into behavior of the day – surprise them

• Time is your “ally”

Be A Kid Again

• Have Fun in session….its OK…its good to have fun…its good to laugh…its good to play…its great modeling

• Playgrounds (challenge game), skating, community sports

• Basically some sessions are just about living and laughing life!

If They Can Control You….

• You will not be able to help them and it will put you at risk and exacerbate their diagnosis

• Subtleies of control (walking in front of you while talking to a parent, interrupting you, becoming verbally aggressive in first session, getting you to believe a lie (could be in the form of painting themselves as a victim-ie.MM), second guess yourself, feel afraid, frustrated & hopeless or to dislike them)

• Reframe it is how they organize a system and the adults in it to meet their need of primarily the perception of safety by means of unhealthy control of others…i.e. They would make good lawyers or CEO’s!

What To Do????

• Be aware of you feelings – if you feel tugged (because we are therapists after all) – it is a light bulb – don’t acknowledge process much – move right past attempt to get you to see other as problem – more extreme process by client – use “we can call that person right now and talk to them about it “ - be ready to follow through on this – this is part of a system intervention and often times you will have to educate others on how to do this as well

• Trust your instincts regarding lying (1 of 10 times you’ll be wrong and you just acknowledge this) TA Phone Cord Example

• Challenge these if you see them in the first session…this is critical!

More Insights!

• Create a System of Predictable Unpredictability

• The Art of Saying “No”

• Metaphors for Confronting Fear

5 Grad School Myths DebunkedTaught

1) Self Disclosure is Bad

2) Safety in the therapeutic R2 is established by empathic listening and UPR

3) Therapy is somehow separate from real life and occurs in an office

4) Client needs to be in complete control of the session and process

5) We can help people change their lives

Truth (for these clients)

1) Only if its more about you

2) healthy level of authority and respect being established (yelling PTSD analogy)

3) No way you can truly separate this…so embrace this reality

4) Establishing healthy authority actually produces and context for change

5) They choose to change their lives…we set the stage…and we are not the main character in that play

Other Obstacles to Helping

• Bureaucracy• Paperwork• Meetings and more meetings• Functionally Dysfunctional Administration/FOO/Treatment Team• Fear: Litigation, Losing License/Career• Secondary Trauma• Systemic Stress (i.e. caseload/vacation)• Reactive Treatment vs. Proactive Treatment• Systemic Enabling (police not wanting to do job)

20 Creative Interventions

1) I action Language

2) Silence Shift: Don’t always fill space with talk (way to establish small amount of authority, become unpredictable) Car Radio ex:

3) Use Your Words: Developmental Considerations and Need fulfillment

4) Angry Soda Bottle/Make Me Mad Exercise

5) Challenge Them and Win (Bball-CS Running) – betting $ for Push Ups

6) Regulate 4-7-8

7) Create Relief for Family First if Behaviors are severe

8) Healing Hand

9) Grounding Statements (DW example)

10) One Minute Scolding

20 Creative Interventions cont.

11) Me versus All of you (promotes prosocial bx and context for potential tx)

12) Don’t read the File at first (and let them know it)

13) Anecdotes of success stories – clients included obviously omitting identifying info

14) Do not own their choices (TR example)

15) Every Child has a gift …find it, develop it and help them believe in it!

16) Short therapeutic Sessions …followed with activity

17) 4-7-8 BioFeedback Run Challenge (promoting/getting buy in about self regulation)

18) Movie and Social Media (Touching The Void ex to address overwhelming feelinging re: changing patterns)

19) Soaked Sponge Exercise/Weighted Backpack

20) Third Party Alternating Confrontation (DH example with Dads Trauma Hx) – mechanism to address clients efforts to control via agreeing with you, tuning you out, when you are challenging them – addresses the avoidance tactics

BONUS: Free Association Singing

“One Liners”

• 1: You are never a bad kid…you simply make wrong choices sometimes and you can learn to make better choices

• 2. You do not determine if I like you or not…I do.• 3. We give you what you need not always what you want• 4. Anger is a self protective defense response to perceived threat

each and every time without exception• 5. This is not about me…this is about you and your choices!• 6: Use you words to ask for what you need…not your behavior!• 7. No one makes you mad…it’s a choice!• 8. You are not your diagnosis..you are (name)

“One Liners” cont.

9. Are you getting angry now?….(said in a mildly stern tone typically after client notes they are not angry or afraid (avoidance/denial) – often used in conjunction with Third Party Alternating Confrontation Technique

10. Im gonna talk about the fear behind your anger so much your gonna actually start to realize how terrified you’ve actually been your whole life

11. You were victimized but you are not a victim!

12. There is nothing in this life you cannot accomplish if simply you decide

13. (Stern Tone with Direct Eye Contact) Excuse me…did I give you permission to______?

Healthy Accountability Looks Like…..

• Colo. Rev. Stat. § 18-3-206Menacing

Menacing occurs when a person, by threat or physical action, knowingly places or attempts to place another person in fear of imminent serious bodily injury. Menacing is a Class 3 misdemeanor, but it is a Class 5 felony if it involves the use or threatened use of a deadly weapon. This includes items designed to look like and displayed as deadly weapons (replica guns, rubber knives), in addition to verbal or physical representations that the one is armed with a deadly weapon

• Colo. Rev. Stat. § 18-3-2043rd Degree Assault

Third degree assault occurs when a person knowingly, recklessly, or through criminal negligence causes bodily injury to another person by means of a deadly weapon; or when they knowingly threaten, annoy, harass or injure a peace officer or other protected employee with a dangerous substance. Third degree assault is a Class 1 misdemeanor. However, if the crime is directed at a peace officer or other protected employee, harsher penalties can be imposed, up to twice the minimum sentence and/or fine

Don’t Take it From Me…..Listen to Them!