The Case of ‘Charlie’

My thanks to Donna Adams-Weiss, Ph.D. for collaborating on the case of “Charlie”. I also want to thank her for being a co-presenter at the MASOC 2011 Conference and discussing her challenges and experiences regarding this case. The following are 8 email correspondence we shared between April 20, 2010 and March 23, 2011.

Eliot P Kaplan, PhD

 

4-20-10 Donna writes: Email #1

Eliot:

I spoke with you on the break during your presentation about The Case of “C”, one of the adolescents I see at our adjudicated facility in Alabama. I started a paradoxical intervention with him last week.  If you are willing, I would like to do an email exchange with you.  Below is background info regarding “C”. Let’s call him Charlie.

Charlie is an African-American male who is 15 years old.  He has been here at Mt. Meigs for about 1 year and 3 months without any progress.  Charlie has many delinquent behaviors along with sexual acting out.  Charlie was severely physically abused by his father and his father was arrested and incarcerated for two years for felony child abuse charges.  Charlie witnessed much domestic violence as his father would beat his mother and she suffered many severe injuries.  He lived with his biological parents until he was 10 years old when he was placed in foster care.  He was tossed from one foster home to another, and from one group home to another.  He was sent to a psychiatric facility for breaking a staff member’s wrist in the group home in 2006.  Finally his grandmother was granted custody in 2007.  Charlie’s mother is reported to have a delusional disorder, narcissistic personality disorder and an anxiety disorder. His grandmother from reports is highly oppositional and argumentative (at best).  His grandmother currently refuses to visit him here due to his behavior.  She has told me on the phone that she is thinking about giving up custody because he is not improving.  She has not come to any family sessions.  She has told Charlie that she is not coming back and she has “wiped her hands clean of him.”

Charlie has a long list of previous arrests.  These are primarily theft charges.  He has been banned from all Wal-Marts as a result.

Charlie was sexually victimized by several girls in one of the group homes he was in.  He has a diagnosis of PTSD, depression, conduct disorder, impulse control disorder (anger), and borderline intellectual functioning (full scale IQ in the low 70’s).  Was suspended 120 times from school (prior to coming to Mt. Meigs) for fighting.

Charlie interprets the world in terms of power and control.  He does not trust authority, does not take responsibility.  All brain formation appears to be organized around coping with early abuse/neglect.  He bullies other boys on campus, steals their food, and tells everyone that he is “the top dog” in his new dorm (he was recently transferred out of his old dorm for injuring another smaller boy for his pancakes), even though these boys are older and bigger than him.

I saw Charlie last week, and I pointed out how predictable his behavior is (stealing, fighting, attempting to con staff, gang activity on campus).  I did not point out sexual activity that he has been engaged in here while adjudicated.  Charlie’s main line is, “nobody care’s about me, so why should i care about anybody else?”  After telling him how predictable he is, he wanted to bet me that he would not go to the cell.  I told him that since he was going to go to the cell anyway because “that is what he does”, - that it would be nice if he could do that by 3 pm on Thursday (last week) since I wasn’t going to be here on Friday and I have a lot of work to do. 

He said he “couldn’t plan when he was going to the cell.”  I told him that he convinced me that he really doesn’t care about going back with his grandmother.  He frantically told me he DID care about what happened to him.  At one point he said “my plan is to stay here with you Dr. Adams-Weiss until I’m 21, since no one cares about me.  My response was “well you have convinced me that you don’t care, your behavior is so predictable, you seem happy not having any freedom, not being able to see any of your friends on the outside, and doing things that according to your grandmother cause her to not want to come visit you.  At least you are accomplishing your goals of wanting to stay here and not having family contact.  By the way, in order really accomplish your goals that you have, you need to get back on your usual red sheets instead of this green sheet you have now!”  (Red is the worst behavioral level, green is the second highest behavioral level).  He quickly stated that he really wanted out of here and to go home.

So far, this is the first time since he has been here that he has been this responsive in a positive way.  However, later on that evening he went to the cell for fighting with dorm staff.

Let me know if you would like to email back and forth regarding him.

Donna Adams-Weiss, Ph.D., LPC,   Auburn University/ABSOP,  Mt. Meigs, Alabama

 

4-21-10  EPK Response #1 for Charlie

Topics addressed: 1) Predictable behavior –business as usual; 2) strategic interventions -solar system model; 3) ‘The reason I like you …’; 4) making a bet; 5) detailing what sets him off; 6) Reframing –  Charlie’s acting out protects others; 7) Creating an ‘ordeal intervention’; 8) impulse control leads to self esteem.

Hi Donna,

You mentioned Charlie has full scale IQ in the low 70’s. Just to let you know, -unless the client has profound developmental disabilities or retardation, it doesn’t matter to me whether a client’s IQ is high or low. The power of PdxI is in its simplicity – since it’s only about identifying predictable patterns and reflecting it back to the client in various ways. This means that PdxI is effective with ‘low IQ’ clients like Charlie since they can ‘get what you’re talking about’, and also effective on ‘high IQ’ clients (who often try to rationalize their way around therapy), since they can not ‘escape’ from the non-verbal aspect of obvious predictable behavior.

Just to let you know - you would think that since I know the ‘ins and outs’ of my own system, I would be able to get around it. However, I must admit that the nature of this work is such - that if someone ‘calls me’ on a predictable pattern that I might have, I can’t even get around it . . .

I lifted your last paragraph and will comment along the way:

Donna: I saw Charlie last week, and I pointed out how predictable his behavior is (stealing, fighting, attempting to con staff, gang activity on campus). 

[EPK: OK, good start. You’ve identified and called him on some of his ‘business as usual’ behaviors. I suspect he now feels seen by you and is aware he is on your radar. What we now want to do is to identify and focus on the 1 or 2 behaviors that are the most frequent (the mercury orbits) that are likely to be happening on an hourly or daily basis. If we focus on the predictability of these frequent orbits, and Charlie starts to demonstrate impulse control to undo these behaviors, - this will be a big step toward him gaining some self esteem. Challenging the client to demonstrate impulse control is a main focus of PdxI since it directly strengthens the person’s “human” self-esteem experience. The act of engaging the client around his predictable impulses -even before he starts to struggle to undo behavior - is the first step in ‘turning around’ destructive patterns. From what you’ve written, it seems like ‘fighting’ and needing to be ‘top dog’ may fit the bill.]

Donna: I did not point out sexual activity that he has been engaged in here while adjudicated. 

[EPK: In general ‘sexual acting out’ is too volatile an issue to directly target with PdxI. I don’t use PdxI on criminal type behavior because when the client gets arrested it would be easy for him to tell the police / judge that you are to blame since ‘My counselor told me it was OK!’. When criminal behavior is involved, we need to use a ‘strategic’ paradoxical approach.

 

The advantage of strategic PdxI is that it is possible to impact targeted criminal behavior through addressing secondary non-criminogenic behaviors. It is key to understand that by influencing change in non-criminogenic behaviors we simultaneously impact primary volatile criminal behaviors. We can understand this logic through the orbits-gravity / solar system model above. The human personality can be seen to parallel an orbits-gravity model in that there are numerous patterns of emotions, thoughts, and behaviors occurring simultaneously. Since the system works as a whole, if we are able to shift inner and more frequent orbits, we simultaneously impact less frequent and harder to reach outer orbits.

Using this model, we see that Mercury / Venus orbits occurs the most frequently. These M/V orbits correspond to high frequency behaviors such as anger, lying, low self esteem, social skills, etc. When treatment can impact a change on these behaviors, the model indicates that the entire system will be affected. As a result there is a simultaneous influence on the more volatile but less frequent behaviors (Jupiter type orbits) that are often our primary concern; ie: PSB (Problem Sexual Behaviors), fire setting, etc.]

Donna: Charlie’s main line is, “nobody care’s about me, so why should I care about anybody else?” 

[EPK: A good Paradoxical Intervention conveys (as Carl Rogers put it) ‘unconditional positive regard’. While it is possible to tell Charlie that ‘you like him’, he probably won’t believe you, since in his mind no adult ever liked him.

To solve this problem, I tell my client I “like and care about him” – but then I then follow up with the “reason”.  “And the ‘reason’ I like you, is because you make my job easy! With most of my other clients I never know what they are going to do next! But with you – you do the same thing everyday, week after week!”

On the surface this comment is an ‘up-side-down’ compliment. In paradoxical fashion it conveys that when he does ‘old behavior’ - he ‘makes your job easy!‘  And lets face it, the last thing on Charlie’s mind is to ‘make your job easy’.  However, such a comment often engages the client as it makes him feel uncomfortable - and places him in numerous double binds! In general clients don’t feel comfortable being “liked or cared for” by an authority / adult. They are much more comfortable being told they are “bad and wrong” as this is familiar to their status-quo self identity. And second it bothers them to hear that their behavior is not considered a challenge or a ‘problem’ for the clinician - (as this would make them special) but rather you find it ‘easy’ since there are never any surprises.]

Donna: After telling him how predictable he is, he wanted to bet me that he would not go to the cell. 

[EPK: The fact that he wants to make a bet with you, means that he feels engaged and seen. You’ve hit a nerve and he now wants to ‘prove you wrong’. When the client wants ‘to bet with you’ it means he is becoming ‘invested’ in his connection with you through the outcome of his behavior’. The ‘bet’ also means that he has to now be responsible for his behavior that follows. Sometimes I’ve told clients, “I would bet you, but the agency rules say I’m not allowed to take advantage / or make money off our clients.” But even in confirming the bet for no money, the client will still feel challenged by his desire to ‘prove you wrong’. The core of any PdxI is to ‘boost the therapeutic alliance’ and help undo the client’s underlying sense of abandonment. The fact that Charlie wants to ‘bet’ you means that your ‘shadow will follow him’ when he walks out of the session.]

Donna: I told him that since he was going to go to the cell anyway - because “that is what he does”, that it would be nice if he could do that by 3 pm on Thursday (last week) since I wasn’t going to be here on Friday and I have a lot of work to do. He said he “couldn’t plan when he was going to the cell.” 

[EPK: Great! The intent here is to convey to Charlie that behavior that he thinks is ‘spontaneous’ is nothing but the usual ‘status-quo’. You could say: ‘Well maybe, you’re not good at planning these things, but that’s why I’m here, so I can help you!’ I then go over all the likely things that will set him off – as these things have set him off before: certain staff, specific kids, things that someone might say, classroom situations, etc. Whatever has been identified as a ‘trigger’ in the past, I will remind him that he can use these as ‘good excuses’ to set him off. By ‘planning with him’, I attach myself , my ‘shadow’ to him. Without me telling him – he suddenly starts to realize that his ‘spontaneous acting out’ is not so spontaneous. I also like to throw in a time frame (as you did, “by 3PM on Thursday). This way if you pass him in the hall later that day or week, all you have to say is ‘Charlie! Remember by 3PM Thursday!’ to remind him (in 3 seconds or less) that even though you are in a rush to your next meeting, he’s still on your radar!]

Donna: I told him that he convinced me that he really doesn’t care about going back with his grandmother.  He frantically told me he DID care about what happened to him.  At one point he said “my plan is to stay here with you Dr. Adams-Weiss until I’m 21, since no one cares about me.  My response was “well you have convinced me that you don’t care, your behavior is so predictable, you seem happy not having any freedom, not being able to see any of your friends on the outside, and doing things that according to your grandmother cause her to not want to come visit you. At least you are accomplishing your goals of wanting to stay here and not having family contact. 

[EPK: Donna, you’ve obviously made an impact on Charlie as he ‘frantically’ is trying to explain himself. Very often in therapy, the clinician is working harder than the client. But for real change to happen the client must be doing the work – and that is what we are beginning to see with Charlie. When doing PdxI the clinician is able to sit back and ‘forecast the weather’ and it is up to the client to prove the forecast to be accurate or not. The bottom line is that Charlie is doing ‘the work’.

The only thing I would change here is that in promoting the ‘alliance’ I like to always reframe the client’s behavior in a ‘positive light’. In other words, I try to identify the ‘kernel of good’ in whatever disruptive repetitive behavior the client is doing. So for example, I would explain to Charlie that his acting out behavior is a good way to ‘protect’ his grandmother and others from having to deal with their own life issues. As long as he keeps getting in trouble then he can be a diversion that lets them blame him for their problems. So its actually very honorable of him to sacrifice his life and freedom to help others maintain the status-quo; Further, I would point out that the best way to keep protecting his family is to just keep doing exactly what he is doing. By continuing to get in trouble, he maintains his role in the family. So really by getting into trouble, he is doing a favor for his family. “Lets be honest, if you stop getting into trouble, what would you grandmother complain about? … That’s right, ‘nothing’ - and then she’d have nothing to ‘moan and groan’ about! Is that what you want?! I don’t think soo!!” The purpose here is to help your alliance with Charlie and also give him another perspective; that maybe he’s not so bad after all.

Regarding other aspects you mentioned, ‘happy not having freedom, not seeing outside friends’- again my suggestion is to reframe it in such a way that on the surface it puts a ‘positive spin’ on maintaining his disruptive behavior. “Hey as long as you’re here you get to hang out with all the cool staff and kids on the unit. And besides, if you where on the outside, you would have to decide if you wanted to go watch your high school football team’s playoff game with your friends!  …  The intent here is to ‘challenge, engage, and join’. By joining we strengthen the ‘gravitational force’ of the therapeutic alliance. The leap here - using the orbits-gravity model - is that by strengthening the gravity, the client will automatically and spontaneously seek to shift and undo habits / orbits of destructive behavior. From a clinical perspective the client makes his own ‘free will choices’ to change his limiting behavior, - rather than the clinician trying to instruct or convince him that “he should want more freedom and to be with his friends”. I imagine that when reading this ‘orbit-gravity stuff’ for the first time, it sounds off the wall, so I would suggest ‘just sitting with it’ for a bit – and see if it starts to make sense.

Regarding him needing to be ‘Top Dog’, this is perfect  for an ‘ordeal’ type of intervention. In the ordeal, you inform him that it is ‘his job’ to be Top Dog. You might go over the ‘job description’ of what he must do as ‘Top Dog’; that he must bully at least 3 kids a day; that he must take things from other kids; that he must never go above Red level for more than a few days; that he must plan on the consequences (ie. constant restriction; loss of privileges, etc.) As you can imagine kids hate being told what they MUST DO. Remind him that this is not what you want (personally) for him to do (ie that you have no personal investment in him doing this behavior), but if he wants to be Top Dog he must put in the necessary time and effort to stay on top. As you keep reminding him of what he must do, what ends up happening is that on his own, he suddenly realizes that he really “doesn’t want this job”. As a result, he will start backing out of all the behaviors you have advised he must do.]

Donna: By the way, in order really accomplish your goals that you have, you need to get back on your usual red sheets instead of this green sheet you have now!”  (Red is the worst behavioral level, green is the second highest behavioral level). He quickly stated that he really wanted out of here and to go home.

[EPK: Great - you’re identifying his ‘usual’ behavior and encouraging him to maintain the status-quo. One of the therapeutic advantages of PdxI is that since the clinician does not outwardly try to convince, tell, or reward the client, when change actually starts to occur, the client will be able to take full credit and responsibility for initiating new behaviors.]

Donna: So far, this is the first time since he has been here that he has been this responsive in a positive way.  However, later on that evening he went to the cell for fighting with dorm staff.

[EPK: Charles relapse is a blessing in disguise in terms of treatment. Sometimes it can take weeks for the tension to build until finally the client relapses. You want to use this as an opportunity to remind him the bond, connection, therapeutic alliance between you. My suggestion is too praise Charles for his ‘cooperation’. Remind him that “of course you went to the cell for fighting, - this is what I’ve been trying to tell you!” You may want to review the incident with him to identify what triggered him. I suspect that whatever triggered him is an ‘old favorite’. Just be careful not to gloat too much in a way that he might feel shamed. The intent of PdxI is never to shame or be sarcastic, as this would result in the client feeling more isolated and alone. The hope here is to create a challenge in which Charles will get a second chance to redeem himself. As he redeems himself, the intent is for him to gain in self esteem. Ultimately, the way for him to begin developing self-esteem is by demonstrating impulse control - particularly around this trigger issue. By the way, ‘self-esteem’ is the ‘reward’ that drives the success of PdxI.]

Donna, let me know it you have any questions. Keep me informed as to Charlie’s progress.

Eliot

 

5/6/10 Donna Email #2

Hi Eliot:

I just thought I would give you an update on Charlie. 

In our last session, I suggested that since his goal is to be “top dog” in the dorm that he MUST bully 3 boys a day, he MUST never go above red level for more than a few days in order to maintain his “job” of being “top dog.”  He seemed to find that amusing as he burst out in laughter at first.  Then as the week progressed I would remind him as I would see him “remember 3 boys a day!”  He would quickly reply back, “I ain’t going to get into trouble….I’m going home! (in an angry tone of voice)”  At one point in time a couple of months ago he said that he was going to be here until he is 21 years old (which being an adjudicated facility, we can do that).  He doesn’t really want to stay here that long, he just says that when he is feeling hopeless.  I have used that line however, and now I have said to him “Let’s make a plan for how you can stay here until you are 21!  Hey, if you are lucky, you might even be the oldest boy to ever stay here!”  He quickly replies that he is going home and is not going to stay here and says that he plans on being out of here by the Fall.  I have to be careful when I use that line with him.  There have been times where I feel like I am knocking him around and you can see the gloom on his face.  There seems to be a fine line between using the PXI’s in an effective way that brings about a bond, and sending them into despair or shame (which is definitely NOT my goal).

One thing that I have noticed is that he frequently tries to call my bluff.  The boys are not allowed to “sag” their pants (you know, with their pants at their knees) or the dorm staff will take points off.  Sometimes if he is walking with me and I see his pants are sagging and his shirt is out, I’ll say to him, “Hey Charlie, here’s your chance to lose points!  If you keep your shirt out while we go around this corner, Mr. T. will surely catch you with your pants sagging!”  He usually quickly pulls them up and states “I don’t want him to take my points!”  Here lately though he has been trying to call me on my game.  Yesterday I said “Here’s your chance to lose some points!”  And then he handed me his point sheet to take his points.  I really didn’t want to take his points (some of the things they take their points are taken away for are silly things that I don’t agree with punishing them for), but I quickly grabbed his point sheet as a gesture to take him up on his offer.  He then begged me not to take his points (which I did not). 

Charlie has been doing well relatively speaking.  In the past, he was going to the cell anywhere from 3-5 times a week.  In the last two weeks he has only gone to the cell 2 times, and he has been on gold sheets as much as he has red sheets (about 50% of the time on gold and 50% on red…not much in between).  He has gotten into a knock-down drag-out fight with another boy which he started (which caused him to go to the cell one time). 

Nobody else on the treatment team besides the treatment coordinator knows what I am up to with the PXI with Charlie.  I am finding it a bit awkward when I am in front of other people on the treatment team and Charlie is there.  I want to do the PXI thing with him, however, I am getting strange looks from the dorm staff and other treatment team members.  I spoke with the treatment coordinator about this and she really didn’t want dorm staff in on it because she was afraid that they would not carry the intervention out properly (and I agree with her).   What I am finding is that I feel in a bind sometimes within the presence of the other staff.  The other staff will praise him for being on gold or whatever, and they will scold him for doing his same old routine that he does, and I am there trying to praise him for doing the “status quo.”  It seems counter-productive sometimes.

His delinquent behaviors have improved (despite his violent aggression and cussing out staff, threatening staff, and making sexual gestures towards staff, holding on to his medications so he can trade them to other gang members on campus ..oh and openly masturbating in the common living areas).  I am leaving on vacation next week and won’t be back until around June 1st.  I’m afraid of him having a setback without any PXI’s while I’m gone.  I’m thinking of things that I can address with him in order to be his shadow while I’m gone.  Any thoughts?

Donna

 

5/7/10 EPK Response #2

Hi Donna,

Thanks for the e-mail. The following includes my comments on: 1) Laughing as a ‘surrender response’ ; 2) taking responsibility for his choices; 3) ‘threatening the consequences of change; 4) keeping staff informed; 5) keeping the ‘connection’ when leaving on vacation.

Hi Eliot:

 I just thought I would give you an update on Charlie. 

In our last session, I suggested that since his goal is to be “top dog” in the dorm that he MUST bully 3 boys a day, he MUST never go above red level for more than a few days in order to maintain his “job” of being “top dog.”  He seemed to find that amusing as he burst out in laughter at first. 

[EPK: I find that when I say something that makes my ‘angry’ client start to laugh it is a good sign. Laughing is an ‘uncontrolled surrender response’ that confirms a connection between us. It highlights the ‘human connection’ since it means that he recognizes the absurdity of my statement, along with the absurdity of his own behavior. When I make a ridiculous statement and the client laughs, it means that his 24/7 defensive barrier has been breached.  On the client’s side, the ‘laugh’ is a form of a spontaneous ‘release of tension’. For the angry client, life is often very lonely because everything is always serious and filled with the need to be on guard. By you aligning or joining with the client’s ‘game’ of needing to be ‘top dog’ there is no way for him to defend against you. The ‘laugh’, therefore, is a moment of connection when he experiences the ‘relief’ of being connected ‘beyond himself’. It is often that flash of a ‘greater connection’ that provides the client with the glimmer of hope ‘that life may hold more’ than he had considered. For me the ‘laugh’ means that I have said or done something that allows his rigid perspectives and overly serious attitude to begin to melt. Also, the nice thing about the ‘laugh’ is that it is a non-verbal indicator that a ‘connection’ is developing between myself and the client.]

Donna: Then as the week progressed I would remind him as I would see him “remember 3 boys a day!”  He would quickly reply back, “I ain’t going to get into trouble….I’m going home! (in an angry tone of voice)”  At one point in time a couple of months ago he said that he was going to be here until he is 21 years old (which being an adjudicated facility, we can do that).  He doesn’t really want to stay here that long, he just says that when he is feeling hopeless.  I have used that line however, and now I have said to him “Let’s make a plan for how you can stay here until you are 21!  Hey, if you are lucky, you might even be the oldest boy to ever stay here!”  He quickly replies that he is going home and is not going to stay here and says that he plans on being out of here by the Fall.  I have to be careful when I use that line with him.  There have been times where I feel like I am knocking him around and you can see the gloom on his face.  There seems to be a fine line between using the PXI’s in an effective way that brings about a bond, and sending them into despair or shame (which is definitely NOT my goal).

[EPK: If he gets angry at some of your comments, that is good because that will motivate him internally to prove you wrong. The fact that he gets ‘angry’ when you talk about him staying is also good in that it indicates a sense of ‘attachment’ with you, as what you say has importance to him.

In terms of reminding him that he ‘can stay until he is 21’, there is (as you mentioned) a thin line between enhancing the bond or pushing him toward despair. As a clinician, all statements I make try to ‘raise’ the client, and thereby enhance the alliance. In terms of him staying in the facility you might want to put a ‘positive twist’; Sometimes I have told a kid that since I like him, I’m hoping that he will make the choice to stay because for my own selfish reasons (more on this later) I don’t want to see him go. By reminding him that he makes choices, we enhance his understanding that he is responsible for himself and doesn’t have to be a victim of the system. By being responsible and making choices, he becomes empowered. Then, since I don’t want him to go, I tell them in detail all the choices (that he is doing already) that ‘I would prefer’ that will keep him there. By detailing all his habitual ‘knee-jerk’ responses (and resulting consequences that I hope will keep him there) he quickly realizes (and takes responsibility for) what habitual behaviors he must undo.]

Donna: One thing that I have noticed is that he frequently tries to call my bluff.  The boys are not allowed to “sag” their pants (you know, with their pants at their knees) or the dorm staff will take points off.  Sometimes if he is walking with me and I see his pants are sagging and his shirt is out, I’ll say to him, “Hey Charlie, here’s your chance to lose points!  If you keep your shirt out while we go around this corner, Mr. T. will surely catch you with your pants sagging!”  He usually quickly pulls them up and states “I don’t want him to take my points!”  Here lately though he has been trying to call me on my game.  Yesterday I said “Here’s your chance to lose some points!”  And then he handed me his point sheet to take his points.  I really didn’t want to take his points (some of the things they take their points are taken away for are silly things that I don’t agree with punishing them for), but I quickly grabbed his point sheet as a gesture to take him up on his offer.  He then begged me not to take his points (which I did not). 

Charlie has been doing well relatively speaking.  In the past, he was going to the cell anywhere from 3-5 times a week.  In the last two weeks he has only gone to the cell 2 times, and he has been on gold sheets as much as he has red sheets (about 50% of the time on gold and 50% on red…not much in between).  He has gotten into a knock-down drag-out fight with another boy which he started (which caused him to go to the cell one time). 

[EPK: Hey, 2 times in the cell in 2 weeks, - down from 3-5 times a week. Nice!]

You might want to ‘threaten’ him that ‘We have rules around here!’ If he doesn’t keep up his aggressive behavior, and only is written up on the gold sheets, he will HAVE TO BE discharged a lot earlier that planned! ‘Is that what YOU want?!! C’mon, I DON”T think so!!]

Donna: Nobody else on the treatment team besides the treatment coordinator knows what I am up to with the PXI with Charlie.  I am finding it a bit awkward when I am in front of other people on the treatment team and Charlie is there.  I want to do the PXI thing with him, however, I am getting strange looks from the dorm staff and other treatment team members.  I spoke with the treatment coordinator about this and she really didn’t want dorm staff in on it because she was afraid that they would not carry the intervention out properly (and I agree with her).   What I am finding is that I feel in a bind sometimes within the presence of the other staff.  The other staff will praise him for being on gold or whatever, and they will scold him for doing his same old routine that he does, and I am there trying to praise him for doing the “status quo.”  It seems counter-productive sometimes.

[EPK: If other staff are not in on what you are doing, it will come back to bite you. You need to let them know that something is going on or the staff will get confused. My suggestion is that without going into detail, tell them that you are doing ‘Good Cop – Bad Cop’ with Charlie. Let them know that while sometimes you may be saying stuff to Charlie that doesn’t seem to make sense from their perspective you are challenging him as ‘Bad Cop’. Let them know that they have a job in this; and that is to be ‘Good Cop’. As part of their job in this intervention, they need to keep doing what they usually do; - that is to keep encouraging him to do well! They will appreciate they have been informed about your intervention, and they will like the idea that they don’t have to do anything different from their previous approach.] 

Donna: His delinquent behaviors have improved (despite his violent aggression and cussing out staff, threatening staff, and making sexual gestures towards staff, holding on to his medications so he can trade them to other gang members on campus..oh and openly masturbating in the common living areas).  I am leaving on vacation next week and won’t be back until around June 1st.  I’m afraid of him having a setback without any PXI’s while I’m gone.  I’m thinking of things that I can address with him in order to be his shadow while I’m gone.  Any thoughts?

[EPK: Regarding all the above behaviors- these are the behaviors that will ‘keep him home in the facility’ and therefore will allow you to “selfishly see him everyday until he is 21!” Before going on vacation, you might discuss with him the number of fights he will have while you are gone; the number of times in the cell, etc. Let him know that when you check in for messages and talk to Mr. ABC, you are expecting to hear ‘good news’! The intent here is that even though you are away, your connection with him remains intact. (Also in particular, I like this thing with the pants! I think it is a simple barometer or indicator as to his commitment) I would put heavy emphasis on reminding to keep his pants low throughout the time you are away. The lower the better! and you will keep tabs on this when you call in.] 

Donna, I’m excited to hear of Charlie’s improvement from our initial email. I hope you are enjoying implementing the interventions. I think you’re getting a sense of its power, and I see that you recognize that the clinician needs to be sensitive whether it is ‘harming’ or ‘helping’. If you have any questions, let me know. Have a great vacation!

Eliot

 

6-17-10 Donna Email #3

Hi Eliot:

It has been an action-packed period of time with Charlie!

Before I left on vacation, I wanted to see Charlie one last time since I wouldn’t have an opportunity to see him for another 2 1/2 weeks.  He happened to be in “the cell” (time-out) for fighting.  He was in terrible spirits when I got to the cell.  He started pleading with me to move him up to Phase III (even though his behavior does not warrant it).  He stated that there is no use that I just should “give up” on him because “I have behavioral problems and I won’t ever be any different.”  I told him that it was OK, that due to my own selfish reasons I would like to keep him until he was 21 because “I like you Charlie, you are so predictable.”  He got very angry and said that he wanted a new therapist.  I told him that we were partners in his treatment and that I wasn’t willing to “end my professional relationship with him, and in order for us to continue our professional relationship I needed him to go to the cell more often.  One interesting thing he said then was “Dr. Adams-Weiss, I want it to be the way it used to be between us!”  Basically from that statement I heard “Dr. Adams-Weiss, I want it to be like it used to be, you know, when I felt like I had you totally conned!!!!!”

A week earlier, he had tried to con another therapist into taking his case over with him.  He also wanted to be in this therapists process group.  My take on this is that Charlie is realizing that he is majorly on my radar, and he is really feeling the heat.  I think he is trying to get another therapist , one that doesn’t know him, so that he can possibly “scoot through treatment” without doing the work. 

Last week he started pressuring me in a session to move him up to phase III again.  He keeps saying “I’m trying as hard as I can, I’m doing better, nobody sees when I do good!”  My response has been something like, “Charlie, I hear you say you want to leave, but when you go to the cell and fight etc, you are telling me that you REALLY want to stay!  And that is OK!!!!!  I’m glad for you to stay here until you are 35!  (He knows I can only keep him until he is 21).  He took one of his phase II tests with me and much to my surprise he got an “A” on it.  I told him, Charlie…I am really worried….if you keep this kind of thing up, I might have to release you sooner than  expected!”  Even after the test though, he went back to trying to get me to move him up without actually demonstrating consistent behavior change.  I related to him that it was his choice.  Of course, my preference would be for him to continue with his “same-old, same-old behavior” so I could keep him here, since “I do really like you Charlie!”  Charlie however, let his anger get out of control, and he acted like he was going to open the door and leave my office without permission.  I told him it was OK for him to leave if he made that choice, but I would have to call security if he made that choice.  So he left.  I called security, and before I got finished talking with security he came back to my room with another staff person with him.  He was flinging his arms, crying and totally unable to hear what I was telling him, so I told security to take him to the cell so that he had time to cool down.  The security guard told me that Charlie was crying in the back of the van when she was taking him to the cell.  She said that she asked him what was wrong and he said (crying) , “Dr. Adams-Weiss says that she likes me!!!!!…….and…..and….. sniff….sniff…..I got an “A” on my phase II test…..sniff….sniff…!!!!”  The guard expressed her confusion!  He went to the cell for  a couple of hours, and later I went to his dorm to talk to him.  He was much calmer then.  I told him that I can’t control his behavior, only he has the power to control his emotions and his behavior.  It is his choice about whether or not he wants to stay or not.   “But you know what my preference is!!!!!”

Our session this week was a bit of a cracked record.  He at this point says he wants to leave, but he outright asked me to move him up even though he keeps losing control of himself.  When we have phone sessions with his grandmother, she tells him that it is OK with her if he wants to stay there until he is 21!  She says “It is up to you Charlie!”  It is weird, she communicates to him that she loves him and wishes that he would come home, but she is halfway talking to him in a “paradoxical way” without anyone telling her to do so!  She tells him that she won’t visit him until he starts doing the things he needs to do to progress.

Yesterday Charlie probably would have acted out sexually but he and another boy were caught before the “act” happened.  They were in the planning stages.

There have been times where I know I have botched up the PXI with him.  It is usually when he gets out of control where I have to catch myself not going back into the same old mode of dealing with him.   One of the areas where I am screwing up is the “twisted praise.”  You know, “Charlie, if you keep tucking your shirt in, the dorm staff won’t be able to take your points away!”  It is really hard to catch him doing what he needs to do.  Charlie currently feels that no one recognizes when he even does one thing right (like I said it is hard to catch him doing things right).  So he tries to plead his case that because he succeeded one time, that is cause for us to move him forward into phase III!  He is going to the psychiatrist next week.  I thought I would go with him, and do the thing of “You know doctor, I am really concerned about Charlie.  He got an “A” on his phase II test!  If he keeps this up he might have to leave earlier than expected.  Can you please give him a thorough exam?  I feel like I don’t know him anymore!”                Any thoughts on all of this?

Donna

7-5-10 EPK Response #3

Hi Donna:

Sorry for the delay. I’ve copied your email and will make comments and suggestions inside. The following includes comments on: 1) gravity-attachment perpetuates ‘normal’ equilibrium; 2) personality system; 3) strengthening the therapeutic alliance; 4) the client will always win any power struggle.

Thanks for hanging in there with Charlie and the paradox approach. He certainly a ‘hand full’, but I think you’re getting a sense of the power and potential of PdxI. I particularly like that it is effective when working with clients that many clinicians might otherwise consider to be ‘hopeless’.

As you know the PdxI approach seems totally absurd; ie ‘planning’ or ‘prescribing’ destructive behavior! But when you start to get ‘the hang’ of the logic behind these seemingly ‘warped’ interventions, the treatment becomes quite exciting and fascinating.

I think the hardest part for the clinician who is first ‘trying on’ this method is to get accustomed to the mindset of PdxI. As mentioned before, rather than focusing on the whirling repetitive orbits of behavior, thoughts, and emotions that the client presents outwardly, the focus of PdxI is to focus on the ‘gravity’ that is keeping those orbits locked in their patterns. The ‘gravity’ as defined here is related to what gravity does in atomic or solar system type scientific models; that is it ‘attaches, bonds, and connects’. It is this sense of gravity-attachment that perpetuates equilibrium in the entirety of a given system.

The ‘system’ from a psychological perspective is the ‘personality system’. As it turns out both functional and dysfunctional personalities are always in a given state of equilibrium. The mark of a functional personality is ‘flexibility’ (ability to make relaxed choices). The mark of the dysfunctional personality is ‘rigidity’ (constricted behavior). In either case, the ‘flexibility’ or ‘rigidity’ of the given system is dependent on ‘gravity’ (the underlying sense of feeling attached). The personality which relates to the mind-body existence of every person is therefore an integration of early parental attachment experiences. The type of attachment (whether nurturing, trauma based, or somewhere in-between) gets played out in what we the clinician can observe in terms of ‘outward orbits’. The nature of the repetitive ‘behavior, emotions, and thoughts’ indicates whether attachment-gravity is more nurture based or trauma based. In a person who has a childhood dominated by ‘nurture based attachment’ will function is a manner that exhibits an outward sense of calm, relaxation, and an ability to adjust and be flexible in handling daily events and life’s unexpected situations. For those who had a childhood in which ‘trauma based attachment’ set the tone, their outward expressions will be marked by tension with rigid types of thoughts, feelings, and behaviors. 

Traditional approaches historically have tried to address each aspect of behavior, emotions or thoughts, separately. However the reality of each person is that these aspects are all part of the ‘unified personality system’. On the surface it seems that this splintered approach can work; - but this is true only if the client is ‘motivated’ to change. The problem however, is that these ‘traditional’ approaches don’t work for the ‘unmotivated’ client who has no intent, interest, or desire to change his current state of equilibrium.  From the client’s self perspective, he experiences his life as ‘normal’ and often has no clue as to the degree of dysfunction that others perceive. From the client’s view, his behavior, emotions, and thoughts are ‘status-quo’ and familiar.

Treatment using traditional approaches sees the external orbits of behavior, emotions, and thoughts as the ‘the problem’. As treatment attempts to address each of these aspects separately the effect is to ‘put a band-aid’ on the surface issue without addressing the core issue underneath. As can be expected, the ‘band-aid’ approach is ultimately ineffective. Unfortunately, when these methods haven’t worked, the profession has historically identified the client as ‘treatment-resistant’ rather than considering that it is the nature of treatment that is at fault.

The outlook presented here does not view clients as ‘treatment-resistant’. I see such clients as ‘systems in equilibrium’ that are doing their best to keep their status-quo reality (equilibrium) intact. From this perspective, the client is simply trying to defend his familiar ‘self identity’ (ego), and life-as-he-knows-it. As you might get a sense, when the clinician has an ‘agenda’ to directly try to change this client’s behavior, emotions, or thoughts, the result is a power struggle between them. The nature of such power struggles is that the client will always win, since the client ultimately controls his behavior. Often this client sees the clinician ‘coming a mile away’ and makes a calculated decision how much or how little he will participate. I don’t believe this decision is made to ‘manipulate’ the clinician or situation, but is rather a self involved calculation as how to best defend his equilibrium state.

A ‘good’ treatment-resistant client is able to keep the clinician ‘involved’ but ‘at a distance’. In this way the client gives the impression that ‘some kind of change is happening’ and ‘progress is being made’, but when the clinician takes a day off , goes on vacation, or (worse) gets another job, all hell breaks loose… .  Of course, this is quite frustrating for the clinician, who had hoped the client had moved forward to a different level.

In the successful use of PdxI, the focus of treatment is totally on the therapeutic alliance or ‘attachment-trust bond’ between the clinician-client (and/or family). When working with a client, my intent is that every comment, joke, prediction, story, etc. will provide another notch in strengthening the therapeutic alliance. Some clinician’s dismiss PxI as ‘manipulative’ and ‘reverse psychology’. They claim that the underlying agenda of treatment is to trick the client into doing new behavior. In their view, when the client ‘figures out the trick’, treatment is likely to ‘backfire’.

However, it is important to understand that a true paradox intervention has nothing to do with being ‘manipulative’. When I talk to my client about a given pattern, and predict that he will ‘go left’, I truly believe in that moment that he will ‘go left’. My thinking is: If he went left yesterday, and last week, and the week before that, -the truth I am offering the client is that he always goes left. My intent is to ‘attach’ with the client by telling him the truth within a context of non-judgment, humor, compassion, and support. From my perspective, if the client does something out of character and ‘goes right’ that is his choice and decision – that has nothing to do with me. When the client advises me that he has ‘gone right’, I’m as ‘surprised’ as anyone. At that point, rather than praising the client over his single change of behavior, I acknowledge that though it is true he went ‘right’ this time, in my view anyone can have a ‘slip up’. In maintaining my intent to ‘strengthen attachment’, I remind him that the overall reality of his ongoing pattern far outweighs this single event. It is not until the client has either stopped an old behavior or has done a certain new behavior 3 or 4 times that I acknowledge that ‘I was wrong!’ and that maybe this change in direction is more than ‘just a flash in the pan’.

The focus of treatment is always on the alliance. A key element of the alliance is that the client gains self-respect in his ability to ‘prove’ my perception wrong’. By ‘proving me wrong’ the client experiences a boost to his self esteem as he has demonstrated an ability to go beyond his habitual pattern. As it was his own personal effort, he is able to take full credit / responsibility for changes that occur. In this way the strengthening of our alliance is simultaneously associated with his experience of an increased self esteem. It is the increase in self esteem that is ultimately the ‘reward’ of PdxI. The paradox of the intervention is that even if the client does his habitual behavior, at that point I can compliment the client for ‘doing exactly as I predicted’ as he has  thereby affirmed ‘the alliance’ between us. 

Donna’s writes:

It has been an action-packed period of time with Charlie!

Before I left on vacation, I wanted to see Charlie one last time since I wouldn’t have an opportunity to see him for another 2 1/2 weeks.  He happened to be in “the cell” (time-out) for fighting.  He was in terrible spirits when I got to the cell.  He started pleading with me to move him up to Phase III (even though his behavior does not warrant it). 

[EPK: In the future you might agree for him to move to Phase III - but only on the condition that he sabotages himself and drops back to Phase II or Phase I.]

Donna: He stated that there is no use that I just should “give up” on him because “I have behavioral problems and I won’t ever be any different.”  I told him that it was OK, that due to my own selfish reasons I would like to keep him until he was 21 because “I like you Charlie, you are so predictable.” 

[EPK: Good response! I like to give clients the ‘reason’ that I like them. It is his predictable behavior that makes him one of your ‘easier clients’, since there are ‘never any surprises’ in how he is going to behave.]

Donna: He got very angry and said that he wanted a new therapist.  I told him that we were partners in his treatment and that I wasn’t willing to “end my professional relationship with him, and in order for us to continue our professional relationship I needed him to go to the cell more often.  One interesting thing he said then was “Dr. Adams-Weiss, I want it to be the way it used to be between us!”  Basically from that statement I heard “Dr. Adams-Weiss, I want it to be like it used to be, you know, when I felt like I had you totally conned!!!!!”

[EPK: Bingo!]

Donna: A week earlier, he had tried to con another therapist into taking his case over with him.  He also wanted to be in this therapists process group.  My take on this is that Charlie is realizing that he is majorly on my radar, and he is really feeling the heat.  I think he is trying to get another therapist, one that doesn’t know him, so that he can possibly “scoot through treatment” without doing the work. 

[EPK: You might let him know that you are very understanding of his desire to get a new therapist. In fact you’d be happy to make ‘finding another therapist’ a project that you both can work on together. Discuss with him the best ways for him to ‘manipulate the system’ and the best things to say to ‘butter up’ potential new therapists. You might even reminisce about some of the ‘old lines’ that he used with you ‘that were very effective’. (By talking to him about ‘manipulating the system’ and ‘buttering up’ staff in a matter-of-fact way, it allows the client to know that he ‘is seen’ while it simultaneously disarms his ability to use these tactics in the future.) Reassure him that you ‘like him and would hope he stays’, but you understand that therapy with you may be “too difficult”.]

Donna: Last week he started pressuring me in a session to move him up to phase III again.  He keeps saying “I’m trying as hard as I can, I’m doing better, nobody sees when I do good!”  My response has been something like, “Charlie, I hear you say you want to leave, but when you go to the cell and fight etc, you are telling me that you REALLY want to stay!  And that is OK!!!!!  I’m glad for you to stay here until you are 35!  (He knows I can only keep him until he is 21). 

[EPK: Exaggeration is good. It gets them thinking!]

Donna: He took one of his phase II tests with me and much to my surprise he got an “A” on it.  I told him, Charlie…I am really worried….if you keep this kind of thing up, I might have to release you sooner than expected!”  Even after the test though, he went back to trying to get me to move him up without actually demonstrating consistent behavior change.  I related to him that it was his choice.  Of course, my preference would be for him to continue with his “same-old, same-old behavior” so I could keep him here, since “I do really like you Charlie!”  Charlie however, let his anger get out of control, and he acted like he was going to open the door and leave my office without permission.  I told him it was OK for him to leave if he made that choice, but I would have to call security if he made that choice.  So he left.  I called security, and before I got finished talking with security he came back to my room with another staff person with him.  He was flinging his arms, crying and totally unable to hear what I was telling him, so I told security to take him to the cell so that he had time to cool down.

[EPK: It sounds like Charlie has no idea what to do with you! If you would reject him and get frustrated with his behavior like everyone else, then he would be in his comfort zone!]

Donna: The security guard told me that Charlie was crying in the back of the van when she was taking him to the cell.  She said that she asked him what was wrong and he said (crying) , “Dr. Adams-Weiss says that she likes me!!!!!…….and…..and….. sniff….sniff…..I got an “A” on my phase II test…..sniff….sniff…!!!!”  The guard expressed her confusion!  He went to the cell for  a couple of hours, and later I went to his dorm to talk to him.  He was much calmer then.  I told him that I can’t control his behavior, only he has the power to control his emotions and his behavior.  It is his choice about whether or not he wants to stay or not.   “But you know what my preference is!!!!!”

Our session this week was a bit of a cracked record.  He at this point says he wants to leave, but he outright asked me to move him up even though he keeps losing control of himself. 

[EPK: You may want to talk to him about the details and nuances of what sets him off. He himself may not be aware of these nuances as in his mind it ’just happens’. Try to plan with him, “the best way to tick him off” (ie: is there any special name that someone might call him; ie “Wimp”, or “Dummy”, etc. Also try to notice other factors that may be consistent in his eruptions like: when, where, and with whom.]

Donna: When we have phone sessions with his grandmother, she tells him that it is OK with her if he wants to stay there until he is 21!  She says “It is up to you Charlie!”  It is weird, she communicates to him that she loves him and wishes that he would come home, but she is halfway talking to him in a “paradoxical way” without anyone telling her to do so!  She tells him that she won’t visit him until he starts doing the things he needs to do to progress.

 [EPK: It sounds like Grandma is doing ‘paradox’ alright, the only problem is that she is placing him in ‘lose-lose’ double binds. She tells him “I love you, I love you, but I just won’t visit you!” “I really want you to come home, … as long as you don’t!” You may want to discuss this ‘contract’ he has with Granny. Again, in terms of strengthening the therapeutic alliance, you want to be a sounding board for the truth. Even though the truth may sometimes hurt, the client will feel relief when you are able to put his dilemma in perspective. Therefore you might want to discuss ‘the contract’ which seems to be - That he will fulfill Granny’s ‘expectations of him to stay in trouble as long, as she ‘calls once a month’ (or whatever minimum contact she is offering.) You may want to predict that if he starts to ‘break this contract’ he may feel initially uncomfortable / anxiety as he will no longer be playing the old game with Grandma. If he changes, this will begin to put pressure on Granny’s perception of him as ‘a troublemaker’… And then what?]

Donna: Yesterday Charlie probably would have acted out sexually but he and another boy were caught before the “act” happened.  They were in the planning stages.

[EPK: The intent of paradoxical interventions is to advance and raise the client’s sense of self esteem. This will occur as he becomes more aware of his habitual patterns and reducing and taking control of repetitive impulsiveness and fighting. As his self esteem improves, his desire to ‘sexually act out’ will become less and less appealing.]

Donna: There have been times where I know I have botched up the PdxI with him.  It is usually when he gets out of control where I have to catch myself not going back into the same old mode of dealing with him.   One of the areas where I am screwing up is the “twisted praise.” You know, “Charlie, if you keep tucking your shirt in, the dorm staff won’t be able to take your points away!”  It is really hard to catch him doing what he needs to do.  Charlie currently feels that no one recognizes when he even does one thing right (like I said it is hard to catch him doing things right).  So he tries to plead his case that because he succeeded one time, that is cause for us to move him forward into phase III!  He is going to the psychiatrist next week.  I thought I would go with him, and do the thing of “You know doctor I am really concerned about Charlie.  He got an “A” on his phase II test!  If he keeps this up he might have to leave earlier than expected.  Can you please give him a thorough exam?  I feel like I don’t know him anymore!”

[EPK: Try not to be too hard on yourself for ‘botching things up’. As you might imagine there is a learning curve here. In terms of doing therapy, especially with a kid like Charlie, he will teach you a lot. If the other methods were working, you probably wouldn’t have an interest in ‘upside down style’ of PdxI. Learning PdxI is kind of like learning to ride a bike – it takes practice. Like anything, you’ll make ‘mistakes’, but the important thing is to learn from them. I know for me, it took me a while to really grasp that the ‘therapeutic alliance’ literally dominates the entire therapeutic process. In my view behavioral, cognitive, and psychodynamic interventions can be effective with the motivated client, but they don’t come close to the effectiveness of PdxI when it comes to the treatment-resistant client.]

OK, hope this is helpful.

Eliot   

 

7-30-10  Donna Email #4

Hi Eliot

Strange things are happening with Charlie.  I think it is due to a few things happening simultaneously.  First of all, Charlie was put on Paxil back in March and after a few weeks his clarity of thought and speech were like night and day.  I have never seen such a dramatic effect with Paxil before.  Unfortunately, Charlie started hoarding his meds in May (for trading purposes with other boys), and the psychiatrist took him off of the meds for a bit.  Within a couple of weeks he was back to his pre-Paxil self.  The doctor recently put him back on it again (mid-June), and once again we see a dramatic change.  Paxil allows him to think more clearly and slow down enough to make more logical choices.

The last two sessions I have had with Charlie have been mind-blowing.  He has been able to articulate very clearly some insights he has had into his behavior.  He speaks of how his father used to beat him (father actually went to prison for what he did to Charlie), and how his lack of feeling safe caused him to want to be more powerful than others as a sort of protective thing.  As the PXI forces him to make choices, he has been talking about his past choices and how it hasn’t served him well.  He has been having more nightmares lately (PTSD).  With the PXI, he has been forced to examine what kind of man he wants to be.  He said that he wanted to be a basketball star when he gets older (like most of our boys).  But he has recently said that he doesn’t think that he will actually be one realistically.  He said that the only other thing he is good at is stealing. 

So a dilemma has arisen in his mind about what he is going to do (he is almost 16).  This uncertainty, this uneasiness reminds him of the uncertainty and fear of the future that he would experience each time DHR would come and take him from the home after his dad would beat on him or his mom would disappear (he was also sexually abused in a group home that he was taken to after he was beaten by his father).  Hence the nightmares.  However, he seems like he feels more in control now.  It seems that he has the insight that life doesn’t just have to “happen” to him, that he can actually take steps to protect himself in a healthier way, after all, he is not as helpless as he was when he was 6 y.o.  Right now he seems to be in a transition period, trying to figure it all out.  Amazing….I look at him and wonder if I am really talking to the same kid!  His insights blow me away, however, he has pulled this “see…I’m a GOOD boy” thing before. 

I have continued with the PXI even though he had appeared that he was doing much better.  He hasn’t had “loss of privileges” in about 5 weeks, and hasn’t been to the cell in about 4 weeks…that is an all-time record for him.  He passed both of his Phase II tests scoring above 90% on both (with oral tests instead of written as his learning disability seems to have impeded movement in the program).  So I  started saying more things like, “I’m really worried,  if you keep this up, I might not have any other choice than to move you up…..Nawwww…..I’m sure this is just a fluke, you’ll do something to keep you in Phase II….after all….that is your ‘M-O’!!!!

With that said, yesterday I was walking back to his classroom with him, and one of the group leaders stopped him and told him to start doing his push-ups!  Huh?!  Apparently he had stolen something from this group leader, and so the group leader said, OK, if you steal something from me, you have to do 200 push-ups (everytime he sees him he has to do 20 until he reaches 200), and if you don’t steal anything, then I have to do 200 push-ups.  Interesting…  Charlie, still is doing his same-old, same-old and still tries to look good in front of me. 

Nothing has changed too much in that regard.  I can see definite changes in him, in his thought processes however.  Like I said, it does seem that he is in a transition period.  We’ll see how long it takes (if ever) for him to straighten out his delinquent behaviors, and ultimately his offending behavior.

Donna

8-16-10  EPK Response #4 :

Topics addressed: 1) Reframe chaos; 2) Neutralizing isolation; 3) Predicting and planning to impose therapeutic alliance; 4) Interventions do not rely on client being cooperative; 5) Obvious behaviors; 5) Instigating ‘Free will’; 7) No behavioral agenda for PdxI; 8) BOREDOM; 9) Self-esteem; 10) A few words on ‘insight’;

Donna writes: Strange things are happening with Charlie.  I think it is due to a few things happening simultaneously.  First of all, Charlie was put on Paxil back in March and after a few weeks his clarity of thought and speech were like night and day.  I have never seen such a dramatic effect with Paxil before.  Unfortunately, Charlie started hoarding his meds in May (for trading purposes with other boys), and the psychiatrist took him off of the meds for a bit.  Within a couple of weeks he was back to his pre-Paxil self.  The doctor recently put him back on it again (mid-June), and once again we see a dramatic change.  Paxil allows him to think more clearly and slow down enough to make more logical choices.

[EPK: The fact that the Paxil slows him down and allows him to think more clearly, is definitely an advantage for treatment. I’d be interested in knowing his perceptions of himself regarding differences in his emotions, thinking, and behavior when he is on Paxil and off Paxil.

Since I focus on repetitive patterns (orbits), it seems that that Paxil may reduce his anxiety so that he reacts less impulsively (that being instinctual ‘fight or flight’ behavior). It is interesting to note that regardless of whether he is on or off Paxil he still has a deep need to perpetuate the ‘chaos orbit’. This is evidenced by the ‘hoarding and selling meds’ and ‘stealing from the group leader (as you mention later). 

Isolated and Alone - From a PdxI perspective, I always try to view the client’s behavior in a ‘positive light’. This means that I often tend to reframe seemingly ‘negative behavior’ as an attempt by the client to maintain an internal sense of ‘balance and equilibrium’. Given (the details you mention regarding) Charlie’s traumatic childhood, -anxiety, panic, and chaos- are feelings that Charlie is familiar with. While I would not say that anyone enjoys ‘anxiety, panic, or chaos’, there is a level that such feelings have become part of his status-quo lifestyle. In other words, if he was to go for an extended period of time without ‘anxiety, panic, and chaos’, he would feel like ‘a fish out of water’.

Now from Charlie’s perspective, these feelings of ‘anxiety, panic and chaos’, are ‘spontaneous feelings’ that somehow follow him around, and that he feels at a loss to control. As you can imagine, whenever these feelings surface, those are the times that his behavior is most volatile.

When these feelings surface, that is when Charlie is actually feeling an acute sense of being ‘isolated and alone’. While logically (when Charlie is in a calmer mood) we can talk about him trying to ‘think differently’ (cognitive intervention) or focus on a possible ‘reward’ (behavioral intervention), the problem is that the feelings overwhelm his ability to ‘think and focus’ during a crisis. The bottom line is that ‘when push comes to shove’ his sense of ‘isolation and aloneness’ will overpower him and result in impulsive ‘fight or flight’ behavior.

The intent of pdxI goes to the root of his issue; that being his perception that he is ‘isolated and alone’. It is by neutralizing this false perception that we are able to interrupt his status-quo pattern. By predicting and planning with Charlie when he will have ‘his next blow up’, the clinician undermines Charlie’s basic perception related to being ‘isolated and alone’. To go one step further, I impose the therapeutic alliance by “insisting that WE schedule a ‘blow up’” When scheduling I let the client know that “he doesn’t have to do anything different than what he normally does.” When doing this, I try to identify the nuances that accompany his habitual behavior; the more details the better in regards to ‘who, when, where, etc’.

The intent here, is that when Charlie is facing his next crisis, the ‘planning phase’ that you did together will undercut his ‘isolated and alone’ experience. Clinically what will happen is that Charlie –out of habit- will ‘back in’ to his usual crisis situation, but instead of him feeling ‘isolated and alone’, the act of ‘planning’ the event with him alters his ‘alone experience’. By reducing his abandoned and ‘alone experience’, the intervention has a soothing effect. The ‘planning stage’ thereby mitigates and softens his compulsive need to act out.

In this way the intervention imposes an expanded reality. This new reality is designed to heal ‘abandonment trauma’ that the client keeps unconsciously recreating and reliving. While historically Charlie may have been abandoned and traumatized, this is not the reality in the ‘here and now’. The truth of this moment is that he is ‘connected’ with you (and others). By undercutting his perceived isolation, the client experiences a sense of relief. This relief soothes and relaxes the tension that previously drove him to ‘act out’. As a result previous triggers to ‘act out’ simply pass without incident.  

By planning and predicting behavior (with as many nuances and details around it), the clinician puts himself in a position of being (metaphorically) ‘in the passenger seat of the car the client is driving’. This puts the client in the (unexpected) position of feeling connected and accompanied by the clinician. The ‘predicting and planning’ activates the subconscious experience that keeps the clinician ‘in arm’s reach’ when the client goes back into his regular life and schedule. As a result there is a strengthening of the ‘therapeutic alliance’

If you get a picture of what is happening here, the client’s role is totally passive, in that he is not required or expected to be ‘compliant’ or ‘cooperative’ around this process. It is therefore the clinician’s ability to ‘reasonably forecast’ the client’s high frequency behaviors that establishes his credibility. It is this credibility that it strengthens the therapeutic alliance

The driving force behind the paradoxical approach is that – when done correctly – interventions are designed to strengthen the therapeutic alliance. The ongoing process of establishing a stronger and stronger therapeutic alliance thereby ‘chips away’ and neutralizes the client’s ‘isolated and alone’ experience. From this perspective, the ‘outer repetitive nature’ of the client’s behavior is of secondary importance. Of primary importance is the imposition of the therapeutic alliance since this is the ‘active ingredient’ for instigating positive change. What I find most exciting about the approach, is that when done correctly, the treatment-resistant client has no defense against this process.  

Obvious - When doing treatment, it is often ‘obvious’ to us (the clinician) what behaviors the client is doing that perpetuate his current situation. As a rule of thumb, I have found that what is most obvious to us is what is least obvious to the client. Clients often have little awareness as the repetitiveness of their patterns. What sometimes ‘throws us off’ is when the client seems to ‘recognize’ a given issue and gives ‘lip service’ to it. The client’s ‘recognition’ is due to the fact that enough people have cited the behavior to him so that he has learned to preempt the discussion with treatment providers. The clinician needs to know, however, that the client’s genuine insight regarding his actions is not at the level his words seem to indicate. For myself, when I identify ‘an obvious negative behavior’, I try to keep in mind, that if the client would truly realize the destructiveness of his behavior, - he would stop.  

Free-will - While it is obvious to us, how Charlie continues to provoke these crisis events, Charlie himself is not fully aware of his role in recreating these situations. Although we may tell him again and again how his actions perpetuate certain situations, from his ‘reality’, he believes that others cause him to react as he does. Responses that we see as ‘obvious’ repetitive patterns, - from Charlie’s perspective, are ‘spontaneous expressions’. As long as he has the mindset that his behavior is ‘spontaneous’, he will think that his actions are an indication of his ability to make ‘free will choices’.

One of the things I most enjoy about Pdx, is that a single intervention has many nuances that impact the client simultaneously on different levels. I have already mentioned how interventions are designed to neutralize his ‘abandonment and isolation’. However on another level, interventions challenge the client regarding his ability to make ‘free will choices.’  In this regard, interventions are non-confrontational. However, the nature of the intervention often raises the question as to whether client responses are expressions of ‘free will’ or simply hum-drum repetitive habits.

As you have noticed, interventions don’t tell the client what ‘he is supposed to do’. However, by pointing out the repetitive nature of his behavior, we elude to the client’s hum-drum predictability. For the client who prides himself on how ‘unpredictable’ he is, the insinuation that his behavior is ‘hum-drum’ is in shocking contrast to his self identity.

One of the assumptions of PdxI is that it is the ‘human condition’ that people, (and adolescents in particular), thrive on the belief that their behavior is an expression of ‘free will’. By us reframing his behavior as ‘predictable’ we set up a scenario that ‘forces’ the client to self-reflect on whether his actions are truly the result of ‘free will’.

When the client becomes aware that his behavior indeed does have a ‘hum-drum quality’, this often instigates motivation to prove the clinician’s prediction wrong. In this way, the nature of the intervention instigates a healthy response in the form of motivation to reassert one’s ‘free will’. In so doing, the client takes responsibility for himself without being ‘convinced, instructed, or rewarded’ to do so. The observable result is that the client becomes invested to demonstrate impulse control over the identified habitual behavior.

In this way the intent of an intervention is to strengthen the client’s ability to make flexible free will choices. It is the process of regaining his flexibility to make ‘free will choices’ that heighten his sense of self esteem. When doing an intervention, I always like to preface the message to the client with, “ I could be wrong … but it seems to me that you doing ‘xxxxxx type’ behavior is very predictable. Everybody knows that you always do ‘xxxxxx’ behavior. I might be wrong about my view of things …but that how it seems to me!” By letting the client know that “I could be wrong …” in essence I am challenging him to prove me wrong. In order to achieve this goal, the client is put in a position of having to take self-responsibility in a manner that he must strengthen his resolve and exert impulse control. Since I am not telling or advising the client to do anything, this resolve is clearly the result of the client’s own free will.

No Agenda for Behavioral Outcome - It is important to note that a ‘good’ Pdx intervention has no agenda as to a given behavioral outcome; ie: whether he does a behavior or not. A good intervention is therefore ‘neutral’ but at the same time acts as a catalyst to undermine habitual behaviors. When doing an intervention, my intent is to ‘attach, bond, and connect’ by simply telling the client the objective truth. In offering the truth, I indicate that behavior he assumes to be ‘a free will expression’ is actually repetitive and habitual.

As part of the therapeutic process, it is important that the client comes to this realization. When the client gains an understanding that his responses represent a ‘lack of free will’, it is similar to turning on a light in a dark room. Suddenly he gets a new perspective on the ‘furniture’ he had previously kept bumping into. This new perspective gives him an opportunity to view himself in a totally new ‘light’.

By helping the client see himself as others see him, this allows him to perceive his connection with others. The realization of this connection has a ‘calming’ affect in a manner that targeted behavior simply atrophies (meaning that he puts surprising little effort into changing). The key factor of the intervention is that as the client feels the presence of the clinician ‘keeping him company’ he will feel soothed to the degree that the old behavior simply doesn’t have the same ‘blind control’ over him.

It is therefore in a ‘backward way’ that the client re-owns his ‘free will’. Rather than ‘doing something’ to change himself in an active way, the ‘change’ that occurs is a result of ‘not doing’ his previous habitual reactions. In this way he is able to re-own flexibility in his choices and thereby his ‘free will’ potential. It is through regaining and strengthening his intrinsic ‘free will’ potential that he experiences an increase in self esteem.   

BOREDOM - A suggestion I would offer is to address the issue of BOREDOM with Charlie. Let him know in a matter of fact way, that given his past trauma it is therefore quite understandable that he has a need to perpetuate chaos. I often like to explore with the client the ‘benefits’ of maintaining chaos; that being that: it is familiar, provides excitement and entertainment, makes him feel alive, etc. I then ask what life would be without chaos? If he gives me the ‘standard answer’ that life would be ‘calm, easy, relaxed, peaceful, etc’, I  ‘respectfully disagree’. I advise him that in my view ‘without chaos’, he would experience a ‘fate worse than death!’ – BOREDOM. 

I usually remind the client that while I am not giving him ‘permission’ to partake in his brand of chaos, I understand why he may choose to continue this pattern. The intent here is to reframe the chaos as a ‘coping strategy’ to avoid life’s worst torture – BOREDOM.

While most treatment gets into a ‘power struggle’ with the client over curtailing or ending chaos, the intent of PdxI is to avoid this struggle. By reframing the client’s behavior, it is important that the clinician understands that the process of reframing is not a ‘ploy to trick’ the client. By seeing the client’s behavior as truly an ‘attempt to survive’, the clinician is able to let go of the usual judgments. It is from this position of ‘non-judgment’ that the clinician is truly able to join and support the client in his wish to stay alive! (–Also note that when the clinician partakes in treatment that involves an underlying ‘power struggle’, -the power struggle itself will ultimately perpetuate the client’s ‘chaos’ agenda.) 

This is another form of neutralizing the client’s sense of feeling ‘isolated and alone’. By discussing ‘boredom’, I am no longer on the ‘outside’ of the client’s ego zone. Through reframing his chaos as a ‘positive attempt to feel alive’, I let the client know that I am not against him, and understand his plight. In establishing myself as an ‘insider’, I convey to the client once again that he is ‘not alone’. I also convey that I am aware of his fear related to BOREDOM  (death), and that I am not trying to change him. It is from this ‘insider’ position, that I can be playful with the client in suggesting absurd ways to maintain chaos as a way to protect himself! It is through these playful suggestions that the client will recognize the straightjacket he has created for himself with his usual chaotic adventures.

As related to chaos, the clinician’s ability to address the topic of BOREDOM is critical to treatment. For our clients the ability to tolerate BOREDOM is central to their recovery. In engaging the client in the topic of BOREDOM and what it means to him, we also convey  that we, as the clinician, are not afraid of ‘going there. As part of developing trust and the therapeutic alliance, it is important that the clinician advise the client that ultimately the exit out of chaos will only occur by going through the ‘door of BOREDOM’.

By predicting ‘Boredom’ as part of the recovery process, the clinician thereby removes the client’s dread over the BOREDOM experience. In fact, it is when the client is ‘welcoming’ of the boredom experience that he is truly on his way to letting go of the chaos that wreaks havoc when gone unchecked.] 

Donna: The last two sessions I have had with Charlie have been mind-blowing.  He has been able to articulate very clearly some insights he has had into his behavior.  He speaks of how his father used to beat him (father actually went to prison for what he did to Charlie), and how his lack of feeling safe caused him to want to be more powerful than others as a sort of protective thing.  As the PXI forces him to make choices, he has been talking about his past choices and how it hasn’t served him well.  He has been having more nightmares lately (PTSD).  With the PXI, he has been forced to examine what kind of man he wants to be.  He said that he wanted to be a basketball star when he gets older (like most of our boys).  But he has recently said that he doesn’t think that he will actually be one realistically.  He said that the only other thing he is good at is stealing. 

[EPK: As part of the healing process, pdxI seeks to raise Charlie’s self-esteem and to realize his worth as a human being. If you are aware of any special talents he may have in music, art, poetry, etc., you may want to focus on these areas to build his self-esteem. Maybe he is good at organizing people to get projects done, etc. Interestingly by his own estimation he is ‘good at stealing’. Is there anyway that we can reframe this ‘talent’ for the good. Maybe he could be a future therapist himself, and help others by ‘stealing’ their depression, addictions, and chaos. He certainly has the prerequisite life experience!] 

Donna: So a dilemma has arisen in his mind about what he is going to do (he is almost 16).  This uncertainty, this uneasiness reminds him of the uncertainty and fear of the future that he would experience each time DHR would come and take him from the home after his dad would beat on him or his mom would disappear (he was also sexually abused in a group home that he was taken to after he was beaten by his father).  Hence the nightmares.  However, he seems like he feels more in control now.  It seems that he has the insight that life doesn’t just have to “happen” to him, that he can actually take steps to protect himself in a healthier way, after all, he is not as helpless as he was when he was 6 years old.  Right now he seems to be in a transition period, trying to figure it all out.  Amazing….I look at him and wonder if I am really talking to the same kid!  His insights blow me away, however, he has pulled this “see…I’m a GOOD boy” thing before. 

[EPK: A few words on ‘insight’. While there is nothing wrong with a client gaining ‘insight’, I believe that ‘insight’ in-and-of-itself is highly overrated in terms of the client’s ability to change behavior. As clinicians we are often encouraged and relieved when a client expresses ‘insight’, as we believe that now armed with this understanding, the client will imminently make the necessary corrections to his life.

My experience is that when a client is able to express insight as purely an intellectual exercise, then often no change in behavior will occur. As an example, it reminds me of the fact that there are physicians who smoke cigarettes. Certainly, they of all people, have insight into the dangers of smoking! Yet when that insight is ‘intellectual’ and not connected to their own personal health, they are able to deny the dangers of smoking.

I think we have to be careful when clients express ‘insight’, as their years of treatment my have taught them the ‘lingo’ and ideas of what will impress their provider.  I have found that even though clients may have ‘insight’ into their trauma, if they still feel alone and isolated in relation to those events, then that sense of abandonment will continue to rule their behavior and override their insight. Alcoholics, drug abusers, and people with long treatment histories often have ‘wonderful insight’ into their situations, however, their impulsive behavior remains unchanged. It is not uncommon that ‘insight’ is used as a wall to keep the clinician out. Their attitude is often, “See, I know where my problem comes from, and what I have to do to change it, but I’m not ready (to use my free will’) to change yet.” 

My suggestion is to use the client’s ‘insight’ in discussing how he coped with his trauma in the past, and then determine how some of those ‘coping strategies’ (ie: chaos, drinking, manipulative behavior, etc.) may still be part of his daily attempt to ‘protect’ himself. When the client insists (as they usually do) that they are ‘making a choice to use’, I like to engage them in a mini-argument that focuses on the fact that their behavior is habitual, and (it seems to me) represents a ‘lack of choice’  I then like to predict where, when, and with whom they will use again..]

Donna: I have continued with the PdxI even though he had appeared that he was doing much better.  He hasn’t had “loss of privileges” in about 5 weeks, and hasn’t been to the cell in about 4 weeks…that is an all-time record for him.  He passed both of his Phase II tests scoring above 90% on both (with oral tests instead of written as his learning disability seems to have impeded movement in the program).  So I  started saying more things like, “I’m really worried,  if you keep this up, I might not have any other choice than to move you up…..Nawwww…..I’m sure this is just a fluke, you’ll do something to keep you in Phase II….afterall….that is your ‘M- O’!!!!

With that said, yesterday I was walking back to his classroom with him, and one of the group leaders stopped him and told him to start doing his push-ups!  Huh?!  Apparently he had stolen something from this group leader, and so the group leader said, OK, if you steal something from me, you have to do 200 push-ups (every time he sees him he has to do 20 until he reaches 200), and if you don’t steal anything, then I have to do 200 push-ups.  Interesting…  Charlie, still is doing his same-old, same-old and still tries to look good in front of me. 

[EPK: You may want to ‘confront’ him as to why he has this need to ‘look good’ in front of you, but act out with everyone else. You know, it’s not fair that he puts on a show for everyone else, but leaves you out! When will it be your turn to see Charlie in action?!]

Donna: Nothing has changed too much in that regard.  I can see definite changes in him, in his thought processes however.  Like I said, it does seem that he is in a transition period.  We’ll see how long it takes (if ever) for him to straighten out his delinquent behaviors, and ultimately his offending behavior.

Thanks for the opportunity to organize my thinking in a written format. Please let me know if you have any questions. I look forward to your next email.

Eliot

 

9-17-10 Donna Email #5

Eliot,

Now that Charlie has been on Paxil his speech is so much more coherent.  I can actually understand what he says most of the time.

The thing that I like about PDXI’s is that they force Charlie to make a choice regarding his behavior.  Charlie is dealing with this in some interesting ways.  One day about 3 or 4 weeks ago he came into my office for a session and he was talking about his goals and he wrote this rapp (it was actually really good) about making choices and how he had the responsibility to make good choices (basically putting on a “good boy” image).  I commented “this rapp doesn’t sound like you Charlie, are you sure YOU wrote this?! Where’s the gangsta’ jargon?  Where are the lines about getting “even” with someone else?!  Common Charlie, is this what you’ve come to?”  As he progressed in his discussion it was becoming more and more obvious that he was doing his best at “playing” me with the good boy image.  (Since he has been on Paxil, he is much smoother and believable in his conning…strange side effect).  When I called him on his behavior and told him that his rapp sounded like someone other than him, he started to grin that “gotcha” kind of grin.  He then started talking about how he has 7 different personalities (in all seriousness).  He had names for each of the personalities.  For example, Pee Wee who is the curious and mischieveous one, C.J. who is the calm, cool, and collected one who is rational and does what is right, and so on and so forth.  He was trying to present himself like he had DID (I found out that he had read a book similar to Sybil about someone who had multiple personality disorder).  He was talking about how Pee Wee is the one who gets into trouble, NOT him.  After he was finished I emphatically told him that he did NOT have DID, and that he and all of his “friends” would all face the judge as one person, Charlie, and that he as one person would be responsible for ALL of his behavior.  He then came out of his serious façade and laughed.  He seems perplexed about how he is capable of doing good and not doing so good and be the same person.  He seems to be struggling making these choices and about who he really wants to be.  Sometimes of course, he looks for excuses for his behavior.  It seems too much for him to think that he might be like his dad, the one who beat him, the one he cannot stand and abhors.

It has been several weeks since Charlie stole anything.  AMAZING!  He has gotten into fights, but he is much, much quicker to calm down and not let his anger escalate out of control the way he used to.  Also amazing.  I have been proud of how he has resisted other boys trying to engage him in fights (at least some of the time, but not always).  I keep making predictions about his behavior though…..Charlie, I know this is just a fluke.  You’ll be up to your same old, same old…and hey, keep your shoes untied, don’t you know that you’ll keep your points if you tie them up?!

I am slowly seeing some gradual improvements.  He hasn’t sexually acted out in several weeks as far as I know.

Donna

9-20-10 EPK Response #5

Topics addressed in email #5: 1) Neutral discussion of ‘conning skill’; 2) ‘conventional wisdom’s’ take on PdxI; 3) a ‘bad case of Dissociative Identity Disorder’; 4) diagnostic purposes; 5) PdxI as a ‘sharp knife’; 6) reminisce about the ‘old days’; 7) reduction of sexual acting out – ‘animal in heat’

Donna: Now that Charlie has been on Paxil his speech is so much more coherent.  I can actually understand what he says most of the time.

The thing that I like about PdxI’s is that they force Charlie to make a choice regarding his behavior.  Charlie is dealing with this in some interesting ways.  One day about 3 or 4 weeks ago he came into my office for a session and he was talking about his goals and he wrote this rapp (it was actually really good) about making choices and how he had the responsibility to make good choices (basically putting on a “good boy” image).  I commented “this rapp doesn’t sound like you Charlie, are you sure YOU wrote this?! Where’s the gangsta’ jargon?  Where are the lines about getting “even” with someone else?!  Common Charlie, is this what you’ve come to?”  As he progressed in his discussion it was becoming more and more obvious that he was doing his best at “playing” me with the good boy image.  (Since he has been on Paxil, he is much smoother and believable in his conning…strange side effect).  When I called him on his behavior and told him that his rapp sounded like someone other than him, he started to grin that “gotcha” kind of grin.

[EPK:  It sounds like Charlie has a strong investment in ‘conning the world’. He’s interesting, because on the one hand, he does not feel safe in the world, but on the other hand he makes a game out of conning people to get by. As a way of bonding with him, you might want to praise him for his conning skills. Let him know that ‘it’s a good thing he knows how to con people, as this has been his way of surviving’. How does he rank his conning ability compared to others in the facility?

In a matter-of-fact and neutral discussion (ie: Barbara Walters interview), I would suggest you ask him: what was the best con he ever pulled off; what are his best conning techniques (‘good boy’ sounds like one of them); does he have a favorite technique; who are the people that most often fall for his cons; Are there any people he might not con? (gang members, certain relatives, etc.)-why and why not?; and, of course, the ‘I – Thou’ perspective in how he rates his ability to ‘get over’ on you now, and before; and if he was going to teach you how to be a con artist, how would he teach his talents to you; etc.

The list goes on, but basically, it would give him a chance to be seen and heard. If you do it in a neutral way without any agenda, it gives him a chance ‘to be honest’. It would be interesting to see how willing he would be to be open (or not) about this skill that he seems to have developed and put thought into.

Conventional wisdom fears that doing this type intervention might encourage Charlie to keep doing the behavior. Logically it seems that we’re promoting his ‘negative behavior’. However, from a ‘paradox perspective’ your ability to ‘join his con behavior’ neutralizes his underlying abandonment. By neutralizing the abandonment the ‘need’ to con others simply becomes irrelevant. Once he experiences that you are ‘keeping him company’ (with no agenda or struggle to change him), you will see the behavior start to dissipate and evaporate. As long as his conning is kept in the dark, - by trying to squelch it or not talk about it - it will continue to fester. The hard part of PdxI is to forego the struggle, as most clinicians assume that struggling with the client is a necessary part of treatment. However, the more you can convey to Charlie that you ‘see him’ and ‘shine light’ on his conning behavior, the more quickly he will be able to release it.]

Donna: He then started talking about how he has 7 different personalities (in all seriousness).  He had names for each of the personalities.  For example, Pee Wee who is the curious and mischievous one, C.J. who is the calm, cool, and collected one who is rational and does what is right, and so on and so forth.  He was trying to present himself like he had DID (Dissociative Identity Disorder), (I found out that he had read a book similar to Sybil about someone who had multiple personality disorder).  He was talking about how Pee Wee is the one who gets into trouble, NOT him.  After he was finished I emphatically told him that he did NOT have DID and that he and all of his “friends” would all face the judge as one person, Charlie, and that he as one person would be responsible for ALL of his behavior. 

[EPK: I would have handled this one a little differently. I agree with emphasizing that “all of his “friends” would face the judge as one person, and that Mr. Charlie would be responsible for ALL of his behaviors”. However this is where I have fun in turning the tables on his ‘con’.  —  I would have told him that it sounds like he does have a bad case of ‘the DIDs!’ Who knows how many other personalities in there haven’t even signed the attendance sheet yet?!  And by-golly with all those personalities floating around, it may take years and years to sort this out! But that’s OK because you (Dr. Adams) were hoping he would max out his time in the facility, anyway!  -So, from your perspective, -  This Is Great!’

The intervention here is to ‘join’ by “agreeing with” and “exaggerating” his con. The process that occurs is that by ‘jumping into the crazy box’ with him, you essentially ‘crowd/force him out’ of his own the box. As a result, instead of you working hard to ‘emphatically tell him that he does not have DID’, he is now put in the position to ‘emphatically convince you that it was all really a joke’!

The intervention also serves a diagnostic purpose. In this case, it sounds like you’ve pegged Charlie enough to know when he’s doing his con routine. But sometimes we don’t know if the client is playing us or is truly letting a deeper problem come to the surface. The absurd aspect of PdxI helps the clinician gain perspective on the healthy flexibility or unhealthy rigidity of the client’s psychological state. The client’s reaction to an absurd comment or statement allows the clinician to quickly assess whether the client is in a ‘reachable’ state or withdrawn. The client’s reaction, - whether a smile, a surprised glance, or even a smirk - suggests that the client has heard the comment and that a degree of therapeutic contact exists. Absurd statements that draw no reaction generally indicate a client who is withdrawn and unavailable. PdxI therefore offers us a ‘reality check’ tool to clarity and offer insight in assessing the flexibility of the client’s current psychological state. In this way, PdxI can be used to ‘probe’ the client’s perceptions and reality testing.

Those clinicians who use PdxI will soon come to recognize that the method has the properties of a ‘sharp knife’ in that it can be used to heal or harm. The responsible use of PdxI is never to ‘cut’ or harm the client in a manner that pushes him to wallow or further accentuate an abandoned and collapsed state). Rather PdxI should be used as a surgeon might in which the clinician keeps in mind his goal to enhance the therapeutic alliance and raise client self-esteem.]

Donna: He then came out of his serious façade and laughed.  He seems perplexed about how he is capable of doing good and not doing so good and be the same person.  He seems to be struggling making these choices and about who he really wants to be.  Sometimes of course, he looks for excuses for his behavior.  It seems too much for him to think that he might be like his dad, the one who beat him, the one he cannot stand and abhors.

It has been several weeks since Charlie stole anything.  AMAZING!  He has gotten into fights, but he is much, much quicker to calm down and not let his anger escalate out of control the way he used to. Also amazing.  I have been proud of how he has resisted other boys trying to engage him in fights (at least some of the time, but not always).

[EPK: Sometimes, I like to reminisce with clients ‘about the old days’. I like remind that I remember their ‘previous life’ when a certain situation “would trigger you to just go nuts!” Do you remember those days? Do you think you might decide to go nuts like that again, - just for the fun of it?” This type statement lets the client know that I’ve seen a change, and have been a witness to his progress. At the same time, I’m often cautious about seeming too eager to give his behavior ‘The Seal of Approval’ as I don’t want him to wonder whether he’s been manipulated to please my personal agenda.

While we of course are glad to see the client’s progress, it is more important for the client to know that he is the one responsible for making his current choices. With this in mind, I like to remind the client that I recognize that he made different choices in the past, and still has the power to decide whether he wants to return to those choices. By talking about his past I let the client know that my agenda is not to sweep his history under the rug. The intent of talking about the past is to let him know that I am a witness to the new broader spectrum of his behavior – that was not available to him 2 or 3 months ago.]

Donna: I keep making predictions about his behavior though…..Charlie, I know this is just a fluke.  You’ll be up to your same old, same old…and hey, keep your shoes untied, don’t you know that you’ll keep your points if you tie them up?!

I am slowly seeing some gradual improvements.  He hasn’t sexually acted out in several weeks as far as I know.

[EPK: As you are probably noticing, as Charlie ‘gets better’, it’s not that he really does any ‘new behavior’. It’s just that he does less of the old chaotic behavior. Also, as he gains (human) self-esteem, the need and desire to act out as an ‘animal in heat’ becomes less relevant or desirable. Notice that the change in his sexual acting out is not something he is ‘forcing’, but rather is a natural progression of feeling better about himself (increase in self-esteem, less reactive to anger, better communication with peers, etc.) as a person.]

 

Hey Donna,

It sounds like Charlie is making strides you wouldn’t have envisioned 6 months ago. It’s very gratifying to see clients struggle to take self-responsibility over their short term impulsive behavior that will lead to positive long term results.  Keep up the good work!  

Eliot

 

1-19-11 Donna Email #6

Eliot,

Whew!  The last few months have been quite busy here.  A lot has gone on with Charlie.  Here is the scoop:

Charlie continued to get involved in a lot of fights.  Over the last 2 months however, there seems to be a shift in his behavior.  Around the middle of October he came to me and wanted me to make up a behavioral contract for him to sign.  Charlie has been trying to convince me to move him up to Phase III.  My reply had been “We’ll have to move you to phase I in order to move you forward.”  He was urging me to make up a contract for him to sign to “prove” to me that he means what he says.  I am not sure if I executed this the way I should have, but what I put in the contract was that in order to move to Phase I, he would need to get involved in more fights (and so on) before a certain date.  At the end of all of the bulleted behaviors that he needed to engage in I put at the bottom “And if these things were not demonstrated and other behaviors such as controlling emotions, being respectful of staff etc were engaged in…we would have no choice but to move him to Phase III.  I’m not sure if I executed it properly….but he did not sign it.  He said that he wasn’t sure he could do it!

Interestingly enough, in my group sessions as well as with another group therapist that has him, he has been saying “all the right things.”  He has been demonstrating that he understands boundaries, and he has been talking about how he has controlled himself by not acting on his impulses.  He has talked about how he used to steal just for fun because he was bored and because everybody has “screwed him” so why should he care.  He talks about his “former” thinking errors.  His “talk” is quite impressive.  Honestly, he is one of the better guys in my group right now.  Nevertheless, I continue with the paradoxical interventions and “language” with him.  Recently his other group therapist was bragging on him to some other therapists.  Interestingly, he asked his group therapist not to tell his therapist (me) about how well he was doing!!!!!  Unbelievable…usually these guys are dying for their therapists to know all about how “beautifully” they are behaving.  I know he really hates the paradoxical “talk” with me, but I thought that was so interesting that he would beg her not to brag on him to me!!!!  It seems as though when I talk “paradoxical” with him, it puts a spot light on his behavior (like he is found out), and it also seems to release the resistance.  It is like playing “judo” with him.  There isn’t anything for him to struggle over.  He ends up doing the right thing despite himself!

I am thinking of moving him to Phase III soon due to his progress.  Any thoughts or ideas about how to present this to him in a paradoxical way?

Donna

 

1-25-2011  EPK Response #6

Topics include: 1) Charlie trying to ‘prove’ that he’s changed; 2) a hidden agenda; 3) conventional ‘therapy contracts’; 4) a ‘paradox contract’ ;5) when paradox is no longer needed; 6) paradox ‘aikido’; 7) soothing abandonment trauma

Hi Donna,  Great to hear from you! I know have some new responsibilities on your end and things have been hectic for you. Below I’ve inserted my comments into your email:

Donna writes: Charlie continued to get involved in a lot of fights.  Over the last 2 months however, there seems to be a shift in his behavior.  Around the middle of October he came to me and wanted me to make up a behavioral contract for him to sign.  Charlie has been trying to convince me to move him up to Phase III.  My reply had been “We’ll have to move you to Phase I in order to move you forward.”  He was urging me to make up a contract for him to sign to “prove” to me that he means what he says. 

[EPK: I always find it to be a ‘red flag’ when the client becomes “invested in proving that he’s changed”. ‘Real change’ happens without a lot of fanfare; usually in a way that the client is self reflective and without the need to draw attention to himself.  So I’m a little suspicious of Charlie (as I think you are …) in that he needs to “convince” you and “prove” to you that he’s “changed”. It seems that his efforts are more to please you, but not necessarily for his own benefit or because he perceives himself or world differently.

When a client ‘changes’ for the therapist (or anyone else), there is always a hidden or unspoken agenda- “I’ll be good for you, but now you owe me …” In the long run this type of ‘change’ is just an attempt to fool or ‘beat the system’. Interestingly, this type of ‘surface’ change can last – but only as long as the therapist ‘keeps his end of the bargain’! However once the therapist ‘breaks the contract’ (by not giving the expected reward; taking a ‘sick day’; going on vacation; etc.), then such surface changes simply become a ‘house of cards’ that collapse back to the underlying previous disruptive behaviors.] 

Donna: I am not sure if I executed this the way I should have, but what I put in the contract was that in order to move to Phase I, he would need to get involved in more fights (and so on) before a certain date.  At the end of all of the bulleted behaviors that he needed to engage in I put at the bottom “And if these things were not demonstrated and other behaviors such as controlling emotions, being respectful of staff etc were engaged in…we would have no choice but to move him to Phase III.  I’m not sure if I executed it properly….but he did not sign it.  He said that he wasn’t sure he could do it!

[EPK: This is great! I love your idea of a ‘contract’ and will add it to the list of paradoxical interventions! The helpful aspect of a ‘contract’ is that it is a written and physical document the client can literally hold and look at. At the same time it reinforces the fact that someone is ‘looking over his shoulder’ and is a witness to his behavior. The contract is therefore a physical reminder that he exists in relation to the therapist (and others). As such, the ‘contract’ has an excellent potential to reinforce the ‘therapeutic alliance’.

Having stated this, I also want to mention that in my view, the conventional and ‘customary use’ of a therapy contract has been an ongoing destructive force in treatment and a ‘recipe for failure’, particularly for the treatment-resistant client. Rather than using the contract as a way to strengthen or boost the ‘therapeutic alliance’, it often follows the clinician’s desire “to be helpful” in identifying a “to do list” of expectations. Even though this ‘list’ seems easy (at least easy enough for the therapist to do) – for the client who is unmotivated to change, such goals are out of reach. So rather promoting a sense of ‘joining’, I find that most contracts are ‘a set-up for failure’ and therefore promote a sense of isolation and aloneness due to his inability to reach and maintain the ‘expected behavior’. And of course the failure at this ‘contract’ is a reminder of the many previous ‘failures’ he has likely experienced.

So now enter a ‘paradox contract’! In this contract we keep the positive aspect of a written document as a ‘witness’ to behavior. However, the ‘twist’ of a ‘paradox contract’ is that it outlines and details what the client has to do to maintain the status-quo – that is , to keep things just as they are! So for example, if the client has been on Level Red (lowest level) with the least privileges for the last 3 weeks, the contract would list in detail all the behaviors he needs to do to keep himself at that level. As part of the ‘contract’ the clinician’s responsibilities would also be noted – that being, that as long as the client maintains his current level of behavior, it is the clinician’s responsibility to maintain the ‘status-quo’ loss of privileges!

The nice part of this ‘contract’ is that the client is ‘guaranteed to be successful’ if he does nothing more than his regular behavior. And in fact, the client will have to put in conscious effort to ‘break the contract’. In classic paradoxical style this places the client in a ‘win-win double bind’. If he does his usual behavior, the clinician can praise him (join with him) for ‘keeping to the contract’. However if the client ‘breaks the contract’ this means that the clinician will have to reinstate privileges (which is also an act of joining). In this way paradoxical interventions put the client in a position that the ‘therapeutic alliance’ will be strengthened. No matter which way he turns – he wins!

I know that by stating it this way it seems upside down. However, the ‘paradox contract’ takes pressure off the client to ‘change and be somebody he is not’. Any changes that occur are the result of the client taking responsibility to undo the details that were keeping him on Level Red]

Donna: Interestingly enough, in my group sessions as well as with another group therapist that has him, he has been saying “all the right things.”  He has been demonstrating that he understands boundaries, and he has been talking about how he has controlled himself by not acting on his impulses.  He has talked about how he used to steal just for fun because he was bored and because everybody has “screwed him” so why should he care.  He talks about his “former” thinking errors.  His “talk” is quite impressive.  Honestly, he is one of the better guys in my group right now.  Nevertheless, I continue with the paradoxical interventions and “language” with him. 

[EPK: You mentioned that “he’s saying all the right things”. My question to you is whether you feel he has turned a corner or is just ‘spouting ’? You should literally sense that he has made true internal change, and not feel you’re being conned with an ‘act’. If it’s an ‘act’, then you can usually feel an edge on his ‘good behavior’. If it’s fake, there will be a sense of, “OK, I did my good behavior, now where is the reward!”

True internal change comes across as calm with a new found sense of self confidence and self-esteem. There is better acceptance of self and others. The need to be manipulative also drops away.

I think as a rule of thumb, you want to note whether his anger and/or need to be ‘slick’ has significantly decreased. If it has and he’s more open to straight discussion, I would say to go with CBT. If his behavior, actions, and words match, then I would suggest cutting back on the paradox. Once the client is headed in the right direction, the continued use of paradoxical ‘double binds’ is no longer needed or called for. At that point, its continued use can give the impression of “kicking a dead horse”. ] 

Donna: Recently his other group therapist was bragging on him to some other therapists.  Interestingly, he asked his group therapist not to tell his therapist (me) about how well he was doing!!!!!  Unbelievable…usually these guys are dying for their therapists to know all about how “beautifully” they are behaving.  I know he really hates the paradoxical “talk” with me, but I thought that was so interesting that he would beg her not to brag on him to me!!!!  It seems as though when I talk “paradoxical” with him, it puts a spot light on his behavior (like he is found out), and it also seems to release the resistance.  It is like playing “judo” with him.  There isn’t anything for him to struggle over.  He ends up doing the right thing despite himself!

I am thinking of moving him to Phase III soon due to his progress. 

[EPK: I’ve heard paradox described as doing psychological ‘aikido’, which is a martial art form.. Anyway, in aikido you use the opponents force against himself. So if one’s opponent throws a punch, rather than block it or try to stop it, in aikido you sidestep the incoming punch while guiding the arm in the same direction forward. In this way the opponent’s own force is used to throw him off balance.

One of the things that still amazes me about the approach, is how little effort I put in to achieve a positive outcome. Like you said, I simply put a ‘spotlight on behavior’ by predicting what is already there in front of me.

It is the action of ‘predicting’ that acts as a gentle wakeup call to remind the client that he is not as abandoned and alone as he had come to believe. Although the banter of the interventions focuses on the ‘surface behavior’, the underlying ‘active ingredient’ is the fact that the intervention negates and soothes ‘abandonment trauma’.

This is probably one of the most important aspects of truly understanding the paradoxical method. While the intervention banters about patterns and orbits of behavior, the actual ‘meat and potatoes’ of the intervention is focused on soothing abandonment trauma. It is this soothing affect that bypasses any conscious attempts by the client to resist or defend against treatment. When the clinician soothes the underlying trauma, “there isn’t anything for the client to struggle against”. As a result the client spontaneously relaxes, - and low and behold presto-chango, he “ends up doing the right thing despite himself!”]

Donna,

Despite all the changes and added responsibilities at your agency, I appreciate that you’ve continued to make time to discuss your paradoxical efforts with Charlie. Hopefully we can do a few more ‘Charlie emails’ before the conference.

Speak to you soon.

Eliot 

 

2-7-11 Donna Email #7

Eliot:

Here is the latest on Charlie. There does seem to be some real change with him, not just a façade of sorts. The other day when I had him in my office we were talking about all of the traumatic events that he has been through. He spoke of how he “used to” hate those who were always “telling (him) what to do.” He said “I always wanted to do the opposite of what they wanted because everybody was always telling me what to do.” “My parents never cared anything about me, my dad threw me out the window like a piece of garbage (his father went to prison as a result of the abuse he inflicted on him, like throwing him out of a second story window when he was 5 years old). I said “why should I care about anyone else?” “I used to try to get attention by stealing things. I knew that adults would want to fight with me if they knew I stole something. I liked the attention and the fight.” “Now I don’t have to fight anymore. I realize that SOME adults don’t want to see me do good, but NOT ALL adults.” “Not everyone is out to get me.”

When Charlie was saying these things, I noticed that he naturally spoke in a past tense like “this is the way I USED to think.” I don’t think it was a put-on the way he used to do. He seems to have sort of a “Zen calm” at times. He has been in the brick masonry trade here on campus. I noticed that he is looking at the future and seems to actually be thinking about some viable life plans, like a job being a brick mason. He loves to rap and he is in a poetry group here on campus where he puts his poetry to rap. All of the leaders say he is the best one in the group. His self-esteem is much better. His therapy group leader says that he steps up and admits his mistakes and holds others’ accountable in group.

I moved him to Phase III as a result of his positive improvements. He still gets verbally aggressive at times with his peers (not generally with those in authority like he used to).

His verbal aggression seems to be more impulsive, more of a knee-jerk reaction than anything else. He does have thinking errors that he needs to work on still. The times that he has verbally been aggressive, he has went back to that person and apologized for his actions. It seems to be like old habits that he is trying to deal with. His PTSD symptoms do seem a bit better as well. Of course, I am always reluctant to brag too much as it seems when I usually do that they turn off and do something particularly ugly. J I am a bit skeptical still. I guess it is because I remember oh so well what he has been like. That is MY struggle. Hmmm. Can I REALLY trust Charlie that he is REALLY made changes and not just another fake act?

When I look back, it seems like his change has come in stages. I think he was confused himself over his change starting back in the late summer. At one point he had names for his “other” personalities (one that tried to do good, another that wanted to be a con, etc).

Overall, Charlie seems like he has hope. That is something that I honestly didn’t think I would ever see from him. He actually looks to the future. Any thoughts?

Donna

 

2-16-11    EPK Response #7:

Topics include: Existential reorientation, confusion, Zen calm; fake change vs real change, utilizing solar system model; ‘reminisce’ about the old days

Donna writes:

Here is the latest on Charlie. There does seem to be some real change with him, not just a façade of sorts. The other day when I had him in my office we were talking about all of the traumatic events that he has been through. He spoke of how he “used to” hate those who were always “telling (him) what to do.” He said “I always wanted to do the opposite of what they wanted because everybody was always telling me what to do.” “My parents never cared anything about me, my dad threw me out the window like a piece of garbage (his father went to prison as a result of the abuse he inflicted on him, like throwing him out of a second story window when he was 5 years old). I said “why should I care about anyone else?” “I used to try to get attention by stealing things. I knew that adults would want to fight with me if they knew I stole something. I liked the attention and the fight.” “Now I don’t have to fight anymore. I realize that SOME adults don’t want to see me do good, but NOT ALL adults.” “Not everyone is out to get me.”

When Charlie was saying these things, I noticed that he naturally spoke in a past tense like “this is the way I USED to think.” I don’t think it was a put-on the way he used to do. He seems to have sort of a “Zen calm” at times. He has been in the brick masonry trade here on campus. I noticed that he is looking at the future and seems to actually be thinking about some viable life plans, like a job being a brick mason. He loves to rap and he is in a poetry group here on campus where he puts his poetry to rap. All of the leaders say he is the best one in the group. His self-esteem is much better. His therapy group leader says that he steps up and admits his mistakes and holds others’ accountable in group.

[EPK: The change that occurs as a result of paradoxical interventions is referred to in the literature as an ‘existential reorientation’. This means that the change noted in the client occurs on multi-levels of behavioral, cognitive, and emotional functioning. I like your term “Zen calm” as it is descriptive of the client’s experience following an ‘existential re-orientation’. As you might sense, this shift is not something the client ‘wills’ upon himself, or makes a ‘progress chart’ in order to achieve. In fact, there is often a short period of ‘healthy confusion’ that the client experiences as he goes through his re-orientation process. This ‘healthy confusion’ is not scary or stressful, but rather a realization that the ‘reality and assumptions’ that one had based his life upon, no longer fit. As a result the person must adjust to a world and new self that is larger and more spacious than he had suspected. This might be compared to an inmate who finally gets out of prison and needs to reacclimatize himself to the outside world; the only difference here is that the client didn’t even know he was in prison. It sounds like Charlie has moved through this experience of an ‘existential re-orientation’ and has reached a new and more peaceful self-identity (Zen calm).]

Donna: I moved him to Phase III as a result of his positive improvements. He still gets verbally aggressive at times with his peers (not generally with those in authority like he used to).

His verbal aggression seems to be more impulsive, more of a knee-jerk reaction than anything else. He does have thinking errors that he needs to work on still. The times that he has verbally been aggressive, he has went back to that person and apologized for his actions. It seems to be like old habits that he is trying to deal with. His PTSD symptoms do seem a bit better as well. Of course, I am always reluctant to brag too much as it seems when I usually do that they turn off and do something particularly ugly. J I am a bit skeptical still. I guess it is because I remember oh so well what he has been like. That is MY struggle. Hmmm. Can I REALLY trust Charlie that he is REALLY made changes and not just another fake act?

[EPK: Hey Donna, You certainly bring up an important issue here. And more particularly with youth who have a known history of being sexually aggressive, - how can the clinician tell the difference between faked change and true change. How do we know whether the kid is just faking it, and saying what he knows we want to hear, or if there has been a true existential shift? And to add fuel to the fire, -kids in residential treatment (in general) have much less of an opportunity to act out than when their unsupervised at home - outside of treatment. So if the kid in residential says “Look how good I’m doing, I have not gotten in trouble for 3 or 4 months. I’ve changed and I’ll never do it again!”, how do we gauge whether its worth taking a risk to release him back into the world. It seems if the kid ‘learns how to play the game’, it would be relatively easy for him to fake us out. If he’s saying ‘all the right things’, and doing ‘what he is supposed to’ (at least in front of us!!), so how do we know?!

Unfortunately, in resolving this problem, clinician’s have relied on “our intuition” to guide whether or not it kid is ready to leave treatment. However, relying on ‘intuition’ to make decisions of this magnitude is not enough.

For this reason, I find the ‘solar-system model’ invaluable to help make these kind of ‘life and death’ decisions. An understanding of this simple model goes a long way in gauging the client’s current status and the success of treatment. The important thing about an ‘orbits-gravity model’ is that represents a system that functions as a whole. Even though the orbits may seem to function independently of each other, in reality the system functions as a unit. Therefore, a shift in one orbit indicates a shift in all orbits.

For the purpose of our work, I like to focus on the solar system ‘orbits gravity’ model – highlighting the orbits of Mercury, Venus, Earth, Mars, and Jupiter.  As it turns out, a single orbit of Mercury orbits the most frequently (88 days), while a single orbit of Jupiter takes almost 11 (Earth) years. In my mind, sexually aggressive behavior can be equated to a Jupiter type orbit. As such, the nature of a sexually aggressive behavior may take many months to reemerge and repeat itself. In addition, if we are only focused on the offender’s sexualized behavior, we must recognize that living in a residential placement will certainly limit any opportunity to act-out.

However, the orbits-gravity system works as a single unit. For this resident, my focus would be on observing ‘Mercury/Venus orbits’. These are orbits that occur more frequently (either everyday or every few days). Such behaviors give insight into the client’s ‘impulse control’ status. Such M/V orbits include: anger, lying, stealing, cursing, disrespect, and other inappropriate social behavior.

In evaluating a kid to determine if he is ready for discharge, my focus is on observing if there has been a change in destructive M/V orbits. If there is a new relaxed ‘Zen calm’ indicated by reduced anger, better social skills, etc. then I know that the outer orbit of sexual aggression has also been affected. However, if a kid is trying to ‘sell himself’ on how well he is doing because he hasn’t had a sexualized incident, but the anger, poor social skills, etc. remain, then I know that if the kid is discharged, he’s a ‘time-bomb waiting to go off’.   

Donna: When I look back, it seems like his change has come in stages. I think he was confused himself over his change starting back in the late summer. At one point he had names for his “other” personalities (one that tried to do good, another that wanted to be a con, etc). Overall, Charlie seems like he has hope. That is something that I honestly didn’t think I would ever see from him. He actually looks to the future.

[EPK: As I mentioned before, my impression is that Charlie has gone through an ‘existential re-organization’. This type of re-organization occurs when the client ‘gets a true awareness that he is not ‘abandoned and alone’. It is this shift in self-perception that literally changes his identity and how he experiences the world.

From what you describe, his behavior indicates to me that he no longer feels alone and isolated, as he once did. By you predicting and planning his habitual behaviors, you challenged his innermost belief that he was ‘alone in the world’. The effect of paradoxical interventions is therefore to re-align his sense of ‘attachment-gravity’. Once there is a shift in gravity then the orbits will spontaneously shift of their own accord.

It sounds like now his energy is more directed toward the future, and less on manipulating the world around him. Obviously the key here is to continue to observe his behavioral orbits over time. While a Jupiter orbit he can probably hide for an extended period, it’s the M/V orbits that will give him away if he’s faking it.

To ‘test’ the client, sometimes I like to ‘reminisce’ about the ‘old days’ and watch their reaction. This helps me gauge where he is at: “I remember when you used to get in trouble for doing xxxxxxx. Weren’t those days fun and exciting, cause you would end up in detention… . Hey maybe you can do xxxxxxx just for ‘old-time sake’!”  The purpose of this intervention has a number of angles to it: 1) It reminds the client that you have unconditional regard for him whether he maintains the behavior or not; 2) it affirms that you haven’t tricked him with ‘reverse psychology’ since you are suggesting a return to old behavior; 3) It reminds him that HE is making the decision to change his own behavior; 4) It lets you gauge whether he is guarded or open about his past behavior. If he’s overcome the past he should be able to talk about it in a relaxed way.

Overall it sounds like Charlie has come a long way. Even if he has a few ‘set-backs’, its also important to see whether he can take these set-backs in stride, learn from them, and how fast he can bounce back.]

Keep up the good work! Let me know how he does over the next few weeks.

Eliot

 

3-23-11 Donna Email #8 and EPK Response

Hi Eliot, 

Would you say that using paradoxical interventions with an adolescent client who is very concrete in their thinking (someone who takes what you say literally) such as those with Asperger’s may not be such a great idea?  Donna

Hi Donna,

The short answer to your question is: I think PdxI would lead to a favorable outcome - if correctly utilized - when addressing ‘concrete thinking’ (including Asperger’s clients.)

Here’s why: 1) PdxI is effective with rigid forms of behavior, emotions, and thinking; 2) Intervention neutralizes client’s underlying experience of isolation; 3) Raises client self-esteem by highlighting his ability to make ‘free will’ choices.

First, let me site the research. In general, research indicates that paradoxical interventions have been shown to be helpful in addressing a wide range of difficult clients. This includes the treatment of oppositional defiant disorder, psychotic patients, eating disorders, and more recently the Borderline client (DBT). While Aspergers Syndrome is considered within the autistic range of functioning, I believe it is possible for PdxI to have positive impact on such clients. As we will discuss, the extremely predictable nature of the ‘concrete thinking’ client makes PdxI a method that can be quite successful with this type client.

John Rosen - Psychosis:  To give a sense that PdxI can be effective with even some of the most difficult types of clients I’ve included a brief section from my website regarding the work of John Rosen, MD (1946, 1953). As a psychiatrist, he was the first to document the success of paradoxical methods in treating psychotic patients.

Rosen developed a system of psychotherapy which emphasized a procedure called “re-enacting an aspect of the psychosis”. This idea matches Alfred Adler’s concept of ‘symptom prescription’. When a patient began acting in a bizarre manner, instead of suggesting that the patient restrain himself, Rosen would encourage the patient in the opposite manner to act out the psychotic episode.

He found that these techniques had the effect of reducing the patient’s anxiety, and therefore resulted in symptom reduction. The significance of Rosen’s work was that it indicates that paradoxical interventions can have an effect on even a hard-to-treat schizophrenic population.

Rosen, J. (1946) A method of resolving acute catatonic excitement. The Psychiatric Quarterly, 20, 183-198

Rosen, J. (1953) Direct Psychoanalysis. New York: Grune and Stratton

1) Rigid / concrete thinking – Dysfunctional behavior is always related the lack of flexibility around a person’s inability to adjust. This lack of flexibility is often noticed by others as rigidity in behavior, emotions, and / or thinking. As you know, PdxI focuses on the predictable quality of rigid behavior (orbits). From a PdxI perspective, the more rigid a given behavior, the more easily it is to influence a flexible “vibration” reaction. You’ve probably heard of the saying, “The bigger they are, the harder they fall”. In a similar way, when a rigid behavior makes even the smallest change in the direction toward flexibility, that small change is extremely noticeable to the client as well as others around him. As such, particularly with highly rigid patterns, a ‘slight change’ is equivalent to a major behavior shift. This is one reason I like working with the treatment-resistant client, since changes to their ‘rigid pattern’ is so obvious and overt.

Ultimately in treatment, the name of the game is ‘flexibility’. As mentioned, the main problem with any dysfunctional energy pattern is the rigidity and constriction attached to it. Healthy energy is marked by ‘flexibility’ as it is indicative of the ability to adjust to one’s situation and environment. The ability to adjust indicates a person has a relaxed attitude in which a wide range of ‘choices’ are available. The problem with rigid energy is that one’s ‘choices’ are limited, and as a result the person keeps repeating a certain “predictable” response. The client with ‘limited choices’ often feels frustrated as the ‘only response he knows’ may have worked in one situation, but is totally ineffective in other situations. PdxI takes advantage of the ‘predictable nature’ of the client’s destructive behavior and utilizes it to dismantle the rigid pattern. This is along the lines of saying: The handle of the axe that chops down the forest, comes from a tree itself!      

One of the main areas of focus with PdxI is to identify ‘rigid’ types of ‘orbits of energy’. The ‘good news’ about rigid energy is that they are easily noticed in the form of highly repetitive behavior, emotions, and thinking. In particular, what I find most interesting, is that while these type of rigid patterns are obvious to us and other people, the client is unaware of how constricted and rigid he is. In fact for the client, his pattern is comfortable and ‘normal’. The orbits I’m most interested in focusing on are the “Mercury or Venus orbits”. Since the personality system works as a single unit, it means that by shifting inner and more frequent orbits we can simultaneously impact less frequent, but often dangerous (ie sexual acting out) behaviors. However it is the Mercury / Venus orbits that occur in the most predictable and frequent manner. There M/V orbits usually relate to: frustration, anger, lack of trust, low self-esteem, and poor social skills, to name a few.

While these are ‘visible’ and overt orbits, from a treatment perspective, these orbits are actually secondary to the ‘real problem’ that needs to be addressed. It is through the ‘orbits-gravity model’ that we recognize that ‘gravity’ (ie: attachment, bonding, and connection) is the actual ‘force’ that controls the nature of the orbits. The ‘stronger’ the gravity, the healthier and more flexible the behavior will be.

However, the problem with ‘gravity’ is that its force is invisible and we can not observe it directly. It turns out that through the ‘process of deduction’ we are able to gauge whether gravity is ‘weak’ or ‘strong’. This is done by observing the flexibility of ‘orbits of behavior’. As the research shows, when the initial ‘gravity’ (attachment) between parent-child is strong, nurturing, and supportive, then this leads to flexible and relaxed orbits / patterns of behavior. When there is trauma to the initial parent-child bond, this ultimately leads to the eventual development of various types of rigid forms of behaviors.

In order to engage (the invisible nature of) ‘weak gravity’ in treatment, we need a ‘hook’ or ‘gateway’ to gain access. As it turns out, this ‘hook’ or ‘gateway’ is often achieved through the predictable nature of the rigidified behavior that is noted to be ‘the problem’. This is so since the rigid nature of the behavior ‘reflects’ the ‘weak (trauma) gravity’ state.

Therefore, the paradox of treatment is that while the surface of a given PdxI intervention seems focused on the behavior, in reality the ‘core of treatment’ is accessing and addressing the client’s  ‘invisible trauma gravity’ (attachment / bonding experience). As such, we ‘latch on’ and utilize the client’s rigid and predictable patterns to our treatment advantage. It is by focusing on the frequency of these predictable orbits that we gain access the true (but hidden) ‘primary treatment issue’; namely, the client’s underlying sense of feeling abandoned, alone, isolated, separate, etc.

2) Intervention neutralizes underlying ‘abandonment’ - As strange as it sounds, a ‘clean’ PdxI has nothing to do with changing behavior! The change in behavior is a secondary reaction to the primary focus of shifting traumatized gravity-attachment. A ‘clean’ intervention reduces and soothes the underlying trauma tension related to the client’s ‘status quo (normal) sense of abandonment’. 

The nature of PdxI is to reduce and sooth trauma by strengthening the ‘therapeutic alliance’ (aka: gravity). When the alliance is strengthened, the repetitive rigid behavior (orbit) will automatically shift to a more flexible (and thereby less rigid) state of its own accord. So the bottom line is that a good PdxI intervention is totally about strengthening the ‘attachment-bond-connection’ with the client.   

Now in working with the Asperger’s client, I do not mean to suggest that following treatment the client is ‘presto-chango’ able to form new and meaningful relationships in a way that is totally different from his initial personality structure. However, I would say, that even a slight change in their ‘attachment-gravity’ experience will have a profound change in increasing the vibration level of his ‘concrete thinking’. In this way a PdxI can alter the client’s rigid thinking enough, to the degree that the client will be able to integrate one or two more new ‘choices’ to their original concrete pattern. Often it is these ‘one or two extra choices’ that will have a profound effect on the client’s ability to cope with daily stressors.  

3) Raises self-esteem by highlighting ‘free will’ potential – The added advantage of PdxI is that the method is designed to raise self-esteem. This is done through the client feeling less abandoned and alone. The neutralization of abandonment is accomplished via the strengthened therapeutic alliance.

Another way PdxI helps increase self-esteem is by strengthening the client’s ‘free will’ expression. PdxI accomplishes this by allowing the client to discover for himself the rigid and predictable nature of his own behavior. In ‘upside down fashion’ as the client comes face-to-face with his own ‘lack of free will’ he simultaneously recognizes what he must do to re-gain his ‘free will’.

Human nature is different from all other creatures, in that man has an innate desire to express ‘free will’. Whether a person is mentally handicapped or not, people desire to make ‘free will’ choices. All other creatures and animals are limited by their instinctual (rigid) behavior. Man is the only creation that has the ability to ‘go beyond’ his instinctual desires in his expression of ‘free will’.

It is when man succumbs (usually on an unconscious level) to rigid and predictable patterns that he becomes ‘animal like’ and thereby wallows in ‘low self-esteem’. However, when the client suddenly becomes aware of his ‘animal like predictability’ there is an automatic response to rebel against this ‘animalistic’ existence. It is this ability to rebel against this ‘lowly existence’ in which man’s ‘free will’ rises up. Therefore, it is by re-owning and undoing predictable behavior that man is able to raise his self-esteem.

Concrete Thinking - So the question remains ‘How is it possible to start to undo ‘concrete thinking’? Without going into detail, it is first important to understand that neither a behavioral (reward) intervention, nor a cognitive (logical / convincing) intervention, nor a psychodynamic (exploring childhood trauma) intervention will lead to positive results.

In my view it is the counter-intuitive absurdity of PdxI that has the potential to ‘chip away’ at the rock of ‘concrete thinking’. From my own experience, I had success working with a 13-14 year old adolescent, Bert, who had ‘concrete thinking’ in which he overtly and unapologetically professed the want and desire to have violent confrontations with other residents in his living quarters (cottage). As it came out in treatment, his self identity and ‘self-esteem’ was entirely based on his ability to be the ‘alpha male’ and intimidate others in his cottage. Although he seemed to take pride in his ‘animalistic prowess’, I understood that this was a cover for the true ‘low self-esteem’ he experienced.

What I found interesting about the case was that I initially expected PdxI to ‘break through the concrete’ relatively quickly (within 1 or 2 weeks). However, it turned out that the ‘concrete’ was much harder and thicker than I had expected. I soon came to realize that Bert had invested his entire life in structuring and defending his behavior, emotions, and thinking in support of his ‘alone identity’ and his ‘animalistic prowess’. As a result, it took about 8 weeks of ongoing ‘joining’ exercises and interventions until Bert finally showed signs of ‘cracking’ in that there was an observable reduction in his talk of violence and a reduction in confrontational behavior.

I bring this up, because I remember thinking during the initial weeks of treatment, that my attempts to ‘join’ seemed to have little impact on his ‘concrete thinking’ process. The shift in his behavior was not as ‘quick and robust’ as I had come to expect with my work with other adolescents. At the time, I remember thinking whether I should ‘give up’ my efforts to ‘get through’ to this resident or to trust my belief that the ‘orbits-gravity theory’ was a valid treatment model. Although it took longer than I expected, my ongoing efforts at ‘continued joining’ finally paid off.

In working with Bert, I did not make any effort to convince him that his ‘alpha’ perception was ‘wrong’ or needed to be toned down. Nor did I try to convince him to view things differently. In fact to the contrary, I went to extreme measures to agree with Bert’s ‘alpha view’, and agreed that the only way he would be respected was by being ‘alpha male’. (Of course I mentioned that other people might get respect without working so hard, but for him, he had to live up to being ‘alpha male’!) In the process I noted to him that his ‘alpha male’ posturing was very predictable and that I understood that he “had no other choice”. Along with advising him that I was a witness to his predictable behavior, I also advised him of the ongoing predictable loss of privileges (privileges that were common and available to other residents, …but not to him) as this was an expected consequence that he had to endure in being the ‘alpha male’ in the cottage.  

As part of ‘joining’, I began planning together with him the order of whom he was ‘scheduled’ to fight that week. During sessions I asked him to repeat the schedule numerous times, since “it was important that he be focused and knew ahead of time’ who was on this week’s menu”. As part of the treatment process, my intent was to make his ‘alpha male’ behavior into an ‘ordeal’ in which he would begin to question whether his behavior was a spontaneous expression or simply a habit.

As part of my work with him, I would constantly remind him that I personally did not want him to fight or lose privileges. However I understood that since his goal was to be the cottage ‘alpha male’, he therefore had ONLY one choice of how he could act and behave with others. Since I was on his side, I thought it would be a good idea to organize his upcoming schedule.

To further the process of ‘joining’ I took the position of being even more concrete and rigid than Bert himself. By becoming ‘more Bert-like than Bert’, I forced him to reflect on his own perceptions and behavior. Sometimes I was ‘critical’ of Bert for ‘missing an opportunity’ to demonstrate his ‘alpha’ prowess, and reminded him that such missed opportunities might give other residents the ‘wrong impression’ that he was ‘getting soft.’ 

At first Bert insisted that his ‘alpha’ mode was an expression of his ‘free will’ choice. However, I remember ‘reframing’ to Bert that in reality he did not have free will over doing this behavior. I informed him that everyone in life has a job. In his case “bullying the cottage was his JOB!” I told him that regardless of the consequences and loss of privileges, that everyone expected him to do his “JOB”. I reminded him that this was a 24/7 JOB, with no time for vacation!  I recall Bert not liking the fact that his ‘alpha male’ behavior had suddenly been reduced to a “JOB”!.

In summary, in dealing with Bert’s ‘concrete thinking’ it was important to get him to experience attachment through the therapeutic alliance. In conjunction with the therapeutic alliance he needed to get a glimpse of himself as others do. In this way he needed to begin to question whether his behavior is habit or ‘free will’. Once he recognizes the predictability of his rigid behavior and thinking, he became increasingly tired of being ‘stuck in his JOB as ‘alpha male’. Although it took a while, Bert’s behavior began to soften. He sometimes got into scraps in the cottage, but his overt aggressive became noticeably reduced. As he become more aware of his own predictability, he became more uncomfortable with previous reactions that had once been comfortable for him. At a certain point he began expressing his ‘free will’ choice by walking away from situations that previously ended with ‘predictable’ violent outcomes. 

Eliot