The Case Of ‘J’ 

                               Email Correspondence April 10 through November 17, 2009

                                            between  Eliot P Kaplan and Adam Brown

My thanks to Adam Brown from Northeast Center for Youth and Families (NCYF) for submitting the following case.  The client’s name has been kept confidential. Using the case as an ‘anchor’, I will try to convey how I conceptualize theory and practice when employing paradoxical interventions (PdxI).

Introduction                                     

I first met Adam after my presentation at the MASOC 2009 Conference, April 1. After my talk, Adam approached me about the case of ‘J’.  He noted that J was being physically restrained numerous times during the week, and he didn’t feel his therapy sessions were having an effect. Below are some more details about J’s problematic behaviors at his residential placement, as well as his early trauma and history.

Adam acknowledged that he was somewhat skeptical of the PdxI method, but since his approach with J was not working, he would give it a try as he had ‘nothing to lose’. We agreed to have an email dialogue and send our correspondence to people who had attended the conference presentation and others on my email list.     

From my perspective the goals in working with J would focus on: better impulse control, reduced volatility, increased sense of responsibility, increased self-esteem.

The Intervention Begins: At the conference Adam noted that Easter was coming up in a few Sundays. J was under the impression that he would be visiting his foster care mother for the holiday. The problem, however, was due to the frequency of J needing to be forcibly restrained (2-3 times per week), it was not likely that he could earn the points needed to leave the residence. Even if he did abstain from his violent behavior for a period of time, given his history, it was likely that he would sabotage himself a day or two before the visit. Although Adam and other staff had in the past tried to encourage J to control his behavior to gain privileges in the residence, there was no noted reduction in the frequency of the ‘holds’.  

The paradoxical interventions I suggested to Adam were based on a ‘predict and plan’ approach. First, J needed to be advised that his ‘acting out’ behavior was not as spontaneous as he wanted to believe. In fact he was quite ‘predictable’. And second, since J’s behavior was a predictable and forgone conclusion, it would behoove Adam to ‘plan’ with J where and when J could best sabotage his home visit!     Those were my suggestions at the conference. What follows is our email exchange regarding the ‘Case of J’.

EPK

4-10-09 Adam writes - Email #1

Hi Eliot,

I decided to use PdxI with a Client (I’ll call him ‘J’) who I described a bit to you.  I see him outpatient., but he is a 12 year old who lives in a residential home and is delivered to me to see him for his sexualized behavior and trauma history, which is enormous (J is the kid who was made to have sex with his twin brother while the mother and boyfriend watched, among many other things). 

He always presents politely in therapy, but his response to most questions which scratch the surface is “I don’t know.”  He’ll be calm and polite and play a game with me, and then go home and bang his head until it bleeds, or throw a chair through a window

Additionally, J has a history of early head trauma as a result of physical abuse, though an above-average IQ.  In addition to his sexualized behaviors in the past (exposing himself, inappropriate sex talk, grabbing others, etc.) he also has a history of torturing and killing animals, fire setting, and violent outbursts.  He is physically restrained multiple times a week both at school and in his residential facility, though he is very calm in session with me thus far.

Here are my session notes from today.  You will see that PdxI worked as prescribed, for which I want to thank you.  I’m a bit concerned for where it will go from here in the event that he does act-out and I am proven right.  For example, in the event he does something, I might say, “I knew you would do it just like I said,” to which he might say, “Yeah, you were right.”    Any advice? 

Thanks again, Eliot.  I’ll see him again tomorrow and be back in touch.

Adam Brown

 

Adam’s case note:

Client report of progress and/or new issues: Client J reports a desire to earn 100 pts. before Friday in order to “go home for Easter.”

TX objectives and therapist interventions (must relate to TX plan): Paradoxical interviewing used to engage J in a discussion of agency over his behaviors.

Clinician assessment of progress: Because J has not been amenable to more traditional methods of talk therapy, a paradoxical strategy was employed in order to engage him. Unlike previous sessions, J was enthusiastic in his speaking about his behavior and enjoyed the challenge of this writer’s attempts to convince him that his behaviors were predictable. J insisted that he would not act-out before Easter, but when he was asked to schedule a time for when he would act out, J stated “I don’t have any control over when it happens.” This will be used for further exploration, pending client’s bx. this week.

Follow up TX planning and/or homework: Client J will return in one week. He was told that this writer was expecting an email from a staff member in his residential home, no later than Friday at 1:00 PM, reporting that J has engaged in destructive bx. resulting in a loss of privileges. J insisted that this would not occur, wanting to bet $5. The bet was denied, although J relished in the prospect of proving this writer wrong and reported this to the staff in the waiting room, waiting to take him home.

Adam Brown, L.C.S.W.

 

4-13-09  EPK Response: 1A  - General Initial Thoughts

Hi Adam,

Some initial thoughts on your case:

12 years old - One of the major factors in J’s favor is his age. Since he is only 12yrs old, the maximum amount of time his destructive repetitive patterns had to set in was 12 years. Age is an important factor in treatment – the younger the better – as the older we become, the more ingrained both our positive and negative habits become. So you can get a sense that if this young child would go untreated, by the time he is 30 / 40 / 50, his patterns and attitudes would become more deeply ingrained in the direction he is now headed. I enjoy working with young children and teens, because you can literally see shifts in behavior / attitude from one week to the next.

Also as a related side issue, when a child or children are included in family treatment sessions, (given my comments above) I rarely attempt to work on changing the parent’s behavior. In family treatment it’s more of an uphill battle to change the parents’ behavior than the kids’. If we view the family as a ‘system’, by changing the children’s responses and behaviors, it inevitably has an impact on the parents. In family sessions, I often educate the kids’ (in front of the parents) regarding their parent’s habitual behavior; ie ‘Daddy likes to yell when he is upset’; ‘Mommy likes to complain that no one helps her’, etc. etc. Parents don’t usually get upset since I’m not ‘accusing’ them, but rather I’m just stating an ‘obvious fact’.

By teaching the kids about their parents’ patterns, it empowers the child to recognize that the parent’s behavior may not be directed at them personally. This allows the child(ren) to adjust his / their behavior in a manner that allows them to take a step back and be more relaxed about the patterns occurring. By reframing the events occurring in the family as ‘repetitive patterns’ the child(ren) gain perspective that  ‘its not their fault’ for the way Mom and Dad react. ‘Repetitive patterns’ allude to status-quo ‘orbits of behavior’ that I spoke about at the conference.

Regarding, any repetitive behavior (i.e: Dad yelling, Mom complaining), I learned from Fritz Perls (in his book Gestalt Therapy Verbatim) not to engage the client in ‘why’ they are doing a certain behavior. He states that when you ask ‘why’, it engages the client in ‘because’ reasoning. The problem with ‘because’ reasoning is that there will always be ‘100 because’ reasons that the client will use to ‘logically justify and support’ his behavior. ‘Why’ questions often lead to deciding ‘who is right and who is wrong’. 

Instead, Gestalt and PdxI focus on the ‘how’ or the process of a given behavior. ‘How’ questions lead to ‘unconditional positive regard’ since we are not judging a behavior to be ‘right or wrong’. ‘How’ simply is asking for the facts; How often does Dad yell – once an hour / day / week – Now we are identifying the rate, range, and frequency of the ‘yelling orbit’ and other details – usually after work, when Mom is home / or not home, etc. Once we’ve identified the ‘orbit’, now the clinician can become a ‘psychological astronomer’ and predict the ‘next family (eclipse) event’.   .. accordingly, which in turn impacts the family as a ‘system’?

So the fact that he is 12 yrs old is good news.

sexualized behavior and trauma history – You describe a child who has been severely traumatized by parental and adult figures. In essence the child has learned not to trust adult figures. Even if he consciously wants to trust you, he doesn’t have a ‘frame of reference’ to do so. The point being, that even if you tell him ‘it’s OK to trust me’, he has no understanding of what that means. So how do you create a connection with someone who has never had the opportunity to form a decent connection?!

The answer is - you create challenges for the client designed to raise his self esteem. By the clinician setting challenges that the client is able to overcome and rise above, the client gains a sense of self mastery. At the same time the clinician becomes associated as a person who he ‘looks forward to being with’ as he intuitively feels better about himself.

As you are learning, one of the most powerful qualities of the PdxI method is its understated and nonchalant way of conveying a challenge to the client. It is through engaging the client in a challenge, that the client gains a sense of feeling connected.

The ‘challenge’ allows him to feel connected even when you and / or other providers are wrapped up doing other things or working with other clients. And once the challenge has been set in an initial (regular) therapy session, it is easy to reconfirm and recharge that challenge in the following days with brief ‘in passing’ 5-15 second interactions; (Hey Johnny, I got you down in my book – by 3 o’clock tomorrow you’ll be walking out math class, - like we talked about yesterday– Right? OK, – don’t forget! I gotta get to a meeting – I’ll talk to you later.)  

Related to your point [in the event that he does act-out and I am proven right] – the idea is to reaffirm the bonding process, by letting him know you saw it coming. Now an important nuance here, particularly with destructive behavior, is you want to be very clear with the client that it is ‘not your personal intent or your idea’ for him to do his destructive pattern.

You are just identifying a repetitive behavior that he does not seem to be in control over. When noting to the client his repetitive behavior, it should be offered in a factual and non-judgmental way – ‘the sun rises and the sun sets’; ‘it is what it is’. PdxI interventions have the best impact when the clinician is a catalyst for change, but (as strange as it sounds) is not invested in the outcome.    (More to Come)

EPK 

4-14-09 EPK Response: 1B

Hi Adam,

Let me know how ‘J’ is doing. He sounds like a tough one, but he seems to have latched on quick to the PdxI challenge you started with last week. That’s a good sign.

The case of Client J that you present is obviously very serious in the scope and nature of this child’s trauma and his acting out behaviors. Using the case as an ‘anchor’, I will try to describe how I conceptualize and prioritize treatment utilizing a PdxI approach. Although there are many simultaneous aspects occurring during an intervention, I will try to separate out these overlapping aspects.

As I mentioned at the MASOC conference, I find the ‘orbits-gravity model’ to be an invaluable tool to conceptualize theory and practice. The advantage of the model is that it gives me a ‘scientific’ diagram that I can ‘plug into’ that doesn’t favor cognitive, behavioral, or psychodynamic orientations – but at the same time addresses them all. The following is the ‘solar system map’ that allows me to gain insight and direction when working with a full range of cases:

            

 

The model indicates the solar system between the planets Mercury and Jupiter. As the map indicates, the orbit of Mercury (relative to the Sun) occurs the most often (88 days), and the rotation of Jupiter happens the least often (11.9 years). A significant factor of using this model, is that although it seems that each orbit is separate from the others, in fact, the system works as a unified whole. In brief, that means that if we change the orbit of any one planet, it will have a simultaneous impact on the orbits of other planets.

From your case presentation you mention J has a history of “sexualized behaviors (exposing himself, inappropriate sex talk, grabbing others, etc.), torturing and killing animals, fire setting, and violent outbursts”. You also mentioned that he “is physically restrained multiple times a week both at school and in his residential facility” and is known to “bang his head until he bleeds, and throw chairs through windows”.

Using the ‘solar model’ we can classify J’s known repetitive behaviors into basically 2 categories; ‘mercury type’ repetitive behavior, and ‘jupiter type’ repetitive behavior. The ‘mercury’ behavior is what is currently happening every day / week. This is observable to yourself and other staff: his impulsivity, anger / violent outbursts, head banging, chair throwing, poor communication and social skills (you didn’t mention ‘social skills’, but its part of the ‘package’).

The ‘Jupiter’ behavior is the type of behavior that may have happened in the past, staff is not seeing now, but has the ‘potential’ to surface. These behaviors include: the sexualized behaviors, fire setting, and torturing of animals. Regarding this ‘orbit’ we know that certain incidents have happened at least once (so we know he is capable of doing it again).

The staff is often most concerned about these behaviors due to their legal implications and potential impact on other people. In fact, if the client is savvy enough –because he knows that this is what you want to hear- he may even tell you that he ‘learned his lesson and will never do’ these behaviors again in the future.

Given the infrequency of these ‘Jupiter’ behaviors they are often considered difficult to treat, especially if the client claims such behaviors to ‘no longer be an issue’. In addition, given the fact that the client is in residential treatment and under constant supervision, there is little opportunity to get involved in these dangerous activities. So how do we know upon discharge that the client is truly ‘cured’ of engaging in these volatile behaviors?

The ‘orbits-gravity model’ helps us solve this riddle. Since the model indicates that the personality and behavior can be viewed as a ‘unified whole’, this means that by successfully treating the mercury behaviors we will have a simultaneous impact on influencing the ‘Jupiter’ behaviors. As J becomes less impulsive, less angry, better able to communicate, and (of extreme importance) better able to make meaningful friendships, (we can extrapolate from the orbits-gravity model) that there has been a simultaneous impact on the ‘jupiter’ behaviors. If you see no improvement in the ‘mercury’ behaviors, we also know (no matter how much J may assert to the contrary) that no change has occurred in the volatility of the ‘Jupiter’ orbits.

In starting to address his ‘mercury’ behaviors, we want to start to undo J’s severe attachment trauma by letting him know that you ‘see him’ and are ‘connected’ to him. I find that the absurd humor of PdxI often throws the client into a ‘healing state of confusion’ that makes the client reassess his ‘status quo reality’.

Given what you’ve noted in the case presentation that “He’ll be calm and polite and play a game with me” in your office, but get restrained “multiple times at school and at the residential facility”, I’d be interested to find out how he would react if you told him how ‘disappointed’ you are and how ‘unfair’ it is that he gets himself restrained in all these other locations, but he always acts so nice with you! Why are you being deprived of seeing him in action!? You might want to tell him how you feel left out, and then demand that ‘you and he together’ schedule a time for him to ‘lose it’ in your office!

Keep me informed. (More to come)

EPK

                                                                            

4-21-09 Adam E-mail #2

Thanks Eliot,

I’m seeing him again today. I spoke to the counselor at his home and discovered that he has gone a second week in a row with no behavior problems.  This isn’t a first, but it’s never gone more than a couple of weeks before multiple incidents in a row occur.  So, we’ll see what happens from here.

-Adam

 

4-21-09 EPK Response: 2

Adam,

Great! Sounds like he’s invested in the challenge you’ve set up, and very conscious of your ‘shadow’.

My PdxI suggestion: Tell him that you are ‘very worried’ about him. Lead him in a way that he’ll ask you ‘what are you worried about?’

Then explain to him - that his acting out behavior is ‘way overdue’ - and that you wouldn’t be surprised if he has a ‘major blowup’ even as soon as today …

If he says that he won’t have a blow up, tell him that this is very out of character for him. If possible, insist on taking him to the medical office. At the medical office, explain to the nurse your concern - that J is just not ‘himself’.

(The medical staff now become additional ‘witnesses’ to J’s ability to control himself.)

Also let him know, that even if he has a ‘blow up’, you will still like him. Tell him, that he should not feel he has to change ‘just for you’.

Just some ideas. Let me know how it goes.

EPK

 

4-23-09 Adam Email#3

Hi Eliot,

Here’s an update from last session.  Your suggestion to go to the med staff was well timed; it just so happened that I saw him after immediately after his monthly med review and was able to pull the doctor aside with the Client and ask if the Client is okay.  The doc and the Client were both confused by the inquiry, but after she assured me that he was medically sound, the Client was very pleased with himself. 

And so now we’re onto potentially record-breaking material, as the little guy has never gone more than 20 days without a restraint.

-Adam

 

4-24-09 EPK Response: #3

Adam,

Good going! Some quick thoughts …

You are right. Now comes the ‘real work’ for him - as he is ‘stretching’ for a new record. On one level you want to ‘compliment’ (acknowledge his success) him - not by saying how ‘great he is doing’ - but rather how ‘surprised’ you are that he has not had an episode.

On the other side, you want to let him know this is a ‘big weekend’. Since it’s a given that over the weekend he is going to ‘lose it’, tell him that you are going to recommend that he be placed ‘on restriction’ now.

Obviously he won’t like this idea. I suggest that you ‘reluctantly given in’, but that at the very least, you will be telling the staff to be ready for a ‘big blowup’. If possible, talk to the staff in a way that he is present - either in your office when you call on the phone, or he is standing with staff on the other end of the phone. If that is not possible, staff should inform him later, that you spoke to them previously.

The key here is that we are letting him know that ‘we are all connected’ in preparing for his behavior. The hope is that even though you will not physically be there over the weekend, your ‘long shadow’ will be present.

Again, what is interesting is that no one is telling J to change. As he controls his own impulses his ‘self esteem’ skyrockets. This is the ‘reward’ of this kind of intervention.

EPK

 

EPK Responding to comments from David T who is following our email exchange:

Topics include: Telling client ‘great job’; Immunity from PdxI;

Apr 25, 2009      David T has been following case. He wrote:

Adam and Eliot,

A sincere thank you for sharing in real time the work with J.  I find myself pulling for this little guy I don’t know.  It must be hard containing the more conventional response, like “great job”.  Eliot, I know it must be hard for you to take the time to share these postings.
I will not be surprised if next week you can’t update us.  It’s okay!
David

EPK Responds:

April 27, 2009

Hey Dave,

Thanks for your response.

You raised a couple of interesting points that I would like to address.

First, it’s true that as clinicians our natural response when a client is doing well is to say ‘great job’. And in fact for the client who is motivated toward making positive change, we should tell this to the client as a way of acknowledging the client’s efforts, and strengthening the therapeutic alliance.

However, for the client who is more invested in ‘resisting authority’ and defeating treatment, the response of ‘great job’ of often taken the wrong way.  When this client hears ‘great job’, he translates this to mean, that he is doing behavior that YOU want. If that’s his interpretation, you can see how it wouldn’t take long to be back to his old patterns.

However, obviously we want to give this client encouragement as well. The question is how? The key is to phrase the client’s progress in a way that does not overtly judge his behavior as good / bad or right / wrong. The intent is never to shame the client.

Behavior should be framed in a nonjudgmental manner. Often I talk to clients about their “old behaviors” which can be ‘expected’ or “new behaviors” which I would “never expect” from them. Without judgment my focus is simply on identifying ‘factual’ and observable reality.

Keep in mind that we want to allow the client to take full responsibility for his behavior. When the client is able to take full responsibility for new / unexpected behavior this will naturally lead toward an increase in self-esteem. ‘New behavior’ means he has ‘stretched’ his ability to make a new choice in behavior.

Along these lines, I like to tell the client how ‘surprised’ I am that he / she didn’t do their usual ‘x’ behavior. “I mean you did that ‘x’ behavior last week, and the week before, and the week before that - I was sure you were going to do it again this week.”

In this way it is possible to acknowledge real changes the client has demonstrated without necessarily putting the “Good Housekeeping Seal of Approval” on it.

If we tell the ‘resistant’ client “great job”, the client is likely to undermine himself by questioning ‘whether he made the changes for clinician or himself”. I find that when I let the client know that I was ‘surprised’ by his new behavior, he often has an immediate response of taking pride in making a decision that was unexpected by others.  

Second, I see that you trying to use a little paradoxical challenge on LOM (Lil Ole Me)!

One of the interesting things that I find about the concepts that I’m presenting is that I can’t even get around them! You would think that since I know the “in’s and out’s” of this ‘paradoxical therapy method’ that somehow, I should be immune to someone attempting to put me in a PdxI bind!  Not so!

A side story -  I did a presentation a few years back. At some point during the training I happened to mention to the group that I had a ‘habit of being a little late coming back from lunch’.

So right before lunch, 4 (troublemakers!) people in the front row raised their hands, and ‘predicted’ to the group that I would be late coming back after lunch! 

I was shocked! Who were they to predict my behavior! They don’t even know me!   - But there was nothing I could say …  They were only repeating what I had mentioned earlier.    …So I just went back to my room.

 - - - Throughout my lunch, I felt as if the 4 of them had come back with me and ‘parked themselves in my room’. As much as I wanted, I couldn’t get them to leave or stop thinking of their ‘forecast’. I remember thinking to myself, “I know what they are doing! I know exactly what they are doing!!” But it didn’t matter. They were calling me on my admitted pattern.   

The upshot of the story is that I got the last laugh!! I came back to the hall early - even before they showed up! Yep, I showed them how little they knew me and how ‘wrrrong’ they were! 

But to answer your email ‘challenge’ more directly … It is my hope to send out weekly ‘progress’ emails.

Thanks for your note!

EPK

                                                                       

4-28-09  Adam  Email #4                                                                                                                                                                                                              Eliot,  

Just finished the note.  Saw him this afternoon.  Amazing results thus far, though now I’m wondering if he’s tiring of the “game” and act out again this week, as he stated that he would (before taking it back).        Adam Brown, L.C.S.W.

 

4-29-09 EPK Responds: 4

Topics include: Wizard of Oz / attachment; broaden ‘attachment network’;

Hey Adam,

In your note you reported that he’s gone for ‘a record 29 days’, however you are concerned that he is ‘tiring of the game’.

The first thing you should know is that you have been doing a great job keeping J involved and challenging him.

However, now we are beginning to differentiate between Phase 1 and Phase 2 of treatment.

Tangent - There’s a scene in the Wizard of OZ where Dorothy and company go back to meet the Wizard to convince him to send her home. When they enter the castle the lights are flashing and the Wizard is projected onto a big screen and thunders “I AM THE GREAT OZ” as he tries to intimidate them. In the meantime the  Professor (Wizard) who is off on the side pulling the levers and talking into the microphone gets caught up in the curtain he’s hiding behind. This attracts the attention of Dorothy and the group. When the Wizard realizes they are watching him, he thunders into the microphone, “DON’T PAY ATTENTION TO THE MAN BEHIND THE CURTAIN!” But at that point the jig is up.

The point here: In doing therapy, our tendency is to get caught in the ‘flashing lights and thunder’ (the client’s behavior, thinking, or emotions). While the ‘flashing lights / thunder’ draws our attention, in reality it is the hidden aspect (behind the curtain)’ that is pulling the levers and running the show. This hidden aspect is the client’s underlying ‘attachment experience’.

One of the confusing aspects of PdxI is that the focus of treatment is NOT to change behavior, but rather to change ‘attachment’. As long as we are able to change the client’s sense of ‘attachment’, the behavior change will occur as a natural secondary outcome. This concept is supported by ‘orbits-gravity theory’ where we see that by changing gravity, the orbits will shift automatically.

Once the clinician realizes that his job is not to ‘change behavior’, this actually frees him up, by taking the pressure off to ‘make change happen’. In treatment the client often becomes guarded and defended around perceived attempts to change his behavior. The treatment-resistant client will use a tremendous amount of energy to guard against the clinician’s attempts to ‘change him’. However, the client can not guard or defend against the clinician’s overtures to ‘join and attach’. When the clinician ‘predicts, prescribes, etc’, the client has nowhere to hide, and has no defense to keep him out. 

Back to J - In Phase 1 we often see amazing results and are struck by the client’s absolute progress. From the clinician’s perspective, this phase is very important as it shows us the client’s potential to function in an appropriate manner. In Phase 1 we often get caught up in the ‘flashing lights’ of the client’s new behavior, and question ‘what we can do’ to somehow maintain the client’s new found level of functioning. 

At this point we enter into Phase 2. In Phase 2, J is starting to waver a bit, and feeling nostalgic for the ‘old days’; as he misses the excitement of fights, restraints, etc. Hopefully, as we enter into this phase, you as the clinician, may realize how futile it is to try to control J’s behavior, but how possible it is to maintain and increase the therapeutic alliance.

Basically at this point in time, one of two things will happen: J will either have a ‘melt down’ or he won’t. However, either way, you want to use his actions and behavior that place him in a ‘win-win double bind’ that will further deepen his awareness of the therapeutic alliance.

If he has a ‘relapse incident’, you want to remind him that this is something you talked about, and was not unexpected, and that you’ve been ‘waiting for him at the finish line’. Since this was to be expected, you want to emphasize that he has ‘not failed’ by falling back into previous behavior.  You may even want to berate him for ‘being late’ and ‘taking so long’. But now that he had an incident, you’re glad to see that the ‘old predictable J’ is back.

The object here is not to ‘shame’ J for ‘messing up’, but rather ‘compliment’ him on being the ‘old J everyone knows and loves’. If done correctly, this will rankle J, as he will gain perspective that his own ‘impulsive’ acting out - as he will realize that these events are not spontaneous expressions of his ‘free- will’. The hope here is that J will make an internal vow to not be as ‘predictable’ in the future.

Obviously, we hope that J will continue to ‘stretch himself’ away from acting out.  An idea that I have for facilitating this is to broaden his ‘attachment network’. In other words, the more he feels seen and connected to others (beyond you as the therapist), the less likely he will act out.

To do this, I would suggest an absurd intervention. The intervention would be to get a calendar that has today’s date through the end of May. When you speak to J, let him know that you recognize that its getting harder and harder for him not to act out. You can tell him, “Let’s you and me figure out which kids or situation will likely ‘trigger’ you!’   - And now just to keep things interesting, we’re going to make a ‘contest’ by asking people (staff) to pick one or two days that they think you will have your next ‘melt down’. The winner might get $5 or lunch; and if he (J) goes the whole month without incident (which everyone knows won’t happen!!) he gets the $5 / lunch!”             

Such an intervention would make J keenly aware that people are observing his every move. People can even remind J when their date is ‘coming up’. The facts that he knows people are watching him, will likely boost his energy and desire to continue ‘winning’ the challenge. At the same time, the fact that people are watching his success will raise his ‘attachment experience’ and have a comforting and soothing effect.

Keep me informed.

EPK

                                                                          

5-1-09 Adam Email #5

Topics include: Treatment -Manipulative (Reverse Psychology) vs Authentic (Honest, Straight Forward) ; Reactance Theory; Instinctual Behavior; Self Esteem

Eliot,

Here is an abridged and edited email that I received late yesterday from the social worker assigned to J’s house.  She does therapy with the kids in his house and consults with the staff, but they farm J out to see me in an outpatient setting b/c of his past sexual behaviors.  She and I check-in once per week or so and I’ve let her know what I’m doing.  She checks-in with him.

Social Worker writes:  [ FYI, J is REALLY buying in to your paradoxical therapeutic approach!  He talked enthusiastically with his DCF worker and with me about all the bets he wins against you.  His behavior continues to be pretty good, even though Tuesday afternoon he verbalized that he was doing (feeling) “bad”. Great work! ]

Also, I talked with his DCF worker about the future possibility of him living with [his last foster mother] again.  (Note to Eliot: this foster mother was going to adopt J and his twin brother, who lived with her and her husband for a few years, until they started torturing her pets.  She currently takes them for scheduled visits, separately.)  She feels that it is a risk, but it might be the best possibility for him, after he completes residential treatment and [foster mom’s] life stabilizes.  (Note to Eliot: she is getting a divorce, but the boys don’t know yet this.)  At some point, I think we might want to have a group conversation with J about his future and what it would take for him to have the kind of life he wants.  At this point, J thinks of [foster mom’s] house as “home” but no one else is reinforcing that. 

 -Adam

  

5-3-09 EPK Responds: 5

Hi Adam,

A point of clarification?:

Does J feel the challenges are coming from you, or does J think the challenges are coming from me, and you are the middle man relaying them?

When you describe his behavior as ‘REALLY buying in’ - I cringe a little because it sounds ‘manipulative’. My intent is not to trick or manipulate the client, as the eventual result will be a loss of trust (once the client concludes that he’s been “gamed or tricked”) rather than strengthening the therapeutic alliance.

From my perspective, PdxI simply offers the client unconditional positive regard and in a nonjudgmental way acknowledges his current patterns / orbits of behavior. As you have noticed the method does not tell or instruct the client ‘to do anything’.

However by ‘predicting’ his behavior in the future, we do 2 things: 1) We impose ‘attachment’ since we elude that we know him well enough to know his behavior ahead of time, and 2) we present to him a challenge / quandary as to whether his actions are the result of spontaneous ‘free will’ or is he simply a robot with ‘no free will’. The quandary squarely ‘puts the ball in his court’ to prove to us and himself his ‘free will status’.

J’s anger/rage as demonstrated by ‘torture and sexual acting out’ indicate his deep underlying feelings and ‘hunger’ of not being seen and always feeling like a ‘loser’.

His reaction to the PdxI is like a starving person, who can’t get his fill.  PdxI not only allows him the satisfaction of feeling seen, but proving to himself that he can be a ‘winner’ / hero. And what kid doesn’t dream of being a ‘hero’?

In terms of the foster mom, it would be really great if she could commit to keeping him. Hopefully, if she sees a sustained improvement in his behavior, she will be more willing to stay involved. I obviously don’t know the full extent of this situation, but it sounds like J has an emotional connection to her. The loss of this connection could potentially be devastating to treatment and his emotional stability. 

The work right now, is to keep building J’s self esteem- that thru his own efforts he is a ‘winner’. The longer he is able to go without incident (off the old orbit due to a deeper sense of attachment) the harder it will be for him to go back to old behavior, even if someone or event ‘triggers’ him. 

EPK

 

5-4-09  Adam Email #6

Hi Eliot,

I’m sorry for bullet pts., but I’m rushed at this moment and I want to clarify this for you:

— I don’t feel like I’m challenging J at all; he sees it as a challenge, but I’m just reflecting what I see (per your script).  And no, we haven’t discussed you.  Is that what you were asking?

— “Buying-in” was the language used by a social worker whose email I forwarded to you.  I had the same reaction you did and I immediately clarified that this is not about judging the behavior, but just challenging his attachment to the behavior.  This poor guy has been brutalized by adults in his life and I wouldn’t take a chance like this if it didn’t feel authentic to me.  So, while it may appear like manipulation to others, I don’t feel as if it is, and I am confident that J understands this too.

—  The foster mom stuff is complicated by a) her divorce and b) the existence of J’s twin brother.  I’ll get into that more later, but the original goal was adoption.  This remains a long-term goal, but there are a few issues which need to be addressed.  For now, she continues to take J for a few hours each weekend and do activities with him.  He still refers to her house as home.

I really appreciate your ongoing attention to this case and your thoughtful responses to the work I’m doing.

Until Tuesday,  Adam

 

5-7-09 EPK Responds: 6

Hey Adam,

I appreciate that you used the word ‘authentic’ in describing your work with J.

One of the main criticisms of the paradoxical approach is that some clinicians consider the method to be ‘manipulative’ and dismiss it as simply ‘reverse psychology’ - In their view, while the intervention tells the client to do ‘A’, the real underlying agenda is for the client to do ‘B’. From this perspective, the clinician is concerned that once the client figures out the ‘reverse psychology trick’, then the method will no longer have any effectiveness.

Clinicians who view the method as ‘manipulative’ lack an understanding of the importance of the therapeutic alliance as the essential piece to this approach. The intervention will become manipulative if the provider is not concerned about strengthening the alliance, but is rather invested in ‘doing something’ to impact the ‘flashing lights’.

When the provider is focused only on the outer manifestations (‘flashing lights’) of repetitive orbits of behavior, emotions, thoughts, but loses sight that the ‘active ingredient’ is in addressing the client’s underlying need to feel seen, noticed, and included (attachment / gravity), then it is quite likely that the client will eventually ‘see through the trick’. If the client concludes that you have used ‘reverse psychology’ as an attempt to trick him, instead of strengthening the alliance, the intervention will ‘backfire’ and the client will become distrustful.  

An ‘authentic’ PdxI Intervention is really the “reverse of reverse psychology”. By this I mean that the clinician’s intent is not to ‘trick or manipulate’ the client’s behavior, but rather to be ‘honest and straightforward’ in a manner that heightens the client’s awareness regarding his repetitive patterns.  Ultimately, an ‘authentic’ PdxI is only about strengthening the alliance.

In being ‘honest and straightforward’ the intent is to strengthen the therapeutic alliance bit by bit. In being ‘honest’ with the client, I usually review his / her history in a factual, accepting, and non-confrontational manner. In doing this, the intent is to show the client that there is a pattern to their history, and that behavior he / she might have considered to be a ‘spontaneous (free-will) expression’ at the time when it occurred, was really just another predictable event in an ongoing pattern of similar incidents. 

In being honest with the client regarding their history, the intervention seeks to create a ‘foundation of reality’ that I, the client, and others can agree is valid. The goal is to identify a repetitive pattern of events and behavior that we can all objectively agree with. (When I engage the client, I try to present the objective history of his behavior as: You did behavior ‘X’ a week ago; you did behavior ‘X’ 2 weeks ago; and you did behavior ‘X’ 3 weeks ago)

In being ‘straightforward’, we now take this recognized pattern, and project ‘where, when, how, and with whom’ this pattern will likely be repeated again. Since the client has shown a rigid propensity to repeat his patterns of behavior, the clinician can now forecast to the client the likely parameters when the pattern is likely to repeat. In so doing, the clinician eludes that these patterns are not in the realm of the client’s ‘free-will’. 

Jack and Sharon Brehm came up with the concept of ‘Reactance Theory’. Reactance theory basically states that all people value the ability to make ‘free-will’ decisions. Free-will decisions indicate a person’s ability to make flexible choices. When people perceive a potential loss of their free-will status, they will often react in a manner that emphasizes and highlights their ability to make free-will choices. In this regard, an oppositional child who is told that he “must sit down”, will often do the opposite in an effort to prove that he has free-will.

SD Schneerson notes that human beings are the only animals that have the ability to express free-will. While all other animals are ruled by their ‘instinctual behavior’, humans have the ability to transcend their animal instincts. In psychological terms, instinctual behavior can be seen as rigid pre-programmed patterns of behavior that lack flexibility.

Along these lines, a person’s ability to transcend oneself is specifically related to the concept of ‘self esteem’. Since animals do not have the ability to transcend ‘self’ due to the instinctual quality of their behavior, ‘self-esteem’ is not relevant to their existence. However, for people a sense of ‘self-esteem’ is very important.

People with a good or ‘high’ sense of self esteem have been able to learn to master their animalistic impulses, while those with ‘low’ self esteem often react impulsively in an animalistic / instinctual fashion. In extreme cases, those who are unable to demonstrate an ability to control their impulses are ultimately treated like animals, and are confined to cages called ‘prisons’ or ‘psychiatric wards’.     

 

An ‘authentic’ PdxI Intervention is a catalyst for change, but does not manipulate or directly pressure the client to ‘make change happen’. In a non-judgmental manner, an intervention identifies rigid (animalistic) type patterns the client has become involved with. By simply informing the client that they no longer appear to have ‘free will’ expression around a given behavior, treatment elicits an automatic internal (reactance) response within the client to regain his / her free will expression.

As the client demonstrates his free-will potential to control his previously habitual impulses, there is a natural and automatic response toward an increase in self esteem. In this situation, it is the internal reward of a higher sense of self esteem that perpetuates the client to want to continue and maintain his new level of impulse control. Also since the clinician was the catalyst in facilitating the move toward this higher state of self-esteem, this further builds and strengthens the therapeutic alliance.

Back to J - Speaking of self-esteem, as we look toward the future, you may want to identify interests or talents that J has. As hopefully he will be spending less time getting restrained (and the like), he will have more time to develop talents in music, drawing, writing, etc. As he strengthens his abilities in areas of interest, this will be another source of self-esteem once the current paradoxical exercises become less relevant. 

EPK 

 

5-11-09 Adam Email #7

Case note of 5-5-09:

Client report of progress and/or new issues: After going a record 37 days or so without a hold, the Client acted-out violently last week in his residential home, requiring a seven minute hold, during which time he bit a staff member and broke the skin.

TX objectives and therapist interventions: Paradoxical interviewing: “It’s about time you got back to your old self again; I was starting to wonder if I was as smart as I thought I was, thinking I knew you so well…”

Clinician assessment of progress: Client was much less energetic when the session began, as he seemed disappointed to have acted-out this week. When this writer acted near-celebratory in stark contrast, the Client was willing to process the incident, revealing new information. (Previously, the Client would only say “I don’t know” when asked about these incidents.) For example, when asked about the biting, the Client stated “I don’t bite male staff; I only bite female staff, so I can show them who’s boss.” When asked about his ability to stop himself from acting out, the Client stated “I can stop myself, I just didn’t feel like it this time because I was too pissed off.” Each of these statements represents new material for future exploration.

Follow up TX planning and/or homework: Client stated that he will definitely NOT act-out again for at least two months. When he was assured by this writer that he’ll be back to weekly holds, now that he’s “back in his groove,” the Client insisted on a bet. Three members of his treatment team have each chosen a date between now and July 8th, per the Client’s request. The one who chooses the date closest to the Client’s next incident will receive a $10 lunch. If the Client makes it to July 8th, he will get the lunch.

  

5-12-09 EPK Responds: 7

OK, so after stretching 37 days of not requiring a ‘hold’ (and with tension mounting), our hero succumbed to ‘relapse’ requiring a ‘7 minute hold’.

From a clinical perspective, we can look at this in a number of ways. The first way –(looking at the glass ‘half empty’- which I think would be a mistake) is to say: Oh well, he ‘relapsed’, we therefore have made no or minimal progress. Even though the intervention worked for a while, we are back at ‘square one’. The intervention has ‘run its course’ and now it’s time to move on to another ‘technique’.

Or a second way – (looking at the glass ‘half full’ – which I think is more accurate and realistic) is to identify J’s progress, and work forward from here. If we look at J’s situation objectively, J seems to have come a long way since the case’s introduction on 4-10-09. At that time it was reported that J was being “physically restrained multiple times a week both at school and in his residential facility” and although not stated, I suspect that many of those restraints lasted for at least 30 minutes or more.

We now have a situation that 37 days later, we have a child, who has 1 relapse incident that lasted for ‘7 minutes’. Is J making progress? I admit that I’m biased, -but I think (given Adam’s information) that J has made more progress than anyone would have expected. Also, in hindsight, given J’s background, we can recognize that our hope that J ‘would never relapse again’ can be seen as unrealistic. Obviously, it is important what we do from here on out, to get back to our next ‘winning cycle’ and break the old record.

In doing this, I think it is also important to maintain a ‘theoretical focus’ on what treatment has so far accomplished. Often in our field, we clinicians get caught up in ‘what techniques worked’. However more importantly, I believe that we need to be clear about the underlying theory behind ‘why’ what has been done so far has been successful.  In brief, if we go back to ‘orbits-gravity theory’, I believe Adam managed to facilitate a shift in J’s experience of attachment / gravity, with the result being a secondary shift in his repetitive ‘orbit of restraints’. With this shift in attachment, J went from ‘multiple weekly restraints’ (Fig. 1a - below) to 1 restraint in 37 days (Fig. 1d).

The shift in attachment –allowing J to feel connected and seen- came through Adam’s ability to: 1) convey ‘unconditional positive regard’ around his predictable patterns of behavior; 2) offer ‘challenges’ that were within his ability to achieve; 3) provided a catalyst for J to exercise his free-will to control previous impulsive behavior; and 4) offered J a sense of purpose and accomplishment that in turn promoted the raising of J’s ‘self esteem’.

Using Figure 1, we can illustrate the ‘process of change’ that J has gone and continues to go through: 

 

Figure 1a  represents repetitive cycles of J’s status quo behavior before we started using PdxI. In this state of J’s personality system his experience of attachment is weak. As a result he harbors a strong sense of isolation and aloneness equivalent to (using astronomy terms) a ‘black hole’ of gravity. In this state, his personality system functions around his personal perception that he is ‘abandoned and alone’.

Within this state his lifestyle (as represented by his repetitive patterns of behavior) is severely constricted by constant feelings of anger and mistrust (mercury orbit), ongoing need for restraints (Venus orbit), and the likelihood of sexually acting out (Jupiter orbit) if the opportunity arose (which was the ‘presenting problem’ of most pressing concern). Even though on the outside we can see J’s behavior as constricted and repetitive, from J’s perspective (inside) his feelings of anger, and outbursts that result in restraints are an expression of his free-will.

Figure 1b  indicates PdxI interventions (represented by arrows) designed to intervene in J’s status quo personality system. The arrows indicate a strengthening of the ‘therapeutic alliance’ through unconditional positive regard and predicting J’s repetitive patterns. In so doing the intervention bypasses, dismisses, and negates J’s personal perception of abandonment. While it is true that the former actions of his mother and boyfriend did indeed create a psychological state of abandonment, the mistake (thinking error) of J’s perceived reality (belief system) is that his abandonment is ‘absolute’ in regard to everyone.

However, by Adam predicting J’s habitual patterns, Adam simply and without effort negates J’s false assumption of ‘absolute abandonment’. In other words, Adam’s interventions cut through J’s personal perceptions that have no basis in his present reality. As you might recognize, this forces J to ‘reevaluate and reorganize’ his perception of the world. As this new perception takes hold, old behaviors become less relevant and spontaneously begin to shift to a more open and relaxed cycle of existence (as indicated in Figure 1c).

Figure 1c  illustrates how J’s new perception of feeling connected (gravity) manifests as a shift in his external behavior (orbits). It is interesting to note that after the most recent ‘7 minute restraint’ J insisted to staff that this type of acting out is no longer a part of his lifestyle (as indicated by Figure 1a). Also Figure 1c indicates that while certain behaviors may still reoccur in the short term, there is an overall movement toward an expansive state in the personality that is more flexible, functional, and open (as indicated by Figure 1d).

Figure 1d  indicates a more functional and flexible personality state as compared to Figure 1a. Within this context, it doesn’t mean that treatment with J is over, but rather to give us perspective as to the positive direction treatment is headed. It should be noted that as the personality system of J becomes more expanded (ie less angry, more trustful, better social skills, increased self esteem) his need, desire, and ideation to act out sexually (Jupiter orbit) will simply evaporate. At that point PSB (problem sexual behavior) ideation is just no longer relevant to the expanded state his life will have attained. While he will still have sexual feelings, the illustration indicates that future expression will occur in a more socially acceptable manner.    

In terms of the direction of J’s treatment in the  ‘next round’, I suggest to Adam that: 1) continue to strengthen J’s impulse control / self esteem; 2) give J opportunities to help out and/or take responsibility for certain chores that highlight that his contributions are valuable;  3)strengthen the ‘home connection’ with foster mother;  4) strengthen talents that he may already exhibit that can serve to raise self esteem – in music, art, sports,  writing, etc. 5) provide opportunities to increase social skills and develop meaningful friendships with peers.

Keep up the good work Adam!

EPK

                                                                                                                                                                  

5-18-09 Adam Email #8

Thanks Eliot.  Your responses have been very helpful.

J is back to struggling, though he is better than when we started.  Attached are the notes from last week: 

Case Notes from  5-12-09

Client report of progress and/or new issues: Client went the week without a behavioral incident.  
Client reported that he would be applying for a promotion in the residence, which will earn him more privileges, if approved.

TX objectives and therapist interventions (must relate to TX plan): P.I. to assess the Client for his willingness to take responsibility for his behavior.  
Reflected to Client that he has come within a day of achieving this same promotion on multiple occasions before acting-out and needing to start over.  
Played backgammon with the Client.

Clinician assessment of progress: The Client enjoys backgammon and requests to play it immediately upon the start of each session. Prior to agreeing to play, the Client is asked to reflect a bit on choices he made during the week when confronted with intense affect. Client would not engage in a discussion of this, other than to declare that he would “win the bet,” which is now an official 4-way bet for lunch. He appeared agitated, but denied this to be the case.  
 
When the Client started to lose at backgammon, he began to throw the dice harder on the table and became combative- insisting that this writer was cheating. When offered resistance to his attempts to bully this writer, the Client became more hostile, making the dice bounce onto the floor. When it was noted that he didn’t seem like he wanted to play the game and the game was stopped, the Client got up and walked out. He returned when called back, but then stated, “I should punch you in the face and walk out.”  
 
“Why haven’t you then? What stops you from punching me and walking out?”  
 
He then got up and calmly walked out of the office and met his staff in the lobby, asking to be brought home.  
 
The total session time was approximately 40 minutes.

Follow up TX planning and/or homework: Staff was put on alert, as the Client’s behavior in session was more hostile than in previous sessions, and because the Client’s pattern has been to act-out immediately before becoming eligible for a promotion of level in the home.     Client will return in one week.

Adam 5-18-09 (continues):

Interestingly, he would have made his promotion (see notes) for the first time had the committee met on Wednesday as scheduled.  However, they were sidetracked last week and canceled.  Then, on Friday night, J became involved in a hold after throwing a trophy at a staff member.  (The trophy hit the wall and put a hole in the wall.)  Now, he will have to wait before applying once again.

I’m seeing him tomorrow at 2:30.  After last week, my sense is that my incredulous reactions to his behavior are no longer fun for him.  So, he’s not up for a discussion.  It is what it is and that’s that- is sort of what it feels like.  Should I just lay off the theater (without stopping the PdxI, per se) for a bit and play games with him for now?

 -Adam

 

5-18-09  EPK Responds: 8

Hey Adam,

From your report: J is having a downturn, and has had several incidents in succession. Also he’s worried about being ‘teased about the bet’, and demonstrated lack of frustration tolerance when ‘losing at a board game’. 

A few things:

1) Although you haven’t stated it, I’m assuming that things are status-quo with foster mom; meaning that she and J have regular contact, and J is not experiencing any overt rejection by her or any other significant person that he may be reacting to.

2) The fact that J had 37 days without incident is a documented reality. From a clinical perspective, we see that J is capable of stretching himself and that he can be motivated to do so. From a treatment perspective, it is important to let him know that you continue to be conscious of his strengths and his ability to succeed. In moments that he might express by ‘word or deed’ that he is ‘getting nowhere’, you provide a valuable service by reminding him of this reality of his success.

In times when J might ‘get down on himself’, these 37 days are ‘actual proof’ of his ability to succeed. The point being that no one can take away these 37 days from him - not even himself. As part of advancing the therapeutic alliance, he needs to know that although he has ‘taken a step back’ (relapse) you are still able to acknowledge and focus on his ability to set goals for himself and achieve them.

3) Hindsight is 20/20. This is a process that we learn nuances of  ‘what we should / shouldn’t have done’. I myself, constantly learn from my ‘mistakes’, or how I could have better handled an intervention. In hindsight, I think we let J ‘dig a hole for himself’ by allowing him be in control of the last ‘bet’. As part of developing the therapeutic alliance, sometimes we need to protect the client from himself.

Although J’s intent was good when he ‘insisted on the last bet’, looking back, we should have emphasized his actual progress, and deferred on his desire for another bet. The fact that he was ‘insisting’ was our clue that this probably was not a good idea. By J setting up (controlling) the bet put extra pressure on him to succeed - pressure that he was not ready for. In his ‘win or lose world’, he perceives his failure to win the bet as leaving him open to ‘teasing’ by you and others.

My suggestion is to drop / undo the bet. I suggest that you reassert your control (ability to create a safe environment) and tell him in no uncertain terms that you have decided to cancel the bet. You can give him a ‘reason’ or not. The bottom line is that you are in control and the bet is cancelled - for now. I think he will feel relieved by this: 1) that you are back in control; 2) he saves face by not having ‘really failed’.

4) Maybe we should change the name from ‘paradoxical interventions’ to ‘Increase the Therapeutic Alliance No Matter What You Do’ Therapy. I think you should gauge where J is at and decide if the following ‘straight talk’ would be appropriate at this point.

You might want to remind J of 37 days of success, and also acknowledge that he has had a number of incidents in the last few weeks. You can let him know that you understand that it is ‘easy’ for him to act out - and that’s what he may decide to do. But also, that you know (and he knows) that during the 37 days that it is sometimes ‘hard work’ not to act out when he felt like it.  

…Maybe he needs ‘time off’ right now to do what is ‘easy’.  (And here comes a key point) But he has to ‘make the decision’ (take responsibility) to do what is ‘easy or hard’ right now. Just as he was making a decision everyday for 37 days, to do what was ‘easy or hard’, so too will he make a decision for tomorrow and the day after to do what is ‘easy or hard’.

It is empowering for him to know that his response to ‘act out’ is as much of a decision as ‘not to act out’.

You may want to warn him as to what stressors he may likely confront in the next few days (staff, residents, events, etc.). You might want to go through different scenarios with him, and ask him if he has ‘exit strategies’.  Let him know that an answer of ‘I don’t know’ = acting out.

As you may gain a sense, this approach reasserts and acknowledges his ability to make decisions, and simultaneously works to reestablish you as offering ‘unconditional positive regard’ along with the hope that you can hook your ‘shadow’ to accompany him during the following days.

5) The board game and games in general is a key marker to gauge J’s overall treatment progress. The better he can handle frustration regarding games and the interpersonal contact it includes, the better he will handle frustrations in class and the residence. I suggest to play games that will stretch his ‘frustration tolerance’. During board games (Checkers, backgammon, chess, etc.) you may want to forecast what moves, or rolls of the dice will likely result in him having a COW. Given his low frustration tolerance with games now, I would suggest calling for ‘do overs’ whenever the dice do not fall in his favor. J will soon realize that with so many ‘do overs’ the game no longer has validity. He will let you know when he is more able to take the consequences of rolls of the dice that are not in his favor.

Remember the key factor is always the therapeutic alliance.

Let me know how your session goes tomorrow.

EPK

                                                                                                                                               

5-26 and 6-2-09 Case notes Email #9

Topic: J makes ‘yellow level’ for his first successful promotion!

Adam’s Case notes 5-26-09

Client report of progress and/or new issues: Client was restraint free this week and plans on re-applying for yellow-level in his home in order to earn more privileges.

TX objectives and therapist interventions (must relate to TX plan): Accepted everything the Client said with unconditional positive regard.
Encouraged the Client to change the rules of backgammon in order to assure a win for himself

Clinician assessment of progress: In session this week, the Client identified therapy as something that he “likes to come to.” This, in spite of his recent report to staff that he doesn’t want to go to therapy because he “gets teased about the bet.” At the start of sessions, the Client typically dismantles the unsolved Rubik’s Cube on the table, puts it back together, and returns it to the table exclaiming, “I’m so smart; I did it!.” Prior to playing backgammon this week, the Client was offered an opportunity to re-roll until he liked his roll, or even play both sides in order to ensure the win for himself. He rejected this offer, stating, “that’s not really winning; I’d rather just beat you for real.” Later, while playing, when the Client was asked to decide this writer’s move, the Client eagerly did so, always choosing a move to give the Client an advantage. When the Client found himself losing despite this, the Client accepted offers to re-roll until he liked his roll. When the Client eventually won, he seemed pleased with himself and sought congratulations from this writer, though he neglected to carry-on.


The Client was calmer today that he has been in many weeks. He seemed assured of himself when asked whether or not he would act-out this week before applying to yellow-level: “No.” His proclamation that he wouldn’t be acting out was devoid of his typical urgency to convince this writer that he was sure of himself and that he wanted this writer to be sure too. Perhaps we are seeing less game and more confidence. Or, perhaps we are seeing defeat. It is unclear.

Follow up TX planning and/or homework: Client will apply for yellow level once again this week in his residential home. He will return for therapy next week.

Case Notes: 6-2-09

Client report of progress and/or new issues: Client had zero restraints this week and is applying for yellow-level tomorrow.

TX objectives and therapist interventions (must relate to TX plan): Provided unconditional positive regard for Client’s choices.
Played backgammon to assess tolerance level. (Client was offered opportunities to re-roll the dice when he didn’t like the outcome. He did so on two occasions, then changed it back and stated, “I want to win fair and square.” (Which he did.)
Offered cookies to assess impulse control. (After a two cookie sampling, Client was offered one more cookie immediately, or two cookies to take at the end of the session. He chose the immediate cookie without hesitation and later asked to have more cookies. When denied, he did not argue.)

Clinician assessment of progress: Client is presenting with a quiet confidence not previously observed. When asked to talk about the application to yellow level, the Client stated, “If I talk about it, it won’t happen. So I’m not going to talk about it.” He was, however, willing to discuss hypothetical situations regarding choices he has made and the positive or negative consequences resulting.

Follow up TX planning and/or homework: Client applied for and achieved yellow-level on the evening after the session. This represents his first successful promotion of privileges in the home. He will return in one week for therapy. Attempts will be made to explore Client’s achievement.

 

6-4-09 EPK Responds: 9

The following is a response to Adam’s notes of 5-26 and 6-2-09:

What I find notable about Adam’s 2 weekly notes is the overall change in J’s presenting behavior these past 2 weeks. In the initial sessions (early in April) there was a high sense of ‘drama’ as to ‘if, when, and where’ J would act out. Both of these notes not only indicate the lack of recent restraints, but more importantly an overall change in J’s attitude, behavior, and emotional volatility. From the tone of the notes, it sounds like J has ‘turned a corner’.

Victor Frankl and other ‘paradoxical’ therapists described this attitude shift as an ‘existential reorientation’. This change represents an encompassing shift that is inclusive of behavioral, cognitive, and emotional factors. Again, it is important to note that these changes did not occur due to Adam’s specific ‘targeting’ of behavior, thoughts, or emotions, but rather as a result of J feeling more ‘connected’ and ‘seen’ through Adam’s interventions and extending those interventions to J’s immediate social circle.

I thought it was interesting that even in making his new level, J’s shift in attitude resulted in a quiet ‘confidence’ in which the event seemed ‘matter of fact’ even though in actuality this was his ‘first successful promotion’. 

I liked how Adam turned the backgammon game around from a source of tension that played up J’s ‘fear of losing’, to (in just 2 weeks!) an environment that J could feel the confidence of knowing that he could ‘win whenever he wanted to’. Interestingly, J’s frustration tolerance in the game seems to be progressing toward becoming less dependent on ‘re-rolling the dice’ and seems to be moving toward acceptance of the actual ‘roll of the dice’. I’d be interested if J is more willing to talk about this in future sessions, and whether he can apply this ‘lesson’ to other events in his life.

It was interesting to note that at the end of the session on June 2, that when Adam denied his request for more cookies, J ‘did not argue’. 2 months ago, that denial for cookies would have been a perfect provocation for J to make a total scene!

Now that J is on ‘yellow level’, I am curious as to how he handles this ‘new pressure’. Obviously, it is important for Adam to acknowledge J’s progress and further encourage him. As I mentioned at the MASOC conference, I am often leery of directly saying to a client, “Hey great going on making yellow level ((and doing what we – the staff- want!))”. My concern is that such direct praise may still be unfamiliar for J, and it may confuse him as to whether he changed his behavior to please other people or whether this is what he wants for himself.

As mentioned in previous notes the key factor in treatment is boosting the therapeutic alliance and joining. Therefore you may want to gauge (with any client), whether ‘praise’ at a given point in treatment will serve to draw a client closer or cause the client to withdraw from the alliance.

Instead of ‘praising’ J (at least for now), I would suggest that you boost the alliance by acknowledging the ‘fact’ of his present accomplishment of making ‘yellow level’, but also ‘reminisce’ about the good ole days, when he would get restrained for losing it over ‘not getting a cookie’. “I miss those days! And if you decide to go back, and have a tantrum or 2 – just for ole time sake – I’m not going to stop you!”  The intent here is to remind him a) of your ongoing connection over a spectrum of time; b) that your ‘unconditional positive regard’ is not based on his maintaining a certain type of ‘good behavior’, and c) to subtly remind him that it is and continues to be his responsibility to make choices about his behavior.  

EPK

 

6-11-09   Adam’s Email  #10     J in dialogue with Adam; looking toward ‘green level’ 

Hi Eliot,

I decided to put in a bit of the session dialogue this week.  I can’t tell you how much I appreciate the feedback I’m getting from you- just extraordinary stuff.  It seems as if “J” appreciates it too.

Adam’s Case Notes of 6-9-09

Client report of progress and/or new issues: Client reported to have attained “yellow level” and that he will soon be applying for “green.”  Client stated that staying up later (the biggest privilege associated with yellow level) is “cool.”

TX objectives and therapist interventions (must relate to TX plan): Assessed Client’s ability to delay gratification with cookies. (After eating one cookie, he was asked if he wanted an additional cookie immediately, or two cookies at the end of session. He immediately chose to take the immediate cookie, but changed his mind before it was handed to him and requested to wait.)

Clinician assessment of progress: Using paradoxical M.I.:  
Processed Client’s assessment of his progress to “yellow.”  
Explored Client’s goal to attain “green” level.

Although the Client is met in the lobby and escorted to the therapy office, he chose to wait until he was settled in his chair and setting up backgammon before he casually stated:
“I made yellow.”  
This comment was met with a subtle confusion by this writer, “Is that what you want? Yellow?”  
“Yep.”  
“Are you sure that’s what you want?”  
“Uh huh. It’s cool. I get to watch more TV.”  
“Okay then, I guess. Good for you; you seem to feel good about it.”  
“Yep.”  
“You must miss the good ‘ole days of getting all crazy and breaking everything in the house though, don’t you?”  
“No.”  
“Why not? I kinda’ do. That was fun.”  
“I don’t think so.”  
“No? O.K., if you say so.”  
(Client seemed uninterested in this line of questioning and set-up the board without making much eye contact.)  
“You know, if you ever decide that you want to get a little crazy and get yourself into a hold again, just for fun, you know that I’ll still like you and want to hang out with you and play backgammon and stuff.”  
“I know.”  
“Cool.”  
Client was waiting for this writer to make an opening roll. He was clearly done talking about this.  
“So, maybe this week then?”  
“What?”  
“You’ll do it? Get into a hold, or throw a trophy at a staff member, or bite someone? Just for fun?”  
“No. Roll.”  
“Hang on. I need to get this straight before I beat you in backgammon today. Why not?”  
“You’re not going to win. Roll.”  
“I’m definitely going to win. But before I do, tell me why you’re holding out on me? I’m starting to wonder if I even know you anymore.”  
“I told you, because I want to get green. Will you roll already?”  
(Gestured like a roll was coming, then stopped suddenly)  
“Don’t you think green is a bit lofty of a goal? You just made yellow, which must be totally weird for you- like you’re trying on clothes that don’t fit right. Now you’re already talking green? Are you kidding me?”  
“What’s lofty mean?”  
“Big. Trying for green, for you, is kind of a crazy goal, don’t you think? Next week you’re going to come in here and tell me you’re applying to be the director of the house.”  
“Maybe” (laughed) “Will you roll?”  
(Not rolling.)  
(Client continues): “Look, can we just play backgammon? If I talk about getting green, it might not happen. Plus, I really want to beat you twice today and we’re running out of time.”  
 
Throughout the games that followed the conversation, the Client was offered multiple opportunities to re-roll or have this writer re-roll. He accepted one offer in the first game, when he was behind, but denied more opportunities. He won this game by a landslide. In the second game, he denied all offers, despite losing the game. Throughout this all, he remained composed and became playful and silly at times. He seemed disappointed when the time was up and let me know that he’ll be back next week to beat me. (And he forgot his cookies!)

Follow up TX planning and/or homework: Client will return in one week for therapy.

 

6-11-09 EPK Responds: 10

Hey Adam,

I have to say, that I enjoyed ‘listening’ to the above ‘paradoxical’ dialogue. You seem to be getting the hang of this!

The 2 things that I appreciated about the dialogue was 1) that it sounded like you were having ‘fun’, and 2) I didn’t get a sense that you were ‘working hard’ during the therapy session to ‘make something happen’.  –These are both aspects of a good paradoxical intervention.

There is a general assumption in therapy, that it is the clinician’s ‘job’ to get the client to ‘move in treatment’. So the therapist is expected to ‘work hard’ to try to convince the client to ‘think different’, ‘act different’, or ‘feel different’. The problem, of course, is that when the therapist is ‘working hard’ that usually means that the client is ‘taking it easy’.  The therapist ends up ‘running the laps’ but the client is not doing the necessary underlying self-work to shift his habitual behaviors and develop impulse control. 

Having stated that, it should also be noted that sometimes if the therapist ‘works hard enough’, the client may actually feel ‘obligated’ to change. Well, you might think, if the client changes this way, this is also progress! The problem here is that the client often knows ‘what the therapist is looking for’ – and the client makes a ‘non-verbal deal’ in his mind: “I’ll do what you want – but now you owe me! As you long as you give me what I want in other areas, and you, Mr. Therapist, don’t leave me, I’ll play your ‘game’.” As you can imagine, in this scenario things go well until the therapist starts using the ‘nasty D-word’ … You’re doing so well, it’s time for DISCHARGE! And all of a sudden the client that had been ‘doing so well’ suddenly relapses into behaviors that he had not done for months! 

Often the therapist at this point is wondering, ‘Things were going so well,  - What just happened?!” Well what happened is that the therapist ‘broke the contract’, and from the client’s perspective “if the deal is off, then I’ll just go back doing what I did before”. The real issue in this situation is that the client didn’t change for himself, but rather changed for the therapist!  

… And of course, on a certain level, it is the clinician’s ‘job’ to get the client to ‘move in treatment’. However, as discussed, PdxI is counter-intuitive on many levels. The function of the clinician employing PdxI is that he / she is a ‘catalyst’ for change, rather than a force that directs specific change. The paradox of PdxI is that the more the client feels accepted and connected to you and other staff, and less pressured to move in a certain pre-planned direction, - the more he will be able to spontaneously shift to new attitudes and behavior that is more relaxed and open.

[In orbits-gravity terminology: The stronger the client’s experience of ‘attachment-gravity’ (a therapeutic alliance that is safe and trustworthy), the greater the entire ‘client system’ (action, emotions, thoughts) will spontaneously let go / release from constricted / rigid orbits to patterns (orbits) of behavior that are more open and relaxed.]

Again, it should be emphasized that PdxI interventions are geared more toward the resistant / dysfunctional client who doesn’t have a frame of reference of what constitutes ‘normal’ behavior. For clients who are more functional and socialized, PdxI is not recommended nor is it necessary.

For clients who are more functional, motivated, and have an ability to form trusting relationships, the standard approaches of behavioral, cognitive, and psychodynamic treatment are  more highly recommended. With these types of clients PdxI would be counter productive since these clients are more accepting and available to strengthen the therapeutic alliance. We should keep in mind that as J hopefully continues his positive direction, it will become less necessary to employ PdxI, as these methods would better support and maintain the continued development of the therapeutic alliance. 

PdxI are effective with clients who are in denial regarding the habitual patterns of dysfunctional behavior. From these clients’ perspective, their anger, constant sense of isolation and self involved destructiveness are ‘normal’ to their world. The ‘mistake in perception’ that this client makes, is that he believes he is making a free-will choice when he gets angry for the 100th time that month. He doesn’t recognize the depth and degree of the rigidity of his habitual behavior.

And this is were PdxI comes in. In a non-confrontational manner, the clinician simply (and matter-of-factly) identifies in various ways (forecasting, prescribing, scheduling, etc.) that behavior the client thinks is free-will generated is ‘ho-hum’ habitual. Sharon and Jack Brehm wrote about reactance theory. Reactance theory states that people of all cultures are prideful about their free-will expression. They report that when people feel their free-will is threatened, they will go to great lengths to prove to themselves and others that their free-will remains intact. PdxI questions the client’s free-will status by identifying client behaviors as habitual. This in turn motivates the treatment resistant client to take the necessary steps (usually involving an increase in impulse control) to prove that their free-will remains intact.  

Adam your intervention with J captured the counter-intuitive nature of PdxI. The overall tone of the conversation was a relaxed banter, where J obviously feels very comfortable with you. At no point did you ‘tell him to change’. You accepted (the true reality) that he has the option to go back and ‘loss it’ resulting in a restraint. It is clear from the interaction that J is able to accept full responsibility for his new behavior and the choices he is making. Of his own ‘free will’ he has chosen to work on his impulse control, The fact that he no longer is behaving like a ‘wild animal’ and is exhibiting more self control attests to an increase in his self esteem.

And what about one of the main issues at the start of treatment, regarding (PSB) problem sexual behavior? Puff, Up in smoke!  Given your information, J’s internal attitude and focus has gone through an existential shift, where sexual ideation is not even on the radar. With J’s new sense of self control, moving up to ‘yellow’, and setting his sights on ‘green’, the time and effort needed to focus on ‘sexual ideation’ just isn’t there. As discussed in the orbits-gravity model, by working on secondary overt behavioral issues, you have simultaneously had an impact on the outer PSB orbit.

What’s next?

1) My recommendation is to reinforce and stabilize his comfort zone on ‘yellow’. Predict what other kids might say or do to set him off. Maybe do some role plays to get him more in touch problem kids or trigger issues.

2) Using role plays, you can focus him on the ‘here and now’ aspect of his breathing. He will need to learn to ‘breath through’ attempts by others to set him off. Also predict which kids he may need to look out for.

3) Monitor his attitude toward ‘green level’. If he’s pressuring himself (like last time) too hard and too fast, that could mean trouble for ‘yellow’ as well. You may have to take an active role in protecting him from himself and setting some guidelines and limits. I think a positive indication toward ‘green’ would be an ability ‘to talk about’ what he sees as positive and potential pitfalls. In prepping him for ‘green’ level, you may want to let him know about the ‘downside’ of the new responsibilities, chores, etc. 

4) Also, I’d be interested in a growing ability to ‘get out of himself’; meaning a healthy ability to start relating to others and making friends at the residence. 

Keep up the good work!

EPK

                                                                           

6-17-09 Adam writes: Email #11

Hi Eliot,

I felt a bit stuck this week with J.  After the interesting progression in the last few weeks, maybe I was looking for too much.  He seems more stable than he has been, certainly, which is a good thing.  However, now there seems to be an opening to get to some of the morbid obsessions I’ve read about in his chart, though I’m not quite sure how to tackle them.  With many kids, I might indulge the fantasies and go along with them, maybe even upping the ante.  However, my fear of indulging the fantasies too much with him is that his history indicates the possibility he is a budding sadist.  This is why I chose to comment on prison in the progress notes: reminding him that it is in his best interest to not hurt others, just as I would with an adult psychopath, for instance.

I’m curious what your thoughts are.

-Adam

 

EPK Responds: 11 A

Using Adam’s notes, I have added my comments as to potential interventions for J in the future:  

6-17-09 Adam’s Case Notes:

Client report of progress and/or new issues: Client stated that he became agitated with a staff member and “punched [his] door as hard as he could,” hurting his hand.  
Client stated to have maintained yellow level, despite this.  
Client stated that he is able to control his behavior because “[He’s] different now.”  

[EPK’s comments: Remind J that a couple of punches on the door is not going to be good enough to get him demoted from yellow. If he wants to get demoted he is going to have to make a ‘real effort’, and that you know he is capable if he puts his mind to it.]

TX objectives and therapist interventions (must relate to TX plan): Played backgammon while reviewing Client’s week on yellow-level. Explored what Client would do if there were no consequences for his behavior.

[EPK: It appears that the backgammon game truly is a microcosm for J’s current functioning and offers many opportunities to address impulse control and frustration tolerance issues.]

Clinician assessment of progress: Client was playful in session, albeit a tad too aggressively at times. When he became frustrated with the slow pace of the backgammon game by this writer, he raised his voice and, at one point, waved his hands closely to this writer’s face aggressively. When this happened, the Client was asked enthusiastically, “Are you going to hit me now?” “Are you going to bite me?” Each time, he sank in his chair and said “No. Just go.” In his increasing impatience, the Client rolled himself three turns in a row. When this writer finally did roll, the Client returned his pieces to their original place, negating the extra turns he took.  

[EPK: I suggest that you ‘plan with J’ for his impatience as part of the game. Each time he gets impatient, he gets a check mark. 10 checks get him an extra snack! Discuss with him the details of what will count as ‘impatience’ during the game – comments like “Just go already!”, actions – hand waving in face, etc. (Adam reports on this suggestion in e-mail #12)]

When asked the top five things he’s like to do without consequence, the Client named five very violent things he would do to a classmate he dislikes, including “shoot him in the head in a dark alley.” When it was reflected back that he must “really dislike” someone if he would be willing to go to prison for the rest of his life, he described a plan reminiscent of a television drama in which he “wouldn’t get caught.” 

[EPK: If he brings up the topic, and states he ‘won’t get caught’ – agree with him. Agree that he might not get caught the first, second, or even the third time …but when he does get caught, you will be looking forward to visiting him in jail!]  

Despite the door-punching transgression, the Client is remaining stable. His preoccupation with violence and death (which permeates the historical psychiatric notes) is concerning, especially in light of his history of torturing animals and his stated desire to inflict pain on others.  

[EPK: I think the key is to continue to work on his anger, mistrust issues, social skills, encourage areas of talent, connection with foster mom, etc. As impulse control improves, so will his self esteem improve as well. At that time ‘morbid obsessions’ will naturally evaporate as they will not be relevant to his current life.] 

Follow up TX planning and/or homework: Client will return in one week.

Keep me informed.

EPK

 

6-20-09 EPK Responds: 11B

I’m glad to hear that J’s ‘fireworks behavior’ continues to move in a direction that is less volatile. As you recall his ‘normal’ state of equilibrium a couple of months ago was based on the constant need for attention with physical restraints. At that time he exhibited little control over his impulses and was basically responding like a ‘wild animal’.

It is interesting to note that if you were to ask J back at that time about his ‘wild’ behavior, he probably would have insisted that such behavior was an expression of his ‘free will’. One of the focuses of PdxI has been to help J shift this false perception. Through predicting and forecasting his acting out responses you created a double–bind that ultimately allowed him to take responsibility and reevaluate whether his ‘wild’ behavior was truly an act of free will.

Animals don’t have self-esteem or free-will as they are run by their instinctual impulses. For a human to live in society he must demonstrate self control over his impulses. Those people who do not demonstrate control over their impulses ultimately are taken out of society and put in (‘cages’) prison or ‘locked mental wards’. As J is gaining the ability to control his impulses it means that he is rising above his ‘animalistic’ urges. Although initially it takes focus and concentration to undo habitual impulsive responses, there is a sense of accomplishment and pride in being in control of ones actions.

A major part of PdxI treatment is to empower the client to take responsibility for himself by undoing impulsive and habitual behavior. It is the purpose of treatment to create opportunities for the client to struggle and overcome impulsive behavior ‘drop by drop’.  As the client overcomes these impulses, there is a simultaneous increase in self esteem. In behavioral terms, “self esteem is the reward of using one’s ‘free will potential’ to control one’s impulses”.

In regards to his ‘morbid obsessions’, torturing animals, and problem sexualized behavior (PSB) ideation as mentioned in the chart, these represent his state of mind in the heyday of his ‘wild animal’ days. Although in the session notes (below) he mentions a continued ideation toward violence, his recent actual day to day behavior represents an obvious reduction in impulsive and extended violent acts.

(In the notes, you mentioned that he ‘punched his door’, but the outburst didn’t get out of control to the point that he lost yellow level.)  Obviously there is still therapeutic work to done, but J’s impulse control is certainly improving in the right direction.

Having stated this, I also want to address your current concerns regarding his ‘morbid obsessions’ etc. and his potential for sadistic and psychopathic type behavior. The question is how we proceed in treatment to hopefully address these issues.  As stated in previous notes, one of the important factors working in J’s favor is his young age. By this I mean that any behavior patterns or ideations listed in the chart have not had time to become ‘ingrained’ in his personality. As such it is up to us, his treatment providers, to be a catalyst to guide him out of his trauma history.

One of the great advantages of PdxI is that it allows us to use a ‘strategic’ approach to address ‘hard to reach’ targeted issues; In J’s case this refers specifically to his potential to torture animals and PSB issues. The assumption of most treatment is that in order to change a targeted behavior, we have to address and work directly on that particular behavior. However, this can be difficult for behaviors that happen infrequently / irregularly or where there is no present opportunity to act out. Since J is under constant supervision, the opportunity to act out in both these issues is unlikely. The eventual question at his future discharge will be whether he has ‘recovered’ to the degree that he is no longer a threat to society. Can we as treatment providers have some degree of confidence that treatment has been successful?

As a ‘strategic’ approach PdxI allows us to work on secondary behaviors, but to simultaneously have impact on primary targeted behavior. The concept of ‘strategic’ can be understood by the strategy in a chess game: The object of the game is to capture the King. However a direct attack on the King is not always possible. Therefore chess games revolve around the strategy of ‘gaining position’ and capturing lesser pieces. By gaining ground in accomplishing these secondary goals, the chess player makes simultaneous progress toward achieving the primary goal of capturing the opponents King. 

The ‘orbits gravity’ model (below) gives us an objective theory to conceptualize how and why a strategic interventions work. The model gives us a theoretical perspective as to why working on secondary behaviors such as anger, social skills, and self esteem will ultimately influence change in J’s ‘morbid obsessions’.

In J’s traumatized personality system ‘gravity’ represents the state of early attachment experiences. Gravity is the central force that keeps the orbits intact. From the chart we know that J’s early attachment experience has a strong element of abuse and neglect. His orbits of behavior are consistent with some one who has experienced extreme abuse.  Although the orbits are illustrated as separate and distinct, in reality the entire orbits-gravity system functions as a single unified unit.  Orbit 1 (anger – mistrust) represents the innermost orbit, and as such this type of repetitive behavior occurs the most frequently; happening hourly and as a regular part of J’s interaction. The furthest Orbit 5 (hostile behaviors, animal torture, PSB) represents the behaviors of most concern, but at the same time are likely to occur the most infrequently if at all in the treatment settling. Orbits 2, 3, 4, also occur regularly, but not with the same frequency as Orbit 1. These orbits are generally frequent and predictable in a daily and weekly fashion as well.    

 

 

In a strategic fashion the model provides us with insight to work with J’s ‘morbid obsessions’. The model indicates that by shifting his experience of gravity-attachment in relation to any of the ‘secondary’ Orbits 1 through 4, we will have a simultaneous impact on influencing the ‘primary targeted behavior’ in Orbit 5.

 

Email #12   J continues to make progress. – Absurd intervention highlights ‘free-will potential’

7-7-09 Adam writes:

Here’s the latest, Eliot.  I can’t believe that the cookie-checkmark thing worked.  I thought it was a crazy idea, honestly, but he responded beautifully to it.  Enjoy the fruits of your labor!

-Adam

EPK responds: 12 A    Adam’s Case Notes 7-7-09 along with EPK’s comments:

Client report of progress and/or new issues: Client stated to have had a good two weeks. He visited with his foster care (f.c.) mother at her home on Sunday, as he has been doing for many weeks. He reported 0 holds and 1 timeout. He stated that there were multiple occasions in which he became angry, but that he went to his room to calm down. As a reward for his good behavior in the last few weeks, the Client was one of 3 youth in his house who has been chosen to go to Fenway Park tonight to sit in the Dunkin Donuts box for the Sox/A’s game (the return of Nomahh Series!).

[EPK suggestion: Tell J – I can’t believe you got to sit in the Dunkin Donuts Box at Fenway. I mean 2 months ago we were holding you down in the living room! Who would have thunk that you would have gone to the A’s game!]

TX objectives and therapist interventions (must relate to TX plan): Attempted to process the experience of being chosen as a standout among his peers who is going to Fenway tonight.
Explored the experience of seeing his f.c. mother weekly.
Assessed mastery of frustration tolerance with a new challenge in Backgammon.

Clinician assessment of progress: Client wasn’t interested in exploring his new position in the home as “one of the best behaved kids-” instead choosing to be matter-of-fact about the whole situation. (Although, he had trouble containing his excitement about seeing first game at Fenway.) In speaking about his f.c. mother, the Client stated that he would very much like reunification with her, but that his DCF worker told him that he “probably will never go back there.” When asked again why the Client was removed from the home, he stated “Because my brother and I fought too much.” This represents progress, as he has kept a hard line up to this point that they were removed due to a single incident which was a misunderstanding and entirely his brother’s fault, according to the Client. The weekly visits do not include the Client’s twin brother, but the Client states to not know why.

[EPK suggestion: Tell J – Even though you are a different kid than 2 months ago and have made changes in your life, adults sometimes have hard times that they struggle with also. Reinforce to him that if fc mom doesn’t take him back, this has more to do with her. Reinforce that you see the efforts he has made to be a different person, and fc mom may not realize these changes. Try to mitigate any tendency that J might have to blame himself.]

When the Client had too much chatting about his life, he reached for the Backgammon board and set it up, as usual. While he was doing so, this writer commented on how impatient the Client got during the last game and began to imitate the Client’s gestures and vocalized displeasure. The Client agreed to the impatience, but denied the gestures. Then, I numbered one side of a paper all the way down and told the Client that he would get a checkmark every time he did something to exhibit impatience by doing a gesture, swearing, re-rolling, or changing the roll to suit his needs. Unprompted, the Client said, “If I get five checks, no backgammon for three sessions. It has to be five checks in the same day though!”

I replied, “No way. TEN checks and YOU GET A COOKIE!”

This seemed to confuse him. “Okay, fine,” he stated, “let’s play.”

“You’re gonna be eating cookies within five minutes. Look at the clock- it’s five after three; you’re gonna be eating a cookie by ten past- I guarantee.”

“No I’m not.”

“Whatever, we’ll see. Good thing I have so many cookies in my drawer.”

Not only did the Client get creamed in the game, but he had a realistic chance of winning at a point when it easily could have gone either way until he made a fatal mistake. “Gotcha now, kid! You’re all done. Start whining and cheating!”

He continued to play and finished the entire game, never once complaining, re-rolling, or sighing- even after he was clearly losing.

When the game was over, he packed the game up, smiled, and put it away without a comment about the checkmarks or his behavior. Instead, he got up, looked at the clock, and said, “Time’s up.”

Then, as we headed down the hall to the lobby he looked up at me and said, “I’ll hold up a sign that says ‘Hello’ to you and my teacher. Look for me on tv tonight!”

[EPK suggestion: As an ‘inside joke’, you might want to tell J that you realized that last week he was trying to use ‘reverse psychology’ on you by not being his usual impatient self. But this week you’re ready for him to get ‘back to business’ and put on the kind of ‘show’ he is truly capable…  But remind him that he needs to put in some effort!]

Follow up TX planning and/or homework: Client will return in one week. This writer will look into the long-term plan with the Client’s f.c. mother, which is likely TBD due to her life circumstances at this time not accommodating the Client.

___________________________________________________________________

EPK Responds 12B  to Adam’s 7-7-09 comment:                                                                     

Hi Adam,  I’m glad to hear that J continues to respond to y(our) interventions. It’s been a while since he’s had a serious meltdown. Given his ongoing stability, and apparent increased ability to deal with daily frustrations, major meltdowns may be a relic of the past. From your notes, I don’t get a sense of concern or ‘walking on eggshells’ waiting for J’s next restraint.  I think the skills and self-esteem he is gaining through the ‘Backgammon Therapy’ are paying dividends in his life outside therapy. Would you ever have thought in April that the residence would now consider him “one of the best behaved kids”?! 

Absurd Intervention -  I’m glad you tried the suggestion of ‘making a chart’ and promising to ‘REWARD him with a cookie’ with every 10 impatient expressions. Personally, this is one of my favorite types of interventions because it is so absurd and ‘off the wall’. This is one of those paradoxical interventions that (seems to) defy any semblance of logic. I mean its one thing to ‘make a chart’, but it’s totally absurd to offer him a ‘reward’ (cookie) for impatient behavior that treatment seeks to extinguish!

Logically, we would expect him to be ‘over the top’ with his impatience in order to ‘get the maximum cookie rewards’. Instead the exact opposite happens, in which he demonstrates an ability to remain calm - for at least the hour he is with you. Now this doesn’t mean he will always be calm in the future, but it does represent ‘another step’ toward healthy impulse control that now seems solidly in place as treatment continues.

The ‘cringe’ factor - As you are well aware, his response of ‘controlling himself’ in your session would generally be expected to take months of ‘hard work’ using other ‘traditional’ methods. Also, as you can imagine, many seasoned therapists would cringe at the thought of offering a ‘reward’ for the client to continue his ‘impatient behavior’. Such an intervention certainly is in direct contrast to the basic ‘given assumptions’ of ‘cause and effect’ theories that are the foundation for both behavioral and cognitive treatment.

From a logical / linear perspective, -given J’s previous established ‘weakness’ for cookies- it would seem that this is a perfect opportunity for him to let his impulses run wild and get the ‘reward of a cookie’ to boot!  Cognitively, J understands that he has a chance to act out and get a ‘cookie’. From a classic behavioral perspective, we would think that such an intervention would ‘reinforce’ his impatient behavior … . And yet, the exact opposite happens – Not only does he not act out with his usual impatience, he remains calm (without being instructed to do so) and willingly foregoes the coveted ‘cookie prize’. What gives?!

Accessing ‘free-will’ -  To understand J’s behavior on a somewhat linear level, we need to explore the idea of paradoxical intervention in relation to ‘free will’ and how such interventions support the client’s ability to access his ‘free will potential’. In short, the intervention demonstrates that J values his ability to express ‘free will’ more than he values the ‘cookie’. Jack and Sharon Brehm who are noted for their work in Reactance Theory state that if people perceive that their ‘free will potential’ is threatened, they will go to extremes in order to prove to themselves and others that they still maintain their unique human ability to express ‘free will’. From a behavioral human perspective, we see that the ‘reward’ of expressing free will is ultimately valued more than gaining the ‘reward’ of an external object or trinket.

From here we see that ‘free will’ is an intrinsic to the human condition. It is literally the quality of ‘free will’ that separates man from animals – even more than man’s ability to reason.(ie: Even though a person may reason that smoking is unhealthy, he still may value his ‘choice to smoke’ more highly.) Animals do not have ‘choices’ as they are only able to respond to their instincts. Humans have the ability to transcend their (bodily) instinctual desires and thereby ‘raise themselves above their animal nature’. It is the process of rising above one’s animalistic self that a person thereby ‘raises his self-esteem’. In this way the reward of ‘free will’ is self esteem.

Redefining Adam’s intervention -  If we rephrase Adam’s intervention, he is basically advising J that he has no ‘free-will’. Adam is stating that he is expecting J to react in his usual impulsive animalistic manner, and is even willing to give him a ‘cookie’ (animalistic reward) to confirm J’s animal nature. J immediately recognizes that his humanness is being challenged.

Without a second thought, the ‘cookie reward’ becomes irrelevant, and he garners the internal fortitude to prove to himself and Adam the superiority of his inner spirit over his animal body. In terms of treatment, Adam did not “tell or convince” J to control himself. J made the free-will choice to take responsibility for his underlying impulses, and therefore gets the full credit for the change in his behavior.

While some dismiss paradoxical interventions simply as ‘reverse psychology’, by viewing the intervention within the context of ‘free will’, we gain a sense of the potential and depth that such an intervention offers. One can recognize that a shift in behavior that occurs through a person’s ‘free-will choice’ will have a greater likelihood to continue into the future, rather than a behavior that is externally imposed (ie; ‘cookie’ reward, convincing, etc.) By the end of the session, you can imagine the boost J felt in his self esteem as he informed Adam – “Times up!” 

What if intervention ‘backfires?! -  Now the cynical clinician may say, “All well and good, but what if the intervention ‘backfired’ – that J followed the clinician’s ‘permission’ to be impulsive to get a bunch of the coveted cookies?! In this case, if such an event were to happen, it would serve as a diagnostic gauge to recognize the degree J is cut off from his ‘human self’ and his investment in his animalistic impulses. When clients remain invested in their animalistic impulses it is indicative of the underlying depth of the client’s trauma that has not yet been addressed.

With this understanding, the intervention will not be seen as ‘backfiring’, but rather providing a snapshot that this client has not yet fully identified with the potential of his ‘free will’. It should be noted that had this same intervention been (mistakenly) employed earlier in treatment, we may have seen a very different reaction from J. The very fact that in recent weeks J had been making steady progress, allowed for the relatively confident expectation that this intervention would result in a positive outcome.

Using strategy to impact PSB issues -  Also, it is important to note, the intervention is designed to have a ‘strategic’ impact on previous identified concerns about problem sexual behavior (PSB) and ideation. By strengthening impulse control in more repetitive and overt areas of impatience / poor frustration tolerance, we allow the client to gain an appreciation for his new found ability to be in control of his impulses. This leads to a greater sense of ‘self responsibility’, ‘self esteem’, and an improved awareness of his ‘connection to his social community’. The strengthening of these areas has a simultaneous impact on the reduction for the likelihood of PSB and other volatile type behaviors.

It is the intent of PdxI interventions is to strategically impact PSB and other volatile behaviors. The use of PdxI on primary targeted PSB behaviors (ie; ‘OK, I know you have sexual ideation… I predict you will groom little Mary who lives in your neighborhood 4 times next week …) indicates a poor understanding and dangerous misuse of the paradoxical process.

Non-linear theory –   The above represents a more linear / logical approach to PdxI. Simultaneously, we can view Adam’s intervention within a non-linear orbits-gravity model. By Adam strongly attaching to J by including his ‘impatient behavior’ as an expected part of the therapeutic session, Adam further emphasized (without a verbal statement) that he is ever present, connected, an offers unconditional positive regard for the (seeming) subtleties of J’s predictable behavior – even to the point of offering a ‘cookie’ reward for J to maintain his ‘usual expected behavior’.

By Adam provoking this strong shift in attachment-gravity, he acted as a catalyst in J’s ‘free will’ choice to undo the repetitive frequency and expression of his ‘impatience’ orbit. While the ‘cookie’ reward is absurd at face value, the underlying message to J represents a willingness by Adam to further and strengthen the therapeutic alliance. By offering the cookie for the continuance of J’s ‘usual behavior’, Adam dispels any power struggle with J over whose idea it is to undo the ‘impatient behavior’. Ultimately, J made a free-will choice to undo his habitual behavior, for which he can take full credit.

_____________________________________________________________________

EPK comment: After this last intervention, Adam and I did not have e-mail contact for over a month. Partially I think this was related to the fact that it was summertime, and partially due to the fact there was less concern over J’s behavior. The ongoing worry regarding when J will ‘erupt again’ is no longer a primary concern, so there was really no urgency to keeping e-mail contact. As you will see in the following e-mails, we only contacted each other once in August, September, and November.

From my perspective, the paradoxical interventions have accomplished the main behavioral goals we had at the outset of treatment 3 months ago: better impulse control, reduced volatility, increased sense of responsibility, increased self-esteem.

As mentioned earlier, PdxI is recommended for the ‘treatment resistant client’. Since J really doesn’t fit this category anymore, we can now back off of a ‘strong paradox focus’ and bring in more ‘traditional’ methods  – behavioral, cognitive, and psychodynamic approaches - to further address J’s issues.

 

8-19-09 Adam sends Case Notes:Email #13

Client report of progress and/or new issues: Client has received multiple timeouts in the past two weeks and is being officially demoted to “Yellow” level this afternoon.

TX objectives and therapist interventions (must relate to TX plan): Explored Client’s behavior and offered interpretations.

Clinician assessment of progress: Client is beginning to honestly explore and interact with his feelings regarding the transition from residential to foster care. He is frightened and unable to admit this, but his testing of the therapeutic alliance suggests that he is moving toward more process.

Follow up TX planning: Client will have a closely monitored and highly structured family visit with his twin brother tomorrow, to be monitored by this writer and the Client’s twin’s clinician.

8-25-09 EPK Responds: 13

Good progress note. It looks like J is starting to open up.

Some comments and suggestions about the interaction:

The overall objective is to increase the ‘therapeutic alliance’. A good PdxI is both challenging and supportive at the same time – the client feels ‘seen’ and understood usually in a way that he would not

have expected. When the client feels ‘challenged but not supported’ he may interpret your comments as ‘sarcastic’. Regarding J’s demotion back to yellow, I would suggest a more ‘straight empathic approach’ - and not necessarily PdxI on his relapse. You don’t want the client to feel like you are ‘putting salt in the wound’.

Let him know your totally behind him, and it must suck going back to yellow. You might let him know you are ‘surprised’ that he was on green for so long, but he certainly proved to you that he could hold green. Ask him if he wants to get back to green, and if so, how can you help.

J has really come a long way. You’ve done excellent work with him, Adam.

EPK

9-22-10 EPK Hey Adam, How is my friend doing? Eliot 

9-23-09 Adam writes Email #14:

Quite remarkably.  In session today, he was engaged and focused while inquiring about brass knuckles and other weapons.  After it was pointed out to him that he casually used the word “rape” three times and “abuse” twice inside of 30 minutes during which he was making many inquiries regarding weapons or talking about ‘protecting himself,’ he became fidgety and stated “what we say in here is between you and me!”  As I continued to ask questions about what he was saying, he interrupted me with fart noises anytime I spoke, replied to questions with statements that had nothing to do with the question asked, and laughed excessively and at inappropriate times.  When I stopped forcing the issue, he engaged again and was cooperative.

At the conclusion of the session, I asked him to sit and listen, which he did.  When I reflected what happened when I starting pointing out to him the themes he was bringing up, he admitted to have been aware of his behavior and stated that he doesn’t like talking about “certain things.”  He agreed to make an attempt in future sessions to catch himself behaving this way and instead to state, “I am not comfortable talking about that.” 

I also reflected the growth and maturity I have seen in him.  “Now that you feel yourself growing up and see yourself as a guy who can control himself- control his anger, it makes sense that you’re looking around and asking yourself some really hard questions about what the hell happened to you to make you that way in the first place.  Because you know it’s not like most other kids!  And it’s really cool that you’re asking these questions in here!  You don’t realize it maybe, but that’s what you’re doing.  And it’s really hard to do, so of course you’re backing away.  No problem- you back away whenever you need to.  But I hope that you’re proud of how much you’ve matured and how much more you can take a look at.  I could have never asked you about rape and how abusive your parents were back when I met you and you were coming in here with a different staff member’s blood type stained on your teeth every week!  You were a crazy man back then!  Remember?  But not anymore.  Now, you’re starting to put it together- and that’s scary as hell.  So, let’s take our time.”

And so we will…  He’s reapplying for Green level on Tuesday.  I’m out next week for ATSA, so I’ll see him on the 7th.

- Adam

 

11-17-09 Adam writes: E-mail #15

J has reached a plateau in TX that has us both frustrated.  He is not having any significant BX issues and continues to enjoy the privileges associated with this.  However, now he finds therapy “boring” and “annoying,” since my attempts to process trauma I’ve read about in his chart just shut him down.  So, I’ve laid off and mixed things up a bit with him to try and hook him back into enjoying coming to see me.  We’ve played basketball and played Q&A games, for example.  Last session, when I asked why he used to like therapy and now he doesn’t, he said “You never used to ask me tough questions like you do now.”

“You mean about why you bring up the word rape and laugh at the end of sessions, and stuff like that?”

“Yeah.”

“Well, that’s because you were so busy banging your head against the walls and biting staff members, that I was afraid if I asked you hard questions, you’d be trying to figure out my blood type with your teeth!”

(He just nodded his head a bit w/o smiling.)

“But you’re different now.  You don’t bite people or bang your head.  You talk when you’re upset and even empathize with guys who push you!”  (This was in reference to an incident at school a few weeks ago in which he and a kid were joking a bit, but the other guy suddenly got serious and pushed J to the ground in front of other kids.  Staff intervened immediately, but later, J said that he talked to the kid and that the kid explained that he’d had a fight with his dad that morning and was probably still angry about that.  I had said to him, “Yeah, but you must of been really pissed off that he pushed you!  You’re not his dad!”  He replied, “Yeah, a little at first, but I was more confused.  Then, when I found out about his dad, I understood; I know what it’s like to be angry at someone and take it out on someone else.”)

(Back to current conversation) “Yeah,” said J, “but that stuff still makes me uncomfortable to talk about and I don’t want to talk about it.”

“You mean like being raped and the other sexual stuff in your life?”

“Yeah.”  (This was an important confirmation!  Usually he denies this.)

“Okay, but I want you to know that there’s probably a good reason for you to keep bringing it up in here.  I think you might even be testing me to see if I can handle it.  So, I just want you to know that I can handle whatever you have to say, when you’re ready.”

and on it went…

We’ll probably get back to backgammon soon.  We’ve been on hiatus for months and we seemed to do our best work back when we were playing.

-Adam

11-17-09  EPK Responds: 15

As a suggestion with J:  I think talking directly about the trauma may be embarrassing as it reminds him of his powerlessness during that time.

I would suggest doing an ‘end run’. Ask him what he imagines it would have been like growing up in a ‘normal/supportive’ home. What’s his definition of ‘normal’? Are there any TV show characters that he thinks would have made a ‘good parent’ for him? Who’s a ‘good parent’ on staff? How would a ‘good parent’ wake him up in the morning and put him to bed at night. Etc.etc. You get the idea.

This would allow him to feel empowered as he can imagine/create positive family images. You can then contrast his understanding of a ‘normal’ life with the craziness he’s been through.

And that kid that threw him down - Does J think that kid came from a ‘normal’ or crazy home?

Something to consider- you may want to start a ‘Get your Act Together’ group. It might be easier for J to talk and share about his past in a supportive group atmosphere with others who have been thru similar trauma.  If possible, maybe even start it off with just J and this other kid, as they seem to have been able to address the incident between them.

EPK

So there you have it.

As of the MASOC 2010 Conference (April 8), J had been adjusting to a new foster home for a couple of months. Adam has continued to see him for individual sessions and has helped J address his concerns about leaving the ‘security’ of a residential setting.