Manual of Regulation-Focused Psychotherapy for Children (RFP-C) with Externalizing Behaviors

A Psychodynamic Approach

Leon Hoffman, Timothy Rice, Tracy Prout

• Publisher: Routledge
• Year: 2015
• ISBN:
  9781317567615
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

Manual of Regulation-Focused Psychotherapy for Children (RFP-C) with Externalizing Behaviors: A Psychodynamic Approach offers a new, short term psychotherapeutic approach to working dynamically with children who suffer from irritability, oppositional defiance and disruptiveness. RFP-C enables clinicians to help by addressing and detailing how the child's externalizing behaviors have meaning which they can convey to the child. Using clinical examples throughout, Hoffman, Rice and Prout demonstrate that in many dysregulated children, RFP-C can:

• Achieve symptomatic improvement and developmental maturation as a result of gains in the ability to tolerate and metabolize painful emotions, by addressing the crucial underlying emotional component.

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• Diminish the child's use of aggression as the main coping device by allowing painful emotions to be mastered more effectively.

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• Help to systematically address avoidance mechanisms, talking to the child about how their disruptive behavior helps them avoid painful emotions.

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• Facilitate development of an awareness that painful emotions do not have to be so vigorously warded off, allowing the child to reach this implicit awareness within the relationship with the clinician, which can then be expanded to life situations at home and at school.

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This handbook is the first to provide a manualized, short-term dynamic approach to the externalizing behaviors of childhood, offering organizing framework and detailed descriptions of the processes involved in RFP-C. Supplying clinicians with a systematic individual psychotherapy as an alternative or complement to PMT, CBT and psychotropic medication, it also shifts focus away from simply helping parents manage their children's misbehaviors. Significantly, the approach shows that clinical work with these children is compatible with understanding the children's brain functioning, and posits that contemporary affect-oriented conceptualizations of defense mechanisms are theoretically similar to the neuroscience construct of implicit emotion regulation, promoting an interface between psychodynamics and contemporary academic psychiatry and psychology.

Manual of Regulation-Focused Psychotherapy for Children (RFP-C) with Externalizing Behaviors: A Psychodynamic Approach is a comprehensive tool capable of application at all levels of professional training, offering a new approach for psychoanalysts, child and adolescent counselors, psychotherapists and mental health clinicians in fields including social work, psychology and psychiatry.

Section 1 Introduction and theoretical background

1 Introduction Rationale for regulation-focused psychotherapy for children with externalizing behaviors (RFP-C)

DOI: 10.4324/9781315736648-1

The man who first flung a word of abuse at his enemy instead of a spear was the founder of civilization. Thus words are substitutes for deeds.

Sigmund Freud, 1893

This manual is the first attempt to systematize how clinicians can address a child’s defenses (implicit affect regulation mechanisms) when addressing a child’s disruptive behavior.

The nature of externalizing behaviors

Clinical vignette

One session with Stephanie, a seven-year-old girl who was a tomboy, demonstrates the problem we have to address when we consider children with externalizing behaviors. This active, athletic little girl was disruptive in school and needing disciplinary actions; she had one parent who was anxious, overindulgent, and inconsistent and another who was rigid, punitive, and emotionally unavailable. Her play in psychotherapy sessions consisted of a variety of ball games, often kickball. As is typical with young children, winning was of central importance for her. However, unlike with most children, the clinician’s occasional point or win led to dramatic hysterics and accusations that the clinician was cheating (in other words, she utilized the defense mechanism of projection of her own wishes and actions onto the other person). “I am not cheating, you are cheating,” was the implicit message to the clinician playing with her. This defense mechanism of projection was also utilized by the parents.

Stephanie is a typical example of children with externalizing behaviors, and in particular those who can be categorized as oppositional defiant disorder (ODD). These children demonstrate the defense mechanisms (DM) of denial and projection. It is the premise of RFP-C that the construct of unconscious DM (developed within the psychodynamic tradition) is similar to the construct of implicit emotion regulation (ER) (developed within the empirical findings of contemporary affective neuroscience) (Rice & Hoffman 2014). We discuss in more detail the similarity between DM and implicit ER in Chapter 4.

Therefore, we have chosen the term “Regulation-Focused Psychotherapy” instead of “defense-focused” for our therapeutic intervention because the term “regulation” is more descriptive and theory neutral than the term “defense.” And, in fact, in the Research Domain Criteria (RDoC) of the NIMH (Insel 2014), a key feature in children with externalizing behaviors is an inability to regulate their affective responses to negative stimuli. It is important to note that the RDoC project of the NIMH is “intended to serve as a framework for neuroscience research.” RDoC takes an approach different from that of DSM. It assumes (1) that mental disorders can be explained in terms of brain circuits and (2) that abnormalities of these circuits are identifiable and will lead to the discovery of “biosignatures,” ultimately to be integrated with clinical data” (Colibazzi 2014, page 709).

Definition of emotion regulation

“Implicit emotion regulation may be defined as any process that operates without the need for conscious supervision or explicit intentions, and which is aimed at modifying the quality, intensity, or duration of an emotional response. Implicit emotion regulation can thus be instigated even when people do not realize that they are engaging in any form of emotion regulation and when people have no conscious intention of regulating their emotions” (Koole & Rothermund 2011, page 390).

Definition of defense mechanism

The definition of defense mechanisms (DM) is virtually identical. DM are “automatic psychological processes that protect the individual against anxiety and from the awareness of internal or external dangers or stressors. Individuals are often unaware of these processes as they operate. DM mediate the individual’s reaction to emotional conflicts and to internal and external stressors” in the language of the DSM-IV (American Psychiatric Association 2000, page 751).

Children with externalizing behaviors utilize major reality-distorting defenses (such as projection and denial), which can be viewed as similar to developmental delays in their implicit emotion regulation (ER) capacities. An underdeveloped implicit ER system results in heightened prolonged limbic, hormonal, and autonomic nervous system arousal when these children are challenged with strong and painful emotions (Etkin et al. 2010). We hypothesize that these biochemical changes contribute to a tendency towards impulsive action and, when coupled by the cognitive distortions and errors in judgment afforded by their denials and projection, cause major and multiple problems in these children’s lives.

RFP-C hypothetically removes roadblocks to normative development and promotes the maturation of ER processes. The procedures described herein have been conceptualized originally as specific to children with ODD, yet can be applied to other children with a variety of externalizing behaviors. Emotion regulation deficits may be the core deficit in not only ODD (Cavanagh et al. 2014), but it may also account for many of the behavioral disturbances and social deficits of attention deficit/hyperactivity disorder (ADHD; Shaw et al. 2014), disruptive mood dysregulation disorder (DMDD; Dougherty et al. 2014), and perhaps even some children with conduct disorder (CD; Deborde et al. 2014). These children’s deficits render them unable to integrate or usefully consider direct verbal interventions by the clinician about their actions. In this manual, we illustrate how premature direct verbal interventions about children’s disruptive actions are at best not useful and at worst may hamper the treatment. We describe an approach to children with externalizing behaviors in which the clinician carefully addresses the child’s unpleasant emotions and the defenses, such as denial and projection against these unpleasant emotions. Iterative application of these procedures promotes maturation of ER capacities in these children, enabling successes, improved self-esteem, and self-mastery.

Regulation-focused approach to children with externalizing behaviors

The clinician carefully addresses the child’s unpleasant emotions, particularly the defenses, such as denial and projection against these unpleasant emotions.

Lessons from a moment of therapeutic failure

Stephanie, the seven-year-old, often suffered a great deal of tension at home. At school, she was often threatened with suspension. The parents were dissatisfied with her treatment. In the psychotherapy sessions, cheating during games was rampant, and often the clinician felt provoked by the notorious cheating. Only retrospectively did the clinician become aware that her countertransference reactions to this little girl prevented her from addressing the cheating in a therapeutic manner.

The clinician has to be sensitive to his/her own countertransference reactions when working with children who exhibit externalizing behaviors.

Is the universality of countertransference responses to disruptive children one of the sources for the lack of effective psychological treatments for children with externalizing behaviors?

When the clinician discussed this session with colleagues, she became aware that her response to Stephanie was a result of countertransference feelings of which she was unaware at the time of the session. The clinician had said to Stephanie: “You know I really don’t understand why it’s so difficult for you to ever lose a point, even though you win every game.” You certainly can hear in the clinician’s words her own frustration and disguised aggression and wish that Stephanie would “shape up” so the treatment could continue.

The clinician addressed Stephanie’s actions and not her emotions that were masked by her unsocialized actions.

Undoubtedly, the clinician’s tone and affect towards Stephanie were similar to what Stephanie experienced from her teachers and parents. Everyone was, in essence, saying:

“If you just stopped it and shape up and act like other kids, all will be OK.”

A clinician’s job is not to tell a child to “shape up” and “act right.”

The clinician’s task is to help a child with the emotions that trigger the disruptive maladaptive behavior.

Stephanie ran out of the playroom to her mother and screamed inconsolably that the clinician was cheating. “She wants to cheat all the time and stops me from winning!” The extent of the projection was clear. What was unanticipated by the clinician, as a result of her countertransference, no doubt, was Stephanie’s development of a sustained refusal to come into the office alone, precipitating the interruption of the treatment.

This brief vignette highlights a common clinical moment when a clinician may not be aware of his/her personal affective response and affective communication to the patient, and cannot appropriately address the child’s emotional state. In this particular instance, the clinician was engaged in a communication in the cognitive sphere without being aware of the child’s emotional state, affecting her cognitions.

As a result, the clinician did not address the patient’s emotional sphere, the girl’s feelings, or the protective role against painful emotions played by the externalizing behavior.

This moment of therapeutic failure provides us with a valuable lesson in how to address children with externalizing behaviors.

Disruptive symptoms result from impaired emotion regulation (ER) and are the only protection against painful emotions that a child with ODD can utilize.

The challenge:

How to address the emotional sphere of the child with externalizing behaviors.

Countertransference

The lesson of the therapeutic failure with Stephanie is an example of the difficulty in the psychotherapeutic treatment of aggressive children. Aggressive children at times may exhibit a potential real threat to the clinician and his/her possessions. Counterreactions are inevitably evoked in the clinician. As with any other person, the clinician’s experience of the patient is colored by residues from his/her own past (countertransference). That is why a clinician has to understand him/herself as much as possible. This is crucial since the clinician needs to discern clearly the degree to which his/her reactions to the child are derived from his/her own past and how much is provoked by the patient.

Children with regulation problems, such as children with ODD or DMDD, can become aware of their effects on their clinicians. In order to protect themselves from the painful emotions of powerlessness, shame, and distress that emerge in their relationship to the clinician (what is called activation of the attachment system and a reemergence of the distorted attachment patterns that are often present in these children), aggressive children may attempt to cope with those feelings by exhibiting an attitude of superiority or attempting to control the clinician. They attack the clinician; they follow the motto, “A good offense is the best defense.” The provocations of the clinician and the attacks on the clinician are often a repetition of the behaviors that occur at home and/or at school. In the sessions, the child may respond with disruptive, attacking behavior to the clinician’s absences, to the presence of other children in the waiting room, or to the clinician’s attempts to discuss uncomfortable subjects. In order not to feel the shame of missing the clinician, the child will attack instead. These situations are often reenactments of significant precipitants of the disruptive symptoms in the child’s life.

It may be that providing the therapist with a theoretical frame of reference and an active technique such as RFP-C enables the clinician to become aware sooner and more effectively of his/her countertransference and enables the clinician to respond therapeutically rather than in a countertransferential way, which can lead to an escalation of the externalizing behavior, s...

Table of contents

• Cover Page
• Half Title Page
• Series
• Series
• Series
• Title Page
• Copyright Page
• Dedication
• Contents
• Foreword
• SECTION 1 Introduction and theoretical background
• SECTION 2 Practice manual
• Appendix A
• Appendix B
• Appendix C
• Index