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Wise Counsel Interview Transcript: An Interview with Keith Sutton, Psy.D. on Oppositional Defiant Disorder

David Van Nuys, Ph.D.

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David Van Nuys: Welcome to Wise Counsel, a podcast interview series sponsored by Mentalhelp.net, covering topics in mental health, wellness, and psychotherapy. My name is Dr. David Van Nuys. I'm a clinical psychologist and your host.

On today's show, we'll be talking with Dr. Keith Sutton about the family therapy approach to treating kids with Oppositional Defiant Disorder. Dr. Keith Sutton is a licensed psychologist in private practice in San Francisco and San Rafael, California. He's worked with teenagers for 11 years prior to and during his training as a psychologist, in settings such as teen shelters, a residential treatment program, a drug and alcohol outpatient program, a wilderness program, schools and community clinics. He was recently elected the president of the Association of Family Therapists of Northern California. In addition to working with teenagers, he also works with individual adults, couples, and does neuropsychological assessments for learning problems and ADHD. Dr. Sutton uses a number of therapies, including Cognitive Behavioral Therapy, Eye Movement Desensitization Reprocessing, Brief Strategic Therapy, Strategic Family Therapy, Schema Therapy, Narrative Therapy, and Solution Focused Therapy. He and Jim Keim, LCSW, the former director of training for Jay Haley & Cloe Madanes, the creators of Strategic Family Therapy, have started the Bay Area Oppositional and Conduct Disorder Clinic, which is part of the Institute for the Advancement of Psychotherapy. Here they provide therapy to families with oppositional children and provide live training to therapists looking to build their expertise with this population. Therapists receive live supervision, where a team watches from a one-way mirror and calls in to give the therapist suggestions during the session. It's a very effective way to train practitioners and based on the Mental Research Institute model.

Now, here's the interview.

Dr. Keith Sutton, welcome to Wise Counsel.

Keith Sutton: Hi, thank you.

David: If I recall correctly, you're one of my listeners and you recommended a number of leading researchers and practitioners of family therapy as possible guests. But I noticed that you're a president of the Association of Family Therapists of Northern California, and so I kind of turned the tables on you and suggested that you might make a good guest.

Keith Sutton: Yes, I'm a long-time listener and really enjoy your podcasts. And I knew there weren't too many podcasts on family therapy, so I was kind of emailing you to suggest interviewing some people, and you suggested interviewing me. So I'm grateful to be on; it's wonderful.

David: Yeah, well, it was a good suggestion and one that, not only are we remediating right now, but also I have put out feelers to some of the people that you suggested and, hopefully, some of them will get back to me. But coming back to you, tell us a bit about your own background and training, and how you came to be interested in family therapy.

Keith Sutton: Sure. Let's see, I started working with teenagers back when I was an undergraduate. I started working at a teen shelter just when I was about 21. I worked at a few different teen shelters, a residential treatment program, a psychiatric hospital for teenagers, wilderness program, a drug and alcohol outpatient program. And so this has really been kind of the group that I was very interested in; and that was all prior to graduate school. In the beginning, I started thinking I would just work with teenagers alone, but what I found was, when I met the families of the children that I was working with, it really put it all into context and I was really able to work with the family and find them to be really great resources and strength with helping the kids. So that led me to work more with families; and when working with families, you end up working with couples because you're working with the parents; and also with individual adult issues. So I really got this kind of more rounded approach that way.

David: Then you went on to a graduate program. Just say a little bit about that. Did that have any specific focus on working with families?

Keith Sutton: Yes, I went to Alliant International University, California School of Professional Psychology in the Bay Area, and I was in the Child and Family track, so my work was focused on families and adolescents and also with couples and individual adults. So my training and my studies were all kind of in those areas.

David: Okay, so how long have you been in practice at this point?

Keith Sutton: I recently got licensed last January, so I've been working with teenagers for about 11 years with all that time before graduate school and then in my graduate training.

David: Okay, for somebody's who just recently gotten licensed, it seems like you have an awful lot of experience, though.

Keith Sutton: Yes, definitely.

David: And I notice that you also have founded a clinic in the Bay Area with someone else, and you sent me some papers by him, and he seems like a pretty heavy hitter in terms of his research and writing.

Keith Sutton: I had worked with Jim Keim at the Mental Research Institute in Palo Alto, where family therapy started back in the '60s, and he was there also at the time. He had been the clinical director for Jay Haley & Cloe Madanes and had done some writing and work with oppositional children. So, one of the things that I wanted to do, I started the Institute for the Advancement of Psychotherapy in the Bay Area here, and one of the clinics that we started - kind of as a subheading to that - Jim and I started as the Bay Area Oppositional and Conduct Disorder Clinic. So what we do through that is do trainings, workshops for parents, we treat clients, and we also do live training where clinicians can come in and work with a family and get supervision from Jim during the session, where he calls in and gives suggestions. It's a team approach that was used at the Mental Research Institute, and it's a great way to train clinicians.

David: Yes, and I'm very familiar with the Mental Research Institute, not that I've been there, but I certainly know the name. As you say, going back to the '60s, it was really one of the places that did a lot of pioneering work in the field of family therapy. Now, I gather you deal with all sorts of family difficulties, but that you've specialized, to some extent, in a condition that you just mentioned, ODD or Oppositional Defiant Disorder. Is that right?

Keith Sutton: Yes. So, I work with all sorts of issues with families, and one of the specific things that I work with is your defiant, out-of-control teenagers. And I think something to point out first is that the real task in adolescence is individuation. So I was talking to a friend this last weekend saying what I did, and they said, well, aren't all adolescents defiant?

David: Yes.

Keith Sutton: And I said, well, you know, definitely; there's definitely some normality in defiance and, in this time, really becoming independent and trying out their own selves and finding their self in the world. But oppositional defiant disorder is kind of a more extreme case. I can go a little over the DSM-IV diagnosis; DMS-IV is the diagnostic manual for psychologists and psychiatry. Symptoms in the DSM-IV look at if the child is having a lot of impairment in the areas of school or home functioning or other areas of functioning in their life. And some of the symptoms of oppositional defiant disorder are that the children often lose their temper, they often argue with adults, often defy or refuse to comply, deliberately annoy people, blame others for mistakes, often touchy or easily annoyed, often angry or resentful, often spiteful or vindictive. And all these symptoms are, in their mild form, common and normal in everybody, but it's at the one point where it becomes very extreme, is when you have this diagnosis of the oppositional defiant disorder.

David: Yes, and I do recognize it in its milder form as a father of four - now adult - kids, but certainly I saw some of that as they were going through their stages of adolescence. In the DSM-IV that you referred to, is there a cluster of other diagnoses that that ODD appears in conjunction with?

Keith Sutton: Oppositional defiant disorder is also in conjunction with disorders usually diagnosed in childhood or adolescence. You also see some disorders such as Attention Deficit Hyperactivity Disorder, and there's a high comorbidity between the two of those. And my thinking on that is, oftentimes with kids that are ADHD, they tend to be more impulsive, tend to be more hyperactive and tend to break the rules a lot more than kids that aren't. So what often happens is that you get into these interactional patterns - the parents and the children do - where the kids are always getting in trouble, and then they begin to act out some more and kind of feel like, gosh, I'm always getting in trouble. And it becomes a self-perpetuating cycle, which is really hard to break.

David: Yes, now, it seems like behaviorally there might be some overlap with ADD. How does one differentiate between ODD and ADD?

Keith Sutton: I think and the way that Jim Keim, who I work with at the Oppositional Clinic, looks at it, is that with the oppositional defiant kids there's really a difference in their orientation; and he looks at it as the difference between the process orientation and the outcome orientation. Kids who have oppositional defiant disorder are more interested in the process of the interaction with the parent, where oftentimes the parent is interested in the outcome - whether they get the child to turn the TV off, or whether they send the child to their room or things like that. Another way of describing this process and outcome orientation is thinking about it if you were to go to a Japanese tea ceremony. Now, if you went in thinking, I'm really thirsty, I'm going to go in and get some tea, that's an outcome orientation. And you'd be sorely disappointed because you'd be in there for two hours before you actually got your tea, because it's really about the process of the interaction that's going on during that ceremony and the ritual.

So what happens with kids that are oppositional is that they tend to be more focused on the process of the interaction between themselves and the parent than the outcome. And it tends to be in a few areas of timing, direction, and also mood of the conversation. So, for example, if the parent comes to talk to the child about A and the child says, well, what about B? And then the parent starts defending B, and then they get upset and then walk away; and the next thing they know, they say, well, what happened to A? The child has been able to kind of change the direction of the conversation. If you come to the child and say, you know, it's time to take out the garbage and they say, well, you didn't do the dishes last night. Well, that's your chore, and then you start arguing against that and it blows up. Again, you kind of walk out and haven't been able to deal with the particular issue that you came into the situation with.

With the mood, the idea is that child is also kind of changing the direction of the mood in the situation. You've come in with one mood, they come in with another. And they may be pushing your buttons or saying things provocatively, and the parent gets upset, things blow up, and then they leave with the same mood that the child had.

And then with the timing of the interaction, sometimes the parents have a hard time being able to say, you know, we're going to talk about this later, or stop this argument now or this confrontation, or we're going to talk about this later. And what happens is that the child really focuses on doing it now on their terms. So there tends to be a lot of control of the process of the communication.

And your original question was the difference between ADHD and oppositional defiant, and it's really in these kinds of conflict or times of confrontation. Where a kid with ADHD who, you know, is just doing things by mistake or running too fast and knocks something over and you ask him to pick it up and they do it - that's more of a normal reaction. For a kid that oppositional, that might then trigger this process in saying, okay, the parents ask me to pick something up; and then going into a whole issue of whether they can kind of control the mood, the timing, and the direction of that interaction.

David: Okay. It's been a long time since my own training in family therapy, but I had a fair amount of exposure to the Family Systems approach, a la Virginia Satir and others, who I guess came out of MRI, actually. And they talked about the tendency for an IP - that is an "identified patient" - to emerge in the family as a sort of scapegoat for tensions and problems in the family as a whole. As I hear you talking about the process versus outcome approach, I get the impression that you're being careful not to blame or pathologize, but rather providing a model that shows that people are coming at this from different angles, if you will.

Keith Sutton: Exactly. You know one of the issues with oppositional defiant disorder - that label - is that the word "disorder," I think, is a misnomer there. For me a disorder thinks that there's something situated in the particular person that's got this disorder, and that it's something that's going to be stable over a long time. The way I think about oppositional defiant disorder is that it's an interaction between two people, and it's not necessarily because there's something wrong with the child or something wrong with the parents. What it is, is just kind of a habit, a way of interacting, that's occurred. Again, kind of in this ADHD example that we've talked about, it more becomes kind of a habit - it's "the kid's always getting in trouble." The parent and child get into the rules of: you're the one in trouble, I'm the one that's always on your back.

So, when working with these families, it's really important to not pathologize. And, really, the identified patient in the early family therapy literature, there was some kind of pathologizing in the family as whether the family was keeping the child a problem, to deal with their own issues and things like that. And I don't think that it's anything conscious or that's how this happens, but sometimes it just gets into a habit. And oftentimes people get into a way of interacting that's hard to change.

David: So, if I understand you correctly, then, you're saying, not only do you lean over backwards to not blame the child in the family, but also you need to be careful not to blame the family.

Keith Sutton: Exactly. And I think, especially with oppositional defiant disorder, it's really important to incorporate the family in the work, because if you're just doing individual therapy with the child, you're not changing the way that the interaction happens. What you also find, too, is that sometimes one parent and the child will have an oppositional interaction; sometimes it'll happen with both parents; sometimes it will only happen with one teacher and not the parents; or with the parents and not with the school. Another point, too, is that many parents have other children that are doing just fine, because normal parenting styles and their interaction tend to do fine with kids that aren't focused on this process orientation, that don't fall into these patterns. So you can have a parent that's doing great with one, two, three, four other kids in the family, but with one of them, they're just getting into this kind of mismatch.

David: What do we know about the causes of oppositional defiant disorder, if any? I know that in the case of ADD, for example, there are theories relating to the brain and maybe even to genetics. Are there theories out there that say something about the cause?

Keith Sutton: You know, there's a couple things that we know about oppositional defiance and other relationships or correlations. One is that sometimes you find that kids are oppositional when they have a depressed parent, and this really speaks to attachment theory. And what we find in attachment theory is children are young and become bonded to the parent, that they feel a sense of safety, that it's kind of a home base for them to go to; and that they're really looking for their needs to get met. And how they secure they are able to get those needs met, determines the relationship. And what we find when there's a parent that's depressed, is that oftentimes the kids will act out. They'll oftentimes rather have the parent be angry at them than indifferent, because that's a lack of love and a lack of connection; that's very scary. So that's one of the situations that we find. And, actually, there's been some research that they've done with primates, and they found that monkeys who were indifferent to their offspring, the monkey babies were actually attacking the monkey mother to get some sort of connection or reaction out of them. So it's a very, very powerful drive.

David: That's so dramatic. That's amazing that it occurs in monkeys, as well. And, you know, we've sort of known that for a while; we talk about negative attention getting, I guess, is what it's called.

Keith Sutton: Exactly, yes. And there's many roads that lead to Rome. Kids can become oppositional through just going through difficult times that they can't deal with. If their family is going through a divorce or remarriage, if they're getting picked on at school, if they've got a learning disability and they're having difficulties at school - there's all these different things that can lead to the acting out behavior. Also, depression in children often comes out as irritability; all these different things. So it's really important to look at, also, what's involved with oppositional defiance. Also, I don't know if you've heard of "goodness of fit"; but really the idea is a mismatch in temperament sometimes between the child's temperament and the parent's temperament. It doesn't mean that either one is wrong, but it helps you get an idea of how to guide the intervention.

David: That's interesting.

Keith Sutton: I think something at this point, too, is really important to point out. Kids that are oppositional, it doesn't mean that they're going to turn out to be a criminal or anything like that. Many kids that are oppositional turn out to do really great, kind of be really great trial lawyers, CEOs, and tend to have good relationships with their families later on, which some parents are very surprised at - after they're kind of really struggling for years and years during the child's adolescence - to then later have a nice, close relationship with them.

David: Well, that's good to know, that there can be a rainbow at the end of the story here. Talk a bit about the treatment approaches to ODD. I have the impression that you combine elements of behavioral theory, attachment theory, family systems theory. Talk about that a bit and then tell us how it comes down in the nitty-gritty, maybe even giving a case example, if you can.

Keith Sutton: Sure, definitely. So, since I work with kind of the different levels, I also do neuropsychological assessment, so I really think from a micro level up to a macro level, from down on the neurological level to up to the family system, to even the systems of their interactions with schools and such. So, I've really kind of tied in a lot of work, Jim Keim's work, and also other people's theories on approaching dealing with oppositional children. I'm going to talk a little bit about how I usually approach my work with parents. So, really in the beginning when I'm meeting with a family that are dealing with a child that's very difficult, I'm first trying to help the parents to really do some self-care, because having a child that's oppositional or acting out can be exhausting. It's an endurance race, it's like a marathon.

David: So what kind of self-care would you suggest? Going to the movies or getting a massage or is it something else?

Keith Sutton: Exactly, those kind of things. Also, we'll work with the parents on some mindfulness, deep breathing, to help them calm down when they're triggered; work with them on strengthening their relationships - it can be very, very difficult on a couple during this time. If it's a single parent, really making sure that they have some support from friends or family; if it's a separated family, that they're working in a co-parenting relationship to address the issues. What can happen, too, is that the parents can become so overwhelmed with a teenager or child that's acting out, that it takes up all their time, all their thinking states, and they have a really hard time taking a mental break from it. Sometimes I'll suggest for a couple that they go out and begin having date nights, if they're not doing that any more, and that they limit their talk about the child to only, maybe, 20 minutes out of the whole dinner. Because otherwise they'll spend the whole hour lamenting and talking about how hopeless and frustrated they are.

David: Oh, yes.

Keith Sutton: And then they don't get any time to recharge. Another thing that's important is that kids get very anxious at how much power they have over the parents in these situations. When they see that the parents' life is completely revolved around them and how upset the kids are making them, you would think that the kids would say, okay, jeez, I got to give momma a break, she's having a really hard time right now. But what often happens is that anxiety actually increases their acting out behavior, and it's almost into a way of saying, you know, I'm going to go so out of control that you're going to have to step up to the plate and deal with me and make things calm and keep me safe.

David: Fascinating.

Keith Sutton: What I find, too, is that oftentimes these kids, they lose trust in the parent or have a feeling that the parent can't take care of them anymore. And the way I kind of talk about this with parents is: say you went on a plane and the pilot got on and said, gosh, you know, I really don't know where we're going today. I'm going to try and figure this out and, gosh, I'm not feeling well, so just leave me alone. Everybody would get really freaked out on the plane if that happened. Some might even walk off; others might protest and say, hey, we need to get this pilot out of here. Oftentimes with these kids, too, that are oppositional, they tend to try and take on an adult role and try and almost surpass the parent's authority, because they might have some feeling that they don't trust the parents to be able to lead, and so they try and take over the leadership. And you get a lot of arguments and battles around that with oppositional kids.

It might be a good point to talk a little bit about the soft side and the hard side of hierarchy. The way I think about family and kind of the hard and soft side of hierarchy here is, the hard side is around who sets the limits, who gives the consequences, who keep everyone safe, who sets the boundaries, who kind of lets us know what we need to do. The soft side is who takes care of us, who soothes whom when they're upset, who's there for nurturance and guidance and emotional support, the provider of good times. And to the degree when these things aren't being done, oftentimes you get the kids acting out. So, for example, when you might have a situation where a parent is having a really hard time and really confiding a lot in the child, and looking for support and soothing from the child, you get some acting out, to the point when there's no rules or limits, there tends to be some acting out. You'd be surprised how many kids that I have that are oppositional that actually say they'd rather have clearer rules and limits.

David: That sort of gets to another thing that I know that you talk about, which is the authoritarian versus permissive parenting style, and the neglectful parenting style, the authoritative personal style. Maybe you can take us through those.

Keith Sutton: Sure. So if you imagine the hard side in the degree of limits - on one end high limits, on the other end low limits - and then the soft side is high end, meaning love and warmth, and low end, no love and warmth. When you're in the situation where there's parenting with high limits and low warmth, you find yourself in the authoritarian situation. These are the more kind of drill sergeant parents, parents that are very iron-fist ruling and not really focused much on the relationship. On the other side of that coin you have the permissive parenting style, where there's very high warmth and love but very low limits. These are a lot of parents that have a hard time setting any consequences, and they'll worry that the kids are going to hate them and they really want to be best friends with the kids. When you have no love and no limits, then you've kind of got that indifference, that more neglectful kind of parenting saying, you do whatever you do and I'll be over here. So what the research has found is that having a more balanced approach with the love and the limits tends to be really helpful.

David: And that's the one that's called the authoritative, as opposed to authoritarian.

Keith Sutton: Exactly. Yeah, that's the authoritative parenting.

David: In other words, the parent is setting some boundaries and setting some rules, and being firm but not angry.

Keith Sutton: Exactly. They're able to have the love with the limits. And, actually, one of the things that I work with the parents is that you can still give consequences or have a limit, but it doesn't have to necessarily hurt. You can still have your love and say the kid's grounded for the weekend. It doesn't mean that you then have to give him the cold shoulder all weekend. You say, "You know what? You broke the rule; you didn't do your homework that day" or whatever it was. "You can't go out this weekend. That's the consequence, but I know that'll be hard so we can hang out together, we'll go out for ice cream and we can go bowling. Maybe you can have a friend over or something like that, but you can't go out." A lot of parents have a hard time with this. They feel like, well, if the kid did something wrong, I just have to cut kind of everything off. And oftentimes if everything's taken away, or if also that love is taken away, one, you get that kind of acting out to get any type of connection because they'd rather have anger than indifference; or two, they feel like they've lost everything so why not just keep on going and making things worse.

David: Yeah, that all makes a lot of sense to me.

Keith Sutton: So after working with the parents around helping them build up themselves, one of the other biggest points in the beginning is to really address blame. Oftentimes parents are feeling really blamed about what's going on. Sometimes there might be overt blame in the family, in-laws, maybe even their spouse or the other parent - they're separated, they're blaming them. Oftentimes parents involve additional children; they're getting comments while they're at the grocery store, or somebody would say, well, I would have done it like this or that. Really letting them know that they're not to blame, that they're doing the best that they can. And in this situation with an oppositional child, it just needs a bit of a different approach.

So at this time I really work with the parents on helping them to understand this and really noticing, if the parents are really telling me how difficult or how hard the child is or how kind of bad they are, helping them to understand that I hear where they're at. Because sometimes if the parent doesn't understand that you're not blaming them, they tend to tell you even more and more how difficult the child is so that you can say, yes, I hear how much you're trying and how hard this is for you.

I think about it, too, with oppositional children that there's no silver bullet. One thing is not going to fix it, and oftentimes there's this idea that parents get into because, with kids that aren't oppositional, sometimes that one consequence or grounding them for a month will have a big change and then, boom, things change; but with oppositional children that actually amps things up. When the tough nuts get stronger, the line gets drawn in the sand and, really, we need to have a lot of flexibility. The parents are the experts on themselves and their own child.

So what I find is that one out of every five suggestions that I suggest is going to work. About one out of every four suggestions they suggest is going to work. And, really, we want to try and have an attitude of trying more of what works, less of what doesn't and having the flexibility to really try and find new things that do work, and really celebrate when something does work. Because it's more like a football game, where you get touchdowns every once in a while after 10-20 tries or so, and you really celebrate that. But not every throw's going to be a touchdown. So, again, with that kind of understanding that this is an endurance race, really adopting that attitude that first we're going to take care of ourselves, have that oxygen mask, understand that this is really hard, there's no blame here, and that we're trying to make these changes, and we're going to be experimenting.

David: I almost get the impression that you're working more with the parents than with the child.

Keith Sutton: You know, in this talk that I had done that I'd emailed you, it was two parents. Now, what I do with the children is, in the session, I'm trying to help the way that the kids and the parents are interacting a little differently. So, I think one of the confusions about family therapy sometimes is people think of it as always the family being together in the session. And what I really do is I'll oftentimes see the whole family the first session; I'll see the parents individually and do some coaching like this with them; I'll see the teenager a little bit and really build some rapport with them, find out what really motivates them, what they're interested in, find out some of those underlying things they're having difficulty with - they may have concern for a parent who's depressed; they may be feeling the bullying at school or something like that - and really kind of finding what motivates them. Sometimes all the motivation we can find is just to get out of therapy. And we say, okay, well, let's do that. What do you need to do to get out of therapy? What do your parents need to see? And, on the individual level, this is where more of my cognitive behavioral therapy, dialectical behavioral therapy, schema therapy, I use eye movement desensitization reprocessing, all these kind of more individual elements to help the teenagers deal with any traumas that they've experienced, or learning ways of regulating their affect, teaching them communication skills on how to communicate with their parents so they can get what they want without having to act out.

David: It sounds like you're very eclectic, then; you're actually bringing in a lot of different tools to bring some relief to the situation.

Keith Sutton: Exactly.

David: Well, I was wondering if you've ever seen the TV show Super Nanny?

Keith Sutton: Oh, yes. Yeah, that's a great show, actually. I used to work at a clinic in one of my internships, and we would recommend that the parents and young children watch that.

David: Yeah, we often think that parents ought to be watching that show. My wife and I have discussed that many times. It sounds like they're operating from many of the same principles that you've described here, and they're working with, I think, probably younger children than you are, for the most part, right? They put the child on the naughty seat, but then they emphasize that there's this sort of loving reaction afterwards; that the child has to apologize and then there's the hugging and this demonstration that love has not gone away.

Keith Sutton: Yes, because it's really important to have that balance of the love and limits. The way I suggest to parents, too, is having kind of that five to one ratio: for every time they get in trouble, for any criticism, things like that, there's some positives, some "I love you," or just even listening to them, or some sort of positive connection. Because what often happens with oppositional kids is that they're so hard, parents get so burned out and get so resentful, that a lot of that love gets lost. After I've done a bit of that work preparing the parents, I really work with them, too, on understanding that positive reinforcement is the most effective way to change behavior - for children, for teenagers. That really picking out what you would like them to be doing, instead of what they are doing, and reinforcing that is even more effective than punishment.

David: Are there books that you recommend to parents and/or to kids?

Keith Sutton: You know, there's a few books that I recommend. I haven't quite found one that tends to have both that soft and hard side balance. For parents that are more kind of on the harder side and not doing as much of the positive reinforcement, with young children there's a great book called Transforming the Difficult Child: the Nurtured Heart Approach by Howard Glasser. For teenagers there's a great book by a guy named Michael Riera called Staying Connected to Your Teenager. For the parent that has a really hard time setting limits, a book by Scott Sells, Treating the Tough Adolescent, is good - although it's really big on the tough love and it's got one chapter on the softer side, so it's a caveat that I tell parents about to kind of keep an eye on. And then there's also, for younger children, for parents that are more on the kind of permissive side and have a hard time setting limits, 1-2-3 Magic by Thomas Phelan. It's very good; he's got a great video that's engaging and funny, and he's also got a book.

So what I do at this point with parents, after we've kind of gone over self-care and really finding more to their own life and really working on the issues of blaming and such, is to help them observe what behaviors are going on for their children, what they would like them to do instead, and really writing down what are the behaviors they want the kids to stop, what are the goals of those behaviors, and what's the positive alternative behavior that they're going to reinforce.

So, for example, if you want the child to stop yelling, rather than just saying, well, they would just be not yelling - that would be the alternative behavior - you have to look at what the goal is. The child's trying to communicate something, they want to voice their disagreement or they want you to listen to them. So if you were listening [?], what would you want them to be doing instead? Maybe they're saying it politely: hey, I don't agree with this, or can we talk about this, can we negotiate that, or something; and then when they do that, really reinforcing that. When they say, you know, gosh, Mom, I really don't want to do the chores today; I'm so tired, I had such a hard day at school. And you saying, gosh, I really appreciate that you told me that and didn't just scream or yell or something like that.

What we often find is that we give more energy to the negative behaviors than the positive behaviors. When kids are doing something we don't want them to do, we're often yelling, we're getting in an argument with them; and when they do do the behavior right that we want them to do, sometimes we just ignore it or a quick kind of thanks for doing the dishes, or something like that. So really making sure that we're giving the energy to those positive behaviors, because the energy that we give to those negative behaviors is actually reinforcing, because oftentimes the kids want that attention or that energy, so that actually becomes a reinforcing benefit that they have to them. Even though you're yelling at them, you're still engaging with them; whereas if they were doing what they were told, you might not be engaging with them.

David: Many of us, I think, didn't grow up in families like that, and so we sort of have to train ourselves to focus more on the positive than the negative.

Keith Sutton: Yeah, it can be really hard. And especially, too, if there are things that you just are assuming they should be doing anyway. It kind of feels a little silly for some parents to go out of their way to say, hey, thanks for not bothering me while I'm on the phone, or thanks for taking out the trash like you're supposed to.

David: Are there any other points you want to make about treatment before we wind down here?

Keith Sutton: Sure, definitely. What I think that also is really important - after I really work on that with the parents and having them looking at where they're giving their energy, what they're reinforcing - is developing the rules that they're going to be doing for their children, and really thinking about themselves and grounding that in their values and their hopes. For example, parents are hoping that the child will get a good job, they'll go to a good college, so that leads down to the rule of needing to do your homework. And really picking just a few rules in the beginning to work on with the kids; and also helping the kids get ideas of what positive and negative consequences are. They're really good sometimes at coming up with: gosh, if I get good grades, I really want this, or this would be really motivating to me.

There's this also really important time that the parents be careful about safety, because as soon as that power begins to get challenged, when the parents start taking back the hierarchical position, this is when the kids start acting out and really amp things up. In behavioral terms they could call this an "extinction burst." This is when what happened before - say if mom said turn off the TV and then a son starting arguing, and then she said, oh, forget it and just walked out of the room - then next time that she does that and says turn off the TV, he's going to argue again and if she doesn't back down, oftentimes they'll amp it up to see if what worked before will work again.

And Scott Sells talks about the "five aces". And this idea said oftentimes with oppositional kids they'll really amp it up and they might do: one is cutting on themselves or threatening suicide; another is running away; another is just kind of dropping everything at school or kind of failing out of school; one is drugs or alcohol; or one is getting violent in the home. So before even going into these rules, really if you've got a kid that's in a dangerous situation, consulting with a professional to make sure that you can have things that are safe before getting into that.

So the next part that I really work with parents on is how to enforce the rules and consequences, because this is really where the rubber meets the road with oppositional kids. It's that process of interaction, of setting the limit and then fighting against it. So in the way I think about it, is helping the parent to go from being a bull locking horns with another bull, to being the bullfighter, where the bull comes at them and they're able to step out of the way.

David: Yes, that's a great metaphor.

Keith Sutton: So, what we're trying to help the parents do is to change the timing and the mood and the direction of the interaction, and really setting the limit or making the statement it's time to do your chore or you can't go out tonight, or something like that; and then being able to deal with the button pushing that happens afterwards. Kids are experts on parents. They have been watching you for years; they know what they can say to get you to react. Sometimes in therapy I also work with young kids, and it's great to have the young kids say, you know, what can you do to get Mom to back down? And one will say, oh, I cry or I whine or I say you don't love me, or something like that. And the parent will sit there thinking, gosh, I didn't know that they actually knew that this is what would get me to back off.

So, really, what we're trying to do here is kind of change the mood and the timing and the direction, so that the parent's able to go in, set the limit, be able to deal with the button pushing - or the I call it fishing, also, when they start provoking and spin out saying, well, you don't do this… - hoping that the parent will then start engaging in the argument with them. And really being kind of able to step away from getting deeper into that argument, and the parent controlling the timing, mood and direction. And noticing, too, for themselves, if they start becoming agitated, saying to the child, "You know what? I'm going to step away right now because things are getting a little heated and I'm starting to get a little upset. So I'm going to go calm down." This is a way of the parents role modeling some affect regulation for their own self.

What can be also helpful at this time is telling the child, "You know what? I want to give you respect, I don't want to yell at you or anything like that, so I'm going to step away right now, because you deserve respect." Also, saying to the kids that it's something that they will bring up later or at another time; again, controlling that mood, timing, and direction.

Also the idea many parents have is that the last one standing wins. And this oftentimes gets into a confrontation that can't be won by the parent because oftentimes the kids have much more energy and they tend to outlast the parents. So I really work with parents on understanding that - not trying to stay till the end, but finding a way to be able to step out. And one of those ways that I use is with voluntary and involuntary consequences. So a voluntary consequence would be something like having to rake the leaves, or a consequence of not going on Facebook for the weekend or something like that, or not watching TV.

David: You mean this would be something that the kid would have volunteered as a consequence that they think makes sense for them?

Keith Sutton: Well, no, the parent gives the consequence, but the child actually has to comply for it to work. And you can then follow it up with an involuntary consequence. So, for example, it's time to turn the TV off for bed and you're going to ask the child, "It's time to turn the TV off," and they say, "No, forget you, I'm not going to turn it off." Then you can follow it by an involuntary consequence; say, "Okay, if you don't turn the TV off, then I'm going to take the TV out of your room for two days, and you've got five minutes to turn it off," and then walking away. And then the teenagers got to think within themselves, do I break the rule, do I not break the rule, what should I do? And the fight continues with them, but you're no longer part of that fight; it's their decision. And what I tell parents, too, can be really helpful is telling them to tell the child, "You know what? I can't control you, I can't make you do anything, but if you don't do this, this will be the consequence," and then stepping away from it. And then if the kid keeps watching TV, don't go in and start grabbing the TV to pull it out of there. Oftentimes that's where you get violence happening, when there's a struggle or somebody's trying to take the laptop away or something like that. Let them watch TV for the rest of the night if he wants, and then take the TV away the next day for a few days.

David: Avoid power struggles.

Keith Sutton: Exactly. This is all about getting out of that locking horns position.

David: Yes, well, I think we kind of need to wind down now. Do you have any final thought that you'd like to get in here?

Keith Sutton: Well, I think that the last part that I didn't get to mention was really about connecting in the relationship, and spending a lot of one-on-one time with the child doing some child-centered activities, going out to play videogames or going shopping or things like that. Because the relationship is really the money in the bank for when you're needing to set the limits later on, and also being able to talk with the teenager and really finding a way to have that happen. Mike Riera in his book talks about how, when kids are young, you're their manager and at some point you get fired. And when they're teenagers, you have to get rehired on as a consultant.

David: I like that.

Keith Sutton: So really kind of finding a way to be there for your child to talk, where they can actually come to you and ask you about problems that they're dealing with. And the way I describe this, also, to the parents is thinking about it like a cat and a mouse. The mouse pokes its head out of the mouse hole. If the cat jumps too quick, the mouse is gone. So oftentimes you'll have a situation where, say, Johnny comes home and says, "Gosh, Mom, I was running down the hall to talk to Steven." And Mom says, "Why were you running down the hall? You're not supposed to run in school." And Johnny says, "Well, wait, no, I was trying to tell you about what happened with Steven." "Well, you shouldn't be running in school." And then right there the conversation's ended. And really taking the time to restrict judgment, restrict criticism or suggestions or lectures or anything like that, are words of wisdom to be able to draw the teenager out for a little bit; using statements of reflection - just kind of reflecting back: "Oh, you were running to tell Steven something?" Or validation: "Oh, it sounds like you were really excited to tell him something." Or, "Gosh, it sounds like that was really hard at school." These ways to kind of draw them out, and even kind of giving these with talking maybe two or three times to draw the teenager out into a discussion before giving the other information.

David: Well, this all sounds like really wonderful advice. So, Dr. Keith Sutton, you've been very generous with your time and information, and I want to thank you for being my guest today on Wise Counsel.

Keith Sutton: Yes, thanks for having me. It was wonderful.

David: I hope you found this interview with Dr. Keith Sutton interesting. If you wish to contact Dr. Sutton or to learn more about the clinic that he and Jim Keim have set up, you're encouraged to visit his website at www.drkeithsutton.com. One interesting technical note about this interview that might interest some listeners is that both Dr. Sutton and I were speaking via Skype - me by way of my iMac. However, I was surprised to learn that he was on Skype by way of his iPhone. That was a first for me, having conducted about 250 of these podcast interviews now. I thought the voice quality on his end was comparable to that of our other interviews. Also, if I sound funny, I'm still struggling to get over a summer cold and am not back to my normal voice. Here's hoping I will be the next time you tune in.

You've been listening to Wise Counsel, a podcast interview series sponsored by Mentalhelp.net. If you found today's show interesting, we encourage you to visit Mentalhelp.net, where you can add a comment or question to this show's web page, view other shows in the series, or simply page through the site, which is full of interesting mental health and wellness content. Access the show's page and show archive information via the podcast box on the Mentalhelp.net home page.

If you like Wise Counsel, you might also like ShrinkRapRadio, my other interview podcast series, which is available online at www.shrinkrapradio.com. Until next time, this is Dr. David Van Nuys, and you've been listening to Wise Counsel.

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