“I love my child, but I don’t particularly like him.”
This is a common refrain among parents whose children have disruptive behavior problems. When parents arrive at our research lab, they are seeking evaluation and help for relatively longstanding problems. Children with oppositional defiant disorder (ODD) are quick to lose their temper, often get into trouble at home or at school, rebel against the rules, blame others for mistakes, and are easily annoyed. While these behaviors are normal to some degree in children, those with ODD present with an extraordinary level of disruptive behavior. They often belt out a reflexive “No!” before they even know what they are being asked to do.
Parents are right to be concerned. ODD is a disorder that significantly interferes with functioning, particularly in social or interpersonal relationships. Parents tell us, “My child has changed me. I’m not the parent I want to be anymore.” And the research backs this up. Highlighting the complex dynamics between disruptive children and their caregivers, we know that ODD is predictive of worsening parenting practices (Burke, Pardini & Loeber, 2008), family conflict and poor family cohesion (Greene et al., 2002; Tseng, Kawabata, & Gau, 2011).
Furthermore, the problems persist into adulthood. Although classified as a disorder of childhood, ODD symptoms have a significant and negative impact on lifespan development. In one study, researchers controlled for other clinical problems (ADHD, conduct disorder, depression and anxiety) and found that ODD symptoms predicted poorer age-24 functioning with peers, poorer romantic relationships, a poorer paternal relationship, and having nobody who would provide a recommendation for a job (Burke, Rowe & Boylan, 2014). Disruptive behavior problems like ODD have a negative impact on academic and occupational performance across the lifespan (Leadbetter & Ames, 2017), family and interpersonal functioning (Burke, Rowe & Boylan, 2014; Munkvold, Lundervold & Manger, 2011), and are costly to the health care system overall (Guevara, Mandell, Rostain, Zhao & Hadley, 2003).
Lifetime prevalence of ODD is estimated to be 10.2 percent (Nock, Kazdin & Kessler, 2007). Of those with lifetime ODD, 92.4 percent meet criteria for at least one other lifetime DSM-IV disorder, including: mood (45.8 percent), anxiety (62.3 percent), impulse-control (68.2 percent), and substance use (47.2 percent) disorders. Early onset (before age 8) and comorbidity predict slow speed of recovery of ODD (Nock, Kazdin & Kessler, 2007).
Regulation focused psychotherapy for children (RFP-C) (Hoffman, Rice, with Prout, 2016) is a manualized, psychodynamic play therapy intervention for children with ODD and other disruptive behavior problems. The treatment is intended for children ages 5-12 who present with a range of externalizing behaviors. A current randomized controlled trial is being conducted, comparing an active treatment group with a wait-list control group. All 40 children enrolled in the study, including those initially assigned to the wait-list group, will receive the intervention. For information on the study and to make referrals, we encourage readers to visit our website at: .
RFP-C is an alternative to traditional cognitive-behavioral strategies used in the treatment of disruptive behavior, which focus on principles such as behavior modification and use strategies such as reward, praise and active ignoring as tools to manage behavior (Forgatch & Patterson, 2010; Kazdin, 2005; Webster-Stratton, Reid & Hammond, 2004). Instead, clinicians using RFP-C focus largely on affect, attempting to understand the child’s inner world and subjective experience and communicating this inner experience to the child in a developmentally appropriate way (Rice & Hoffman, 2014; Prout et al., 2015).
Additionally, in contrast to cognitive-behavioral modalities which focus on teaching explicit emotional regulation techniques such as self-talk, distraction and relaxation (e.g., Coping Power; Lochman, Boxmeyer, Powell, Barry, & Pardini, 2010), RFP-C focuses on building capacities for implicit emotion regulation (Hoffman et al., 2016). Perhaps most importantly, a psychodynamic approach to childhood disruptive behavior seeks to understand the meaning of these behaviors rather than simply correcting a reinforcement cycle.
In RFP-C, disruptive behaviors are understood as defensive maneuvers that help the child avoid difficult feelings, such as shame, anger, guilt or fear. Whereas cognitive behavioral therapy approaches focus on the mechanisms of parenting as the proximal cause of the behaviors, RFP-C defines the behaviors as maladaptive attempts at emotion regulation that protect the child (and thereby the family itself) from distressing thoughts and feelings. The end goal of RFP-C is to increase the child’s and caregivers’ ability to tolerate those uncomfortable thoughts and feelings so the disruptive behavior is less necessary.
The primary technique used in RFP-C is to interpret these defenses against painful affect. When addressing the child’s defenses, the therapist does not simply reassure the child or emphasize catharsis of painful feelings. Nor does he/she go to extremes of scolding the child for their negative/aggressive feelings or interpreting their unconscious
wishes directly, as these might have a negative impact on the child’s engagement in the therapeutic process. Rather, the therapist attempts to understand, explore and describe to the child the defenses he/she uses to avoid painful feelings in order to help the child master these feelings and feel more comfortable sharing them with others. In other words, systematically interpreting a child’s defenses against unwelcome emotions builds the child’s capacities for emotional self-regulation (Hoffman, 2007; 2015). RFP-C is the first treatment for children in which the key intervention is to systematically address the child’s defenses against unpleasant emotions (Prout et al., 2015).
The protocol for RFP-C involves a 10-week treatment, with the clinician conducting 16 individual sessions with the child and four sessions with the parents. In clinical practice, this framework can be used more flexibly and with modifications appropriate to the child and the family. After an initial meeting with both parents and child, the clinician meets with the child for two sessions before conducting a feedback session with the parents to discuss the child’s strengths and difficulties and to provide an overview of the treatment. There are two additional parent sessions later in the treatment. In these sessions, the clinician provides treatment updates and emphasizes the child’s strengths. In addition, the clinician places an emphasis on understanding the child’s disruptive behavior, thinking about its meaning, and conceptualizing the disruptive behavior as a form of maladaptive emotional regulation.
In contrast to the majority of manualized treatments for disruptive behavior, RFP-C is a child-focused and child-directed intervention (Brinkmeyer & Eyberg, 2003; Forgatch & Patterson, 2010; Kazdin, 2005; Webster-Stratton et al., 2004). The most common treatments for disruptive behavior, including behavioral parent management training and parent-child interaction therapy, rely heavily on parents to implement techniques such as reinforcement and modeling to modify the child’s disruptive behavior (Forgatch & Patterson, 2010; Kazdin, 2005; Prout et al., 2015). By contrast, in RFP-C, most of the clinician’s direct work takes place individually with the child, and during these sessions the child is free to choose the activity he/she engages in.
As with most play therapy approaches, the play in RFP-C is relatively unstructured. Children are encouraged to explore the playroom and are not required to follow basic social conventions of turn-taking, reciprocation and sharing. The purpose of the play is not to foster more adaptive or more developmentally appropriate play; in fact, aggressive and regressive play is encouraged and is helpful to the therapeutic process. All play, especially play that is disruptive, repetitive or unusual, has meaning. RFP-C is distinct from other play therapy approaches in that it specifically targets verbal and nonverbal disruptions in the flow of the child’s communication. These disruptions are understood within the RFP-C paradigm as attempts to ward off uncomfortable and distressing affects. The clinician attends to:
Topics of discussion or play that provoke a disruption
The emotion inherent in the topic that provokes a disruption
The nature of the child’s play or activity when the disruption occurs
And, over time, why the avoided emotion is so disturbing that it needs to be circumvented
With the child, the clinician remains as “experience-near” as possible, using examples that arise in the play therapy room, wondering aloud about what the child might have been feeling when the incident occurred and how the child might have responded to these feelings (i.e., the possibility that the child acted disruptively to avoid unpleasant feelings). This consistent focus on play disruptions is more structured and targeted than the manualized child-centered play therapy approach pioneered by Virginia Axline. This is a critical feature of RFP-C given that it is a short-term approach focused on addressing a particular constellation of symptoms.
RFP-C is distinct from other play therapy approaches in that it specifically targets verbal and nonverbal disruptions in the flow of the child’s communication. These disruptions are understood … as attempts to ward off uncomfortable and distressing affects.
A recent meta-analysis of outcomes of psychodynamic psychotherapy for children and adolescents highlights the critical importance of including parallel parent work in child psychotherapy (Midgley, O’Keeffe, French & Kennedy, 2017). In RFP-C, meeting and forming a relationship with the child’s parents is a crucial component of the treatment. These sessions are used to inform parents what their child is exploring in therapy. In addition, the sessions provide opportunities for parents to develop a deeper understanding of the child’s behavior and the situations that evoke
negative emotions for the child and thus bring on disruptive behaviors. In other words, RFP-C also helps parents understand that behavior has meaning.
One of the main tools the clinician uses to help parents understand their child’s behavior is Malan’s triangle (Malan, 1979; McCullough et al., 2003; Hoffman et al., 2016). With permission from the child, the clinician uses examples from sessions with the child to identify with the parent which emotions are being avoided (e.g., anger, sadness, fear), how the emotions are being avoided (e.g., arguing, physical aggression), and why the child needs to avoid these emotions (e.g., the feelings are too embarrassing or frightening). The use of a pictorial representation of a child’s difficulties is unusual in traditional psychoanalytic work; however, we have found it to be invaluable in giving parents that “a-ha!” moment of truly understanding the meaning of their child’s disruptive behavior. Malan’s triangle also serves as a transitional object for the family between the therapy space and the home and school environments.
Throughout the treatment, the clinician embodies a reflective stance and models reflective functioning to parents. Moreover, the clinician maintains a reflective stance toward the parents, wondering how they might have felt during reported disruptive incidents and whether they responded defensively to the unpleasant emotions evoked by the child’s distress. Through the repeated activation of the parent’s own emotion regulation capacities, the clinician attempts to move the parents away from certainty about the child’s intentions and toward a sense of curiosity about the motivations and feelings that underlie the child’s behavior.
Parent check-ins and sessions that take place in RFP-C are not individual therapy for parents, although the clinician may encourage the parent to seek individual support should this seem necessary. Rather, regular parent contact throughout the treatment is meant to act as a “longitudinal discussion of reflective parenting and/or education about how their child regulates unpleasant emotions” (Hoffman et al., 2016).
The broadest, yet perhaps most important, goal of work with parents in RFP-C is that the clinician conveys a warm, collaborative, nonjudgmental attitude and empathy toward the parents’ feelings and expressed difficulties in parenting their child. In this way, the clinician builds a strong alliance with the parent. One of the aims of RFP-C is to use this strong parental alliance to prevent the high attrition rates observed in existing treatments for externalizing behaviors, particularly for low-income, high-stress families. In particular, the clinician’s collaborative attitude and focus on the child’s behavior is meant to resonate with the parent’s understanding that the problem lies with the child’s capacities to manage their emotions and behaviors and the interplay of parent-child dynamics, rather than solely in their parenting skills (Prout et al., 2015).
The clinician’s alliance with the parent also provides a foundation for the challenging work parents must do in developing what may be a new and different understanding of their child’s externalizing behaviors. The clinician’s empathic stance creates a safe environment for the parent to deal with the unpleasant emotions evoked by the child’s behaviors. The clinician’s ability to tolerate and process the parent’s strong negative emotions provides the parent the opportunity to grow in their ability to tolerate and understand the child’s negative emotions. Similarly, the parent internalizes the clinician’s curious stance about both parents’ and child’s feelings and motivations. This allows the parent to practice drawing connections between the child’s external behavior and his/her interior life. Ideally, ongoing contact with parents in RFP-C is meant to activate and enhance a skillset in parents that will allow them to create a home environment for the child that encourages and builds upon the constructive self-regulatory capacities the child begins to develop in therapy.
The goal of the parent meetings in RFP-C is not to train parents to manage disruptive behavior, as in behavioral parent training approaches, but to encourage and develop an understanding of the child’s behavior. During parent meetings, the clinician helps the parents understand the child’s misbehavior has meaning and arises from a maladaptive mechanism of regulating unpleasant emotions. The clinician also helps the parents identify situations that evoke negative emotions and trigger problematic behaviors for the child, in order to further foster understanding of the child’s behavior. The child and the family also gain an understanding that all of the child’s behavior, especially disruptive behavior, has meaning in the service of emotion regulation.
Our Manual of Regulation Focused Psychotherapy for Children (RFP-C) with Externalizing Behaviors: A Psychodynamic Approach, is intended to be useful for clinicians of all disciplines (mental health counselors, psychiatrists, psychoanalysts, psychologists, social workers, creative arts therapists and others) and theoretical backgrounds who work with children and their families. It has great appeal for residents, as well as psychology and social work trainees who report having a “deeper understanding of the way defense mechanisms function in children,” “more tools to be an effective therapist,” and “a greater understanding of the use of interpretation as an intervention in psychodynamic therapy.” The manual is published by Routledge and a discount code is available on the Publications section of our website: .
Psychodynamic psychotherapy has a long history of emphasizing affect regulation and has made significant contributions to our understanding of emotion regulation (Aldao, Sheppes, & Gross, 2015; Rice & Hoffman, 2014). RFP-C is the first manualized play therapy approach to focus on defense mechanisms as ways of addressing implicit emotion regulation mechanisms in children with disruptive behaviors. Consistent interpretation of a child’s defenses against unpleasant or intolerable affects introduces emotional flexibility (Hoffman et al., 2016) and promotes development of the implicit emotion regulation system (Rice, 2016a, 2016b). RFP-C builds on the history of the play therapy tradition (Axline, 1947, 1969) and defense interpretation (Bornstein, 1945, 1949; Hoffman, 2007; McCullough, 2003), and integrates contemporary neuroscience findings (Etkin, Büchel & Gross, 2015; Rice, 2016b), in order to help children reduce their need for disruptive behaviors and increase their ability to tolerate difficult thoughts and feelings. RFP-C also offers a clear and contemporary treatment approach that is useful for trainees and experienced clinicians alike.
We welcome referrals to our ongoing study. Please visit our website and click RFP-C Study for more information. Providers and families can also call (347) 719-0390 to inquire.
For further information on the references in this article, please contact Tracy A. Prout at .
From the Issues in Child and Adolescent Psychoanalysis Editor
This is the fourth installation of child and adolescent analytic and psychodynamic practices. We have described the work on a new short term psychodynamic treatment of childhood anxiety and we have been privileged to read, in two parts, about the value of a psychodynamic orientation when working in a community setting with problematic children and their families. In those discussions, Nathaniel Donson described the use of videotaped supervision. This modality has become particularly important for me, as well. In our treatment trial of regulation focused psychotherapy for children (RFP-C) (), all sessions are taped. Therapists participating in the study are all Psy.D. predoctoral students, similar to the educational level of those working with Donson. Both therapists and supervisors have always found video supervision to be valuable.
In this issue, I and the other members of our team, led by Tracy Prout, our principal investigator of our randomized controlled trial, write about our work with children with oppositional defiant disorder. In a future issue Paul Hollinger and Robert Galatzer-Levy will begin a two-part series describing the follow-up of child analytic cases.
—Leon Hoffman