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Coping from Violent Pediatric Bipolar Clients
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In the last section, we discussed effects of two triggers on bipolar children: kindling; and seasonal affective disorder. Also, we included three techniques on how to predict these triggers by developing a "Trauma History", a "Trigger List", and "Tactics for when a trigger occurs."
As we discussed on section 2, rage is a common characteristic among bipolar children. These rages can be so terribly violent that at times, it seems a strait jacket would be appropriate. Of course, it is not, but the intensity of a child’s anger over what seems to be trivial matters can be shocking. Normally, child clients contain their rage until they are home, but sometimes a client will burst out in therapy.
In this section, we will examine four steps to cope with a raging bipolar child client. These steps are creating a safe environment; disengaging the child; knowing your comfort zone; and rechanneling. We will also include techniques parents can use when their child begins to rage at home.
4 Steps for Coping with a Raging Bipolar Child Client
♦ Step 1: Creating a Safe Environment
The first step in coping with a raging child is Creating a Safe Environment. Not only does the child pose a threat to those around him or her, but also to him or herself. If a child flies into a rage during a session, assess the child’s immediate environment. Find any sharp or heavy objects that he or she could use as a weapon. I keep several spare pillows and a small punching bag if a child is so angry that he or she refuses to calm down until they punch something.
If the tantrum should occur in the home, I tell the parents of raging children to also separate their child from any siblings, relatives or pets, especially warning younger siblings to isolate themselves immediately if their big brother or sister gets too angry and not to come out until the All Clear is given. I also tell them that if they are in the car when the child flies off the handle to pull over immediately and turn on their hazard lights. If a child should start pulling on the parent’s hair while they are driving, this could cause a terrible accident, harming the parent, the bipolar child, and any other family members in the vehicle.
♦ Step 2: Disengage the Child
The second step in coping with a raging child is to Disengage the Child. When a child is in a rage, he or she could interpret even a look as being provocative. Although it may sound condescending, treat the child client with as much caution as you would a tiger around its cubs. Keep the client within your peripheral vision and do not stare at him or her. Don’t talk to the client when he or she yells at you. A response to that kind of provocation will only be interpreted as a challenge.
If it is essential that you communicate with the client, keep in mind that it will almost be impossible for what you want to say to make rational sense. The client has completely reverted to an almost psychotic state in which their reality is quite different from what is actually going on. When you do speak, it is important that you maintain an even tone and a low voice. I also tell parents to resist any temptation to verbally defend themselves, cajole the client, or answer him back. Any type of challenge could incite an active rage, during which the client will try to injure others or him or herself.
♦ Step 3: Knowing Your Comfort Zone
In addition to Creating a Safe Environment and Disengaging the Child, the third step is Knowing Your Comfort Zone. Although sympathy and compassion is essential during normal therapy, when a child is raging, it is a good idea to make an imaginary ten foot radius. When the client is raging, he or she may stray as far as ten feet in any direction away from me.
Any farther, and I move myself so that he or she is still in my comfort zone. In this way, I can keep the client from harming him or herself. In such situations, windows and mirrors pose an imminent threat because they can be broken and the shards used as a weapon. If the client begins to move toward a dangerous area, I remind him or her that that area is outside the radius.
♦ Step 4: Rechanneling
The fourth step I take when dealing with a raging client is called Rechanneling. A raging child has a lot of energy. See if you can rechannel that energy. I always have available some sort of activity that could spend a child’s energy in a positive and non-lethal manner. For example, I keep a small basketball hoop in my office along with a small drum set. When a client is raging, I hand him or her a basketball and tell him or her to dunk as many balls as they can. Also, I ask him or her if they would rather play on the drum set. A video game player also works well. Often, a child client is attuned to what he needs and will respond to the diversion by becoming immersed in it. By the time he looks up, the rage is long forgotten.
Tactics for the Home
In addition to the above steps of Creating a Safe Environment, Disengaging the Child, and Rechanneling, I give parents of raging children several other techniques that they can use at home. These include the following:
a. Write a plan. Create a safety plan when a bipolar child rages. The plan should include what other family members should do in the event of a crisis. A sibling might be instructed to lock themselves in their parent’s bedroom or run to a neighbor’s home. Emergency phone numbers—a mobile crisis team if available, mental health hot lines, local police—should all be programmed into your telephone. If you’ve tried other measures and you believe that you, your child, or others are in danger, don’t hesitate to call for help.
b. Check you own mood. When your child’s mood is volatile, ask yourself if he or she is reflecting your own mood. If you are not composed and collected, you will not be able to handle your child’s lack of composure. The last thing you want is to fuel his or her fire.
c. Detox. If you are on the road or in a public place when the rage begins, try to eliminate or reduce all stimuli both auditory and visual, as well as smells and motion. If you are in a car, switch off the radio and pull over. If you are inside, go outside. If you are in a crowded public place such as a supermarket, leave your shopping cart in the stores, and take your child to a quiet spot either outside the market or near the rest rooms, where she can "detox" from the mood. Sit with him or her quietly and take deep breaths. Hopefully, your child will follow your lead.
d. Hydrotherapy. There is something to be said for the healing powers of water, whether it is a warm spa bath with herbal chamomile aromas or a pounding shower to wash the angst out of the system. If your child can be reasoned with, or as he or she is "cooling down" after an exhausting rage, draw her a bath or shower. The water will refresh, rejuvenate, and help your child focus.
In this section, we presented four steps to cope with a raging bipolar child client: Creating a safe environment; disengaging the child; knowing your comfort zone; and rechanneling. We also included four techniques parents can use when their child begins to rage at home, write a plan, check your own mood, detox, and hydrotherapy.
In the next section, we will examine techniques to cope with a paranoid or fearful bipolar child client. Three techniques for treating a paranoid client are: Waiting It Out; Reality Check; and Staying on Guard. Two techniques for treating a fearful client are: Breathing Exercises; and Counting.
Peer-Reviewed Journal Article References:
Jenkins, M. M., & Youngstrom, E. A. (2016). A randomized controlled trial of cognitive debiasing improves assessment and treatment selection for pediatric bipolar disorder. Journal of Consulting and Clinical Psychology, 84(4), 323–333.
Unger, K. V. (1992). Review of Learning to cope with depression and manic depression: A workbook for people who experience extreme high and low moods and for people who love and support them [Review of the book Learning to cope with depression and manic depression: A workbook for people who experience extreme high and low moods and for people who love and support them, by M. E. Copeland]. Psychosocial Rehabilitation Journal, 16(1), 177–178.
Veseth, M., Binder, P.-E., Borg, M., & Davidson, L. (2016). Recovery in bipolar disorders: Experienced therapists’ view of their patients’ struggles and efforts when facing a severe mental illness. Journal of Psychotherapy Integration, 26(4), 437–449.
Youngerman, J. K., & Canino, I. A. (1983). Violent kids, violent parents: Family pharmacotherapy. American Journal of Orthopsychiatry, 53(1), 152–156.
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