Ben Furman – Understanding and Dealing With Adolescent Rage

On MIA Radio this week, in the second of a number of podcasts focused on parenting issues, we interview Ben Furman MD. Ben is a Finnish psychiatrist, psychotherapist and internationally renowned teacher of the Solution-Focused approach to preventing and treating mental health problems in both children and adults. His numerous books have been translated into over 20 languages.

What follows is a transcript of the interview, edited for clarity.

*****

Miranda Spencer (MS): Hello and welcome to the Mad in the Family podcast. I’m Miranda Spencer, editor of Mad in America’s Parent Resources section. Today’s topic is adolescent rage: understanding and dealing with teenagers and young adults who are angry and explosive. If they enter the mental health system, these youth might typically receive a psychiatric label of “Oppositional Defiant Disorder” or perhaps “Bipolar Disorder” and be prescribed drugs such as neuroleptics. We’re going to look at some alternatives to that path.

Our guest today is Ben Furman, MD. Dr. Furman is a psychiatrist in Finland and an internationally renowned teacher of solutions-focused therapy. He is the founder of the child-friendly Kids’ Skills method, which is based on the idea of converting children’s problems into skills that children can learn with the help of their family and friends. Ben is one of our resident experts for the Parent Resources page’s Question and Answer section and his essay called “Helping Children with Angry Outbursts” is another one of the resources there.

Welcome.

Ben Furman (BF): Thank you very much. It will be a pleasure to talk with you.

MS: You’ve written a lot about helping younger children who express explosive anger, tantrums, and hitting and so on, and their parents and teachers– how to how to help them all cope better.

But what about the older kids? I hear so many parents who say their teenager is defiant, aggressive, even violent to family members and to others. And these parents say that they’re not only concerned about the disruption and why their daughter or son is so angry, but also that they feel they have to walk on eggshells, and they’re even worried that their child may wind up in prison someday. So, what is this all about? From your perspective, how does solution-focused therapy look at such young people and what methods exist to break the cycle and change whatever underlies those types of behaviors?

BF: Yes, thank you. That is a very important question, particularly in this day and age when all forms of aggression seem to be so ubiquitous; it’s not only teenagers. There are a lot of adults who have aggression problems, there are even five-year-olds who have terrible tantrums. And so, we really are looking for different kinds of tools to stop that kind of behavior.

And you know, the first thing that people usually do when somebody becomes angry is that you, also, become angry. That’s not a very good idea, because it leads to escalation. So, we have to think about other ways of approaching aggressive children, teenagers and adults.

Now, I would like to start with how to train parents to deal with their aggressive kids. I just spoke and met John Sharry from Dublin, Ireland, he is a social worker who teaches parents how to deal better with their kids, teenagers. What they have done in Ireland, which I think will be a very good idea to do in every country, is videotapes—short clips of videos where you can see a mother and a teenager. And the mother says to the teenager, “Tonight you cannot go out with your friends because tonight we get some visitors to our family,” and the teenager starts to yell and shout and say “You cannot dictate [to] me! Why did you promise something like that? You are an idiot!” Verbal aggression that the teenager shows on the video toward his mother. And everybody, all the parents, can see this scene. Then they stop the video and they say “What would you do in that situation? How would you deal with a teenager who goes into a rage and starts shouting and so on?”

And then a lot of the parents say, “That’s exactly like our child, our daughter does exactly like that. Our son does exactly like that, and we don’t know what to do with him. He must have some kind of psychological problem. Even the doctor said that he has ADHD” (or this diagnosis or that diagnosis).

But at the end of the day, it doesn’t matter what diagnosis the child has, because all we have to do is think about what to do in such a situation. Well, then, when parents have discussed this— and they all have their own ideas and so on—you can see (on the video) how the recommendation works. And the recommendation is that the parent, the mother, looks at the child or teenager and says, “You are too emotional right now. We cannot talk. I will leave.” The mother doesn’t tell the son to leave. “I will leave, and we will continue to talk when you have calmed down.” So, this we can see on the video, how the mother does this to the child.

And then you stop the video and then you talk with the parents: “What do you think about this?” Some people would say, “That would not work with my child.” Others would say “Well, we have to try it.” And the parents would kind of start to get ideas of how they can behave differently, how they can learn not to accept verbal aggression from their child. The technique— maybe we could call it non-violent resistance, if you like — like a kind of a Gandhi technique where you are teaching the child, “I’m not going to speak with you at all if you are going to shout at me and therefore I’m going to leave and we can continue talking when you have calmed down.”

That’s the basic tool that all parents who have aggressive children have to learn. And I don’t know how to teach that, because it doesn’t help if I explain how to do it. You actually have to see it on the video, then you have to go home, and you have to try it with your out-of-control teenager to find out for yourself how it works.

MS: Right, now what is this video that you’re referencing?

BF: It is a teaching video that is part of a parent training program. There are hundreds and hundreds of parent-training programs all around the world. I’m just referring to one of them. But all parent-training programs that exist in the world, they all have something similar. Programs where the parents who take these training courses on how to become better at dealing with their out-of-control children, their behavioral problem children, or aggressive children. They all have to learn this. And there are many ways of teaching it. I just mentioned this because I think to show it in the video is a very good way to teach it. Of course, you can also role-play. “OK: I will play your child. I will be the angry child. Now I’m going to shout at you, I’m going to tell you you’re an idiot, I’m going to tell you whatever obscenities come into my mind and you will have to show me that you will not respond to me.”

You will not say something like, “Don’t speak to me like that.” And you’ll not say the ordinary things. You calm yourself down and you say, “I am going to leave. This is not a good way to talk. We can talk in a minute when you have calmed down.”

MS: Would it be a similar situation if the child is being physically violent? Say he is smashing up his room or something like that.

BF: This is just one element. I thought that it would be a good place to start: when a child starts shouting at you, yelling at you, calling you names; how to deal with children who do that kind of thing. First, you have to learn this because there is an escalation process, meaning that if you allow the child to shout and yell at you, then it tends to become worse over time. So, then soon they not only yell at you, but they actually start throwing things, or they start to break things, or they start to attack you physically or something. And then we have to think about the next step. And it is very important to tell children that this is not OK, we don’t accept these kinds of behavior.

The Israeli psychologist that I always like to mention, his name is Haim Omer, He is a professor of psychology at Tel Aviv University, now retired. He wrote many books about how parents can become better at dealing with their impossible children or aggressive children. And these books are very, very popular in Central Europe, in Germany, in Austria and Switzerland. Many countries have found these ideas very useful. I’m hoping that also on the other continents of the globe people would find these ideas useful. But the idea is that when parents try to send a message to their child that you cannot be physical, you cannot hit your mother, you cannot hit your brother, you are not allowed to. It’s not okay to be physical. And if parents try to send that message to their child, first of all they have to be very calm. So, they need a lot of support from other people.

Haim Omer is saying that parents need broader shoulders. This “broader shoulders” is a metaphor, and it means that the parents need other people like grandparents and cousins, aunties, uncles, neighbors, football coaches, teachers. Parents are advised to hook up with maybe other parents… there may be a godmother, godfather family, uncles… Anybody they can find who belongs to their social network and then this social network becomes active. And the social network—not only the parents alone—the parents together with their social network, they send the message to the child. They actually write it down. It’s called an announcement, a written announcement signed not only by parents but also by the other people in the social network. It’s like a “community action”. If I use that word maybe it makes sense.

So, the parents alone cannot do anything. It’s impossible. They are in a struggle with their child. The only thing that they can do is what I described previousl. They can… “I’m not going to listen to you yelling at me. We will talk in a minute when you have calmed yourself down.” But if there is physical aggression, the social network, or the community, has to take a stand. …And they would actually tell the youngster that, “This is not OK. You cannot hit your mother” or “You cannot be physically aggressive toward your own parent.” And if this is not enough, then we also have to do something about it. So, then somebody has to talk with that youngster and maybe the best person is not the parents. Maybe it should be someone else. And it doesn’t have to be a psychologist and it doesn’t have to be a psychiatrist or a social worker or a family worker. It can also be an uncle. It can be a grandfather. It can be whoever has some kind of relationship with that young person. And then if the person has been violent, I always recommend that the first thing to do is to apologize. If I were speaking with a youngster I would say, “You know, I heard that you have been aggressive to your mother. You know that it’s not okay. I think you owe an apology to your mother.”

[In teenager’s voice] “Bah! I don’t owe her apology. My mother is an idiot. Grr, grr.” The teenager will start to rage. So, it takes a while to explain to them that your mother may have her faults and she may also have to apologize to you. But the violence is not acceptable and it’s very difficult to help anyone if we don’t do something about it and we can start with that problem.

MS: So, I think the child probably doesn’t feel good about what’s going on, either. They’re not happy that they’re raging. What I’m hearing you say is first with parents— it starts with them. Start with yourself rather than the child. And also that, as the saying goes, ‘It takes a village.’ This community approach.

BF: Yes. Correct.

MS: Do you have an example or two of a real-life situation where you used the solution-focused approach to get a child with a lot of rage, a teenager specifically or a young adult, to change and evolve and the situation to de-escalate?

BF: I’ll tell you another story. This is an adult case that I haven’t written down, but I thought it’s such a wonderful story so maybe it’s worth telling. This ‘teenager’ was 50 years old. So, the guy is not anymore a teenager but he was behaving like the worst kind of teenager. He was in a psychiatric hospital and he had a reputation of having some terrible tantrums, and he would scream and shout and he wanted the police to come, he wanted the ambulance to come, and the hospital informed that this patient was…they described him as a person who has no impulse control whatsoever. And so that was the reputation of the patient.

It is unimportant what was the diagnosis, but the situation was this: This man was going to be removed from the psychiatric hospital and referred to a residential treatment center, where patients who don’t need to be in the hospital can live and have some kind of a life, a little bit more normal life than you would have in a hospital. So, the administrator, the boss of the residential treatment center, met with this guy.  She said, “You know, if you come to our residential treatment center, you cannot have any of those rage attacks. You cannot have any shouting. We don’t tolerate any shouting here. We don’t accept that kind of behavior that you are famous for, that you have done so many times. And the hospital said that you have no impulse control. So, you have to learn to calm yourself down if you want to come here….” So, he is like, “Ah, I cannot control myself. I’m not able to control myself.”

“Well, l we have to think about something that you can do in the moment when you start to get angry or when you start to get into a rage. What can you do in that situation?” The guy said obviously, “Uh, I don’t know what to do. Nothing helps.” She said, “Well, we have to think about something. And then we have to agree on something that you are going to do in the moment when you ‘go crazy’ like that. We prepare for the next time.”

This, I think, is a very important principle. That the manager of the residential treatment center understood that you have to prepare for the next one.  You may apologize for the previous one, but you have to start by saying “Is it likely that this will happen again? OK, let’s start to prepare. Let’s start to make a plan, for what to do next time when you start to get out of control.” So, the manager suggested all kinds of things, including taking a cold shower. The guy was, “No, no. I’m not going to take any cold showers. I’m not interested. This is not a good idea.” So, the manager said “OK, I can suggest something more to you. But you also may have your own ideas. What are your own ideas?” The guy said, “I don’t have any of my own ideas!”

“OK, so Let me let me think about something that might help you.”

Then the manager comes to the guy and says, “I have an idea. Let’s see what you think about it. Have you heard about the vagus nerve?” the manager asks him. You know, a popular concept, the vagus nerve right now because there is this polyvagal theory and so on. So, she says, “If you take an ice cube into your mouth and you swallow the cold water, the cold water will go down your esophagus and it will affect the vagus nerve and it will help you calm down, even in the moment when your blood is boiling.” So, the guy says, “OK, I’m willing to try that.”  For some reason, he accepted this method.

And so, they started to prepare. There were a couple of freezers in the residential treatment center so together the patient and the manager fixed certain shelves in the freezers where they put plastic bags filled with water to create ice cubes. And then there was a little work to be done, you know, to get the ice cubes right. And to practice grabbing an ice cube in the heat of the moment. After that, the whole residential treatment staff and all the other patients were told that he’s going to use these ice cubes when he starts to get mad.

So now we are back to the community approach, aren’t we, because this is not about you and your ice cubes. This is about the whole community participating in a plan and the plan is that “when you start to get mad, we will remind you of your ice cubes. We will get out of the way so you can run to the freezer as quickly as you can so that you can grab the ice cubes.” And so, this was like a community approach. Everybody participated in figuring out what you could do to calm yourself down when you lose control. Everybody was prepared to remind him of the ice cubes when he would next time start to ‘go crazy.’ Everybody had a strategy. Everybody knew that if you see him starting to go wild or starting to escalate, everybody knew that they could say to him, “Get ice cubes! You need the ice cubes!” And so, the manager told this story and she said that the person had stayed one year already at the residential treatment center and there had been no incidents at all.

MS: So, did he ever use the ice cubes?

BF: Never. He never needed to use the ice cubes.

MS: So, it was more of a concept than any real science behind ice cubes helping you calm down.

BF: Yeah, the manager probably had heard the idea from somewhere and I think it’s been used, so it’s not a totally off-the-wall idea, but it was never used because the community was now prepared, and everybody was kind to him. He was not punished for his behavior. He felt that everybody wanted to help him. And the message was very clear. “We don’t accept that kind of behavior in this residential treatment center. And we believe you can control yourself, and if it is too difficult for you to control yourself, we will be there to help you. And we will think about some method. Now, of course, it doesn’t have to be ice cubes. It can be whatever. It can be even tickling your neck, or massaging your feet, or speaking to you silently, or whispering secret passwords that will help you calm down. We can always find something that will help you. And this is not only for aggression against other people. Exactly the same methods can be used for cutting. You know how big a problem cutting is now, all over the world.

MS: Yes.

BF: We already have teenagers who start cutting at the age of twelve and then by the time they are fifteen they have scars all over their legs and arms and no one knows how to get rid of those scars. They will be there for the rest of your life unless they do skin grafting or something. But these are impulsive acts. People are very impulsive, and they cut themselves or they attack someone, or they break stuff, or they start shouting. Whether they are smaller children, whether they are teenagers, whether they’re fifty-year-old ‘chronic’ psychiatric patients, even many, many people who have an intellectual disability can have aggressive behavior.

Another similar case was a guy who was 20 years old, a man with an intellectual disability in a psychiatric hospital. He had been so aggressive: He attacked people for the mildest, smallest frustration. He was known to hit people, and the hitting had become so bad that they had put him into a psychiatric hospital, where they of course use these drugs. That’s not a very good solution for aggressive behavior, because you know it doesn’t solve the problem at all. It doesn’t help the person to develop any kind of self-control.

Very similar story. This 20-year-old BIG guy; everybody is scared of him because he’s so big. Actually, this young man was using kind of a straitjacket in the hospital. And I’m not talking about the kind of straitjacket in the hospital. Not the kind of thing you see in One Flew Over the Cuckoo’s Nest. There are also modern straitjackets where you can move your hands, you can eat, and you can do stuff but the movement is restricted so you cannot reach out, you cannot hit people in the same way as you could. So, this guy was wearing one of these every day. So, the nurse went to him and said, “You know, I can help you get out of this hospital.”

He didn’t want to be there. He hated it there. He wanted to go home to his parents, and he wanted to continue his shelter work. He was working in a shelter. And so, the nurse said— and now you are going to hear exactly the same story again, just another version— he said, “I can help you get out of here, which is what you want, right?”

He said, “How can you help?”

“Well, you have to learn a skill.”

“What skill do I need to learn?”

“You have to learn that when you become upset, you cannot hit anyone. You have to do something else instead. What’s it going to be?” And I like these words, when you say, “You cannot hit anyone. I can help you. We have to find for you something else that you can do in those situations when you become upset.” And then you ask the person: “So what could it be? What can you do to calm yourself down in that situation when you start to go into a rage?”

And this man, he said: “I can go on my knees and I can shout, ‘Nurse, help!’”

MS: Wow.

We are in a hospital. You can shout, “Nurse” So, this nurse, male nurse said,

“That sounds like a good idea. Let’s see how it works in practice. Let’s get you angry. Let’s test the idea. I want to see you do that. So, let’s imagine you are now angry, you are getting angry because something happened. We have to pretend.”  There was a kind of a pretend element. You might call it role-play, of course. So, there’s a pretend element: “Now we practice you getting angry and then you have to show me that you can do these things.” And the thing was getting on your knees and shouting “Nurse help!” He practiced. He had to show every staff member how he’s going to do it. He even showed his doctor: “I have been talking with my nurse. I’m going to do this. I’m going to go on my knees like this, and I’m going to shout, ‘Nurse help!’”

The whole community is now participating again. This was not only between the nurse and patient. This whole community was participating, including the doctor. And then comes the next question—and this is another very important part. And it is: So, what if we can see that there is fire coming out of your eyes? Meaning that we can see that you are getting angry. From your breathing, or from your hands or from eyes or from your face. From whatever signs there are. So, what do you want us to do? How do you want us to remind you of what you need to do? And then he said, “You can tell me ‘Remember the hands.’”

“OK, so you want us to tell you ‘Remember the hands’?” “Yes. I want you to tell me to remember the hands.” OK, so what does that mean? It meant that when he went down on his knees and he shouted “Nurse, help!” at the same time he also—can I say hugged himself? He like put his arms around himself to make sure he doesn’t hit anyone! He cuddled himself. “Nurse help”. You can see the picture of a big guy going on his knees, and actually on one knee. He would go on one knee and he would cuddle himself, and he would shout, “Nurse, help!”  And this was what he’d needed to learn.

And so, everybody, the whole community—this is the psychiatric ward, of course in this case—but the parents, he had parents, couldn’t take him home because he was so aggressive at home, to his siblings. So, this was also a big problem, his aggressivity. And so, he learned, because everybody was helping him to practice the art of going down on your knees and shouting “Nurse, help!” And everybody reminding him by saying “Remember the hands!” So, this is actually a very simple idea, but it can be applied to all kinds of cases and it needs community involvement.

MS: Right. That’s really interesting because, as you say, it’s so across the board. A parent can do it, a child can do it, anyone, at any age. One question I had. Speaking of residential treatment in hospitals, some parents say, “My kid is out of control and I’m really thinking that he or she needs to go live in a residential treatment for a while.” What can you say to them to convince them maybe they should still stay at home? Or what would you say to that?

BF: I think you are touching on a super-important problem because this is not only a problem of residential treatment centers. So what could happen in our system, in our social work and in our psychiatry and in psychology is that when parents are at wits’ end with their children because of aggressive behavior or verbal aggression or physical aggression or cutting or drugs or suicidal behavior, the parents don’t know what to do. So then obviously they’re going to seek help somewhere and, depending where they seek help… But all over the world it’s very common that the message that the parents get is that “You are not capable of handling your child. Therefore, we will remove the child from you, and we will put that child into an institution, or into a foster home, or into some other place because you are not capable of handling your difficult child.”

Now obviously, the other alternative would be to help parents deal with their ‘impossible’ offspring and to give them tools and help them think about what they could do and how they could invite and recruit their social network to become helpful for them so that they could take care of the problem rather than shove it to society. And then society is supposed to take care of it. Now, even if society was very good at taking care of it, that wouldn’t be a big problem because you would say, “I cannot handle my child, take care of him!” Then if somebody actually was able to take care of them, then maybe that would be a good solution. But what is true is the opposite. So, when they then take the child into custody, and they put the child into a foster family, or they put the child into an institution, they don’t know how to do it, they don’t know any better. So, then we have an escalation where the problem just gets worse and worse. And then you have to put them into more secure facilities. And now we have to go into the next level of institutional security. And of course, any family therapist in the world—my original training is in family therapy—would recommend the other approach, where we actually empower the parents to handle the situation. Not alone, but together with the support of their extended family.

MS: Right. What I see a lot is parents saying that they do feel very alone and that some of the motivation to institutionalize their teenager is because perhaps they’re divorced, and their ex-spouse isn’t supportive. They don’t know how to talk to their friends. So yeah, the whole idea of getting that support group I think could not only help the parent help the child, but also help the parent help themselves.

One last question. Looking at the angry teenagers and angry young adults, I can just imagine myself at that age if I was full of rage. You know, “I don’t want to collaborate with my parents and teachers, it makes me feel like a baby. I’m resisting your authority; I don’t want to work with you!” So how do you deal with the child who just feels like, “I’m not working with my parents, they suck!”

BF: And so maybe that’s the reason why many professionals nowadays are thinking that we don’t have to force the kids to come to us. For example, if you think about Heim Omer, the psychology professor from Israel. So, his recommendation is – let’s say original recommendation because nowadays they have started to work with the kids too – but the recommendation is that you start with the parents. And you invite them to a session, tell them about the idea that you, parents, will need help. You have to get broader shoulders. You have to calm down. You have to learn to not respond to your teenager and you have to send your teenager a clear message in a written form that you don’t accept this kind of behavior and you want your child to learn to calm himself down, or go to school, or take care of whatever it is that you want, and then this wouldn’t be possible without the support of the social network.

So, one solution is to not force the kids to do any kind of therapy. If they don’t want to come into any kind of therapy, we can work through the parents; we can empower the parents. And when I say empower the parents, I don’t mean just empowering the parents, but empowering the social network, meaning grandparents and so on. You know that when parents are told they might want to engage the grandparents, they typically say, “No, we don’t want to bother the grandparents. The grandparents are sick. They have their own problems. They have their illnesses. We haven’t even told them that our child has this kind of problems. We keep it secret from the extended family, so nobody knows that we are struggling with our teenager.”

So, the first step in this kind of an approach is to start to break the ice; break the resistance, because when you finally tell the grandparents that we are in trouble with our teenager, typically the grandparents say, “Why haven’t you told us before? We can talk to him! We are here for him. It is our grandchild and we want to help. We have been just waiting for the call so that we can be helpful!”

So, then it turns out that everybody wants to be helpful, and everybody wants to do something to help the parents who are at their wit’s end with their child. And it’s a very different approach from putting a psychiatric label on their child. That is very easy. Certainly, the child would meet the criteria for more than one psychiatric disturbance. It’s very easy to put psychiatric labels, it’s very easy to put kids on medication. It’s very easy to take the child into custody. It’s very easy to make a referral to an institution where they are not any better at helping the kids as the parents would be with some support and some advice and some suggestions about how to work and speak with their teenager.

I had one teenager; the parents came to me many years ago. I will always remember that case. They said “Our child is impossible. He doesn’t go to school, he doesn’t go to work.” I don’t remember the age, maybe 17 or 18 or something, “…and we want him to see a psychiatrist, but he refuses to see a psychiatrist. What to do?” And they were almost suggesting could I dress up like a pizza delivery man and visit their home, to get him to talk to me? I said, “I don’t think that would work.” But I said tell me about him. Sit down. I want to hear everything about him. What is his talent? What do you love about him? What good qualities does he have? What are you worried about?” and so on. And I said, “Tell me all this information and I will write him a letter.” You know, it was many years ago but there were already computers and I was sitting probably for half an hour just typing a letter to the young man, in which I would say, “I heard from your parents that they love you very much, and they care about you, and they want to help you, and they’re worried about you. And they told me that you are talented at this and you are talented at that.” And then I said to the parents, “Give his letter to him.” Let’s see. And in the end of the letter I of course —maybe that’s obvious—I said, “Your parents are asking me for advice on how they can be helpful to you. And I thought I’d better not give them advice before I’ve talked to you and heard your opinion and your side of the story.” That’s what I said, which I thought was an obvious kind of intervention. And then later the parents contacted me, and they said that they never gave the letter to the boy. My letter! I was almost offended: “You didn’t give my letter? I used half an hour to write that letter!” They said, “We read your letter many times and we learned from your letter how to talk with him.”

MS: Wow.

BF: So, also the young people who have difficulty in controlling their rage, they also need some respect, some caring. They know, they should know, that we care, and we want to help them. And there are ways and they could learn, and find out about these ways. And we can help people control their [rage], whether they are fifty years old or five years old. It actually doesn’t matter.

MS: Well, we have to wrap up now. Thank you so much for being with us.

BF: Thank you.

MS: Listeners who want to learn more about Kids’Skills can watch the video on Mad in America’s Parent Resources page, or download the Kids’Skills app at www.kidsskillsapp.com. I’m Miranda Spencer and this has been Mad in the Family.

Relevant Links

Helping Children With Angry Outbursts

The Kid Skills App