Tag Archives: attachment

Engaging avoidant teens

By David Flack May 4, 2020

Ben** is a 16-year-old high school sophomore. He completed a mental health assessment about four months ago, following a referral from his school due to behavioral concerns, poor attendance and “possible issues with marijuana and other substances.” He previously attended school-based mental health counseling in seventh grade and has been meeting periodically with a school counselor for about a year.

(** Ben is a former client who gave permission to use his story. His name and some identifying details have been changed to protect confidentiality.)

At the time of assessment, Ben was diagnosed with major depressive disorder, moderate. He also completed screening questionnaires for trauma, anxiety and various other issues. All scores came back well below clinical levels. Despite the school’s concerns regarding substances, a formal drug assessment didn’t occur.

Todd and Julie, Ben’s parents, have been divorced since Ben was 3. Ben lived with his mother until about a year ago. Todd now has full custody but frequently travels for work. Both parents have been fairly disengaged in the counseling process. In fact, Doris, Ben’s fraternal grandmother, was the only family member to attend the assessment.

At the assessment, Doris appeared overly enmeshed with both Ben and Todd. She also reported that Julie “has bipolar but won’t take any meds” and “drinks too much, at least if you ask me.” Doris also stated that Ben “probably was abused” by Julie’s ex-boyfriend but refused to provide further details. “I don’t think I should have said anything.”

Following the assessment, Ben entered services reluctantly, meeting with his original counselor for almost two months. At that time, he was referred to me because the original counselor decided, “I can’t be effective with such a resistant kid.” The counselor said Ben’s attendance was poor and that he displayed an unwillingness to engage when present, did not complete treatment homework, and “showed up high at least a few times.”

During our first meeting, Ben reported, “All that other therapist did was keep saying how her office was a safe space to talk about feelings and crap like that. You know, the bullshit therapists always say. The bullshit I bet you’ll say too.”

Numerous studies show that an effective therapeutic alliance is essential for engagement, retention and positive treatment outcomes. However, many teenage clients simply aren’t interested in counseling, let alone creating connection or building rapport with some strange adult. This is especially true when it comes to avoidantly attached teens such as Ben.

Building effective therapeutic alliances with these youth can seem daunting to even the most seasoned counselor. In this article, we’ll explore practical, field-tested strategies for cultivating rapport with avoidantly attached teens. First, though, let’s briefly review some core attachment ideas.

We aren’t sea turtles

When a mother sea turtle is ready to lay eggs, she heads to a beach and digs a hole in the sand with her rear fins. She lays her eggs in this rudimentary nest, covers them, and quickly returns to the ocean. At this point, the mother sea turtle has completed all her parenting tasks and has nothing more to do with the eggs. Male sea turtles have nothing at all to do with their offspring.

When the eggs hatch, the newborn sea turtles awkwardly scamper to the ocean, using fins meant for swimming, not avoiding predators on land. If they survive this mad dash, they’re fully ready to live on their own. No caregiver ever provides nurturing, teaches them life skills or protects them in any other way.

Humans aren’t sea turtles. In our early years, we need caregivers just to survive. If these caregivers are attentive, protective and nurturing, human babies quickly learn that the world is a safe place, their needs will be met and people are glad they’re here. These children will be securely attached. However, if their primary caregiver isn’t dependable, then this healthy attachment process can be disrupted, resulting in an insecure attachment and possibly lifelong challenges with relationships, self-esteem and personality development.

There are three styles of insecure attachment: avoidant, anxious and disorganized. Avoidant attachment is the most common style of insecure attachment, with studies indicating that up to 1 in 4 Americans fall into this category. Undoubtedly, this percentage is higher in clinical settings.

Young children who develop an avoidant attachment style predictably have caregivers who are emotionally unavailable and ignore the child’s needs. These caregivers may reject the child when hurt or sick, typically encourage premature independence, and sometimes are overtly neglectful. As a result, the child learns, “I’m on my own.”

Attachment styles are continuums, so avoidantly attached teens don’t all act the same. That said, these youth often appear defiant, defensive or dismissive. They’re likely to present as highly independent, oppositional and unwilling to change. They’re also likely to be suspicious of any empathetic gesture.

A little more about empathy

Simply put, empathy is the ability to understand the feelings of another person. As counselors, we’re taught that empathy is an essential component of all effective therapeutic relationships. I certainly don’t disagree with this. However, it seems to me that empathetic gestures are far from one-size-fits-all.

With reluctant clients of all ages, many counselors demonstrate empathy by saying things such as, “Seeking support is a courageous step” or “My office is a safe space to explore your feelings.” It’s like turning the volume up on some secret empathy knob. With anxiously attached clients, this could be quite effective. For avoidantly attached teens though, this is often overwhelming. Life has taught these youth to be cautious of such statements. So, when they hear such statements, they retreat.

I’m certainly not suggesting that we turn our empathy off as counselors. However, in the early stages of building therapeutic alliances with avoidantly attached teens, we need to turn the volume down. With this in mind, don’t congratulate avoidantly attached teens for starting counseling, especially if doing so is simply their least bad choice, and don’t declare your office a safe space. They know better.

I believe this more nuanced perspective of empathy is an essential foundation for engaging in the attachment-informed strategies that follow.

Starting out right

With avoidantly attached teens, first impressions are essential for starting out right. Here are four tips to help ensure that first meetings are therapeutically productive:

Emphasize rapport building. First meetings often involve stacks of paperwork, required screening tools and initial treatment planning. I encourage you to put that stuff aside and spend time getting to know the teen sitting across from you. You’ll have to finish all those forms eventually, but if this new client never returns, tidy paperwork and a well-crafted diagnosis won’t matter much. Besides, you’ll get better answers from teens such as Ben once you’ve developed some rapport.

Get parents out of the room. Unlike Todd and Julie, parents or caregivers almost always attend first meetings. When they do, I meet with everyone to cover the basics, such as presenting concerns, my background, and confidentiality issues. I then ask parents what they think I should know. After I get their perspective, I have them leave. That way, most of the first meeting can be focused on learning what the teen wants from services and cultivating rapport.

Focus on what they’re willing to do. Therapists love to focus on internal motivators and lofty treatment goals, but this isn’t useful with avoidantly attached teens, who want one thing — to leave and never come back. You’ll get further by helping them identify external motivators, such as fulfilling probation requirements or keeping parents happy. Helping avoidantly attached teens move toward these concrete goals proves that you’ve actually listened to what they’ve said, makes you an ally, and keeps them coming back.

Don’t hard sell therapy. When confronted with resistant clients, it’s easy to overstate the advantages of engagement. After all, if we didn’t believe in therapy, we wouldn’t be therapists, right? However, our enthusiasm may be exactly what an avoidantly attached teen needs to justify a quick retreat. Instead, objectively present your treatment recommendations, then explore the pros and cons of engaging. In my experience, most avoidantly attached teens agree to services when they don’t feel coerced.

With the first meeting successfully concluded, our next task is to cultivate an effective therapeutic alliance. Edward Bordin (1979) wrote that the therapeutic alliance is composed of
1) a positive bond between the therapist and client, 2) a collaborative approach to the tasks of counseling and 3) mutual agreement regarding treatment goals. When we strive to fully integrate these elements and genuinely embrace a teen’s motivators, we stop being an adversary and become an ally. For avoidantly attached teens, we also become a much-needed secure base — maybe their only one.

Building a strong therapeutic alliance with avoidantly attached teens requires us to focus on being trustworthy and creating connectedness.

Trustworthiness

Avoidantly attached teens have learned to continuously question the honesty of others. As a result, it is essential for us to be absolutely impeccable in our trustworthiness as counselors. It isn’t enough simply to be trustworthy though; we must demonstrate it — and not just once or twice but during every single interaction.

Brené Brown (2015) likened trust to a jar of marbles. Every time that we demonstrate our trustworthiness, we put a metaphorical marble in the jar. As the jar fills, trust grows. When it comes to building therapeutic alliance with avoidantly attached teens, there are five especially important marbles:

Authenticity. In the context of therapeutic alliance, authenticity means being our true, genuine selves during interactions with clients. In other words, we set aside therapeutic personas and canned responses. Instead, we show up as who we really are. This should be our goal with all clients but especially so with avoidantly attached teens, who are often quite sensitive to insincere behaviors or actions — a skill they learned to help them navigate difficult relationships with the adults in their lives.

Consistency. Being consistent means acting in ways that are predictable and reliable, something avoidantly attached teens probably haven’t experienced much. When we are consistent in our interactions with these teens, we are not only demonstrating trustworthiness but also modeling a new way of being in relationships. A few ways to demonstrate consistency include always starting and ending sessions on time, scheduling appointments at the same time every week, and following through on any promises we make.

Nonjudgment. Avoidantly attached teens have often learned to notice seemingly minor cues, such as a slight change in facial expression. This is a useful skill to have in situations in which care is unpredictable. With that in mind, it is important for us to avoid comments, gestures or facial expressions that could be interpreted as judgmental. This seems obvious but can be harder than it sounds, especially when a client is frustrating, evasive or baiting us — you know, like teens do sometimes.

Usefulness. Another way to demonstrate trustworthiness is to provide something useful at every session. This doesn’t mean achieving a major clinical breakthrough every week. That wouldn’t be realistic. However, there should be a tangible takeaway of some sort each time that we meet with an avoidantly attached teen. Possibilities include a helpful skill, a solved problem, an opportunity to vent or a meaningful insight — as long as it adds value to the youth’s life.

Transparency. This means being completely open about the therapy process, including our intentions as a helper and what clients should expect from services. Truly transparent therapists spend time exploring the pros and cons of counseling, reasons for discussing certain topics, and the theoretical underpinnings of proposed treatment approaches. In other words, transparent therapists strive to eliminate the mystery from the process. Like a good magic trick, knowing how it works should make it more engaging.

Connectedness

According to Edward Hallowell (1993), connectedness is “a sense of belonging, or a sense of accompaniment. It is that feeling in your bones that you are not alone.” I often describe this deep connectedness as feeling felt. In order for any of us to truly feel felt, we must believe that we are understood, respected and welcomed. We must feel as though we’re interacting with another person who has purposefully chosen to join us in this exact place and moment.

Avoidantly attached teens haven’t had this lived experience of connectedness. When working with these teens, we should always strive to model connectedness in ways that honor their implicit suspicion of empathy, while simultaneously helping them move toward more secure attachment styles.

Allan Schore (2019) refers to these as “right brain to right brain” connections. We can intentionally create such connections by using approaches that focus on emotion, creativity and attunement. It seems to me that teen therapy typically focuses on problem-solving, decision-making, psychoeducation and similar left-brain approaches, ignoring the importance of helping clients become more comfortable using their whole brain.

Here are five simple yet effective strategies for intentionally fostering right-brain connections:

Validate and normalize. Viewed in the context of his lived experiences, Ben’s distrust, oppositional behavior and even substance use were functional. In other words, Ben found value in these behaviors. In fact, he once said, “I guess what I really want is to push people away, and I’m good at it. Really good!” We can validate intentions without endorsing problematic behaviors. With avoidantly attached teens, this is often an essential step to building therapeutic alliances.

Use first-person plural language. The words we use matter. Here’s one example: Instead of using the pronouns “you” and “your,” shift to “we” and “our.” This shift results in a subtle, yet tangible, change in our interactions with avoidantly attached teens. It also helps reinforce that we’re together in the process and that the teen’s experiences are understandable. I’m not sure that clients overtly notice this word usage, but I definitely believe there is value in making the shift.

Use more reflections, ask fewer questions. Most therapists ask way too many questions. To an avoidantly attached teen, questions can seem intrusive, annoying and disingenuous. It may seem counterintuitive, but fewer questions from you will actually result in more talking by the client. Instead of all those questions, use reflections. While you’re at it, avoid cautiously worded reflections. Instead, commit to what you’re saying, with statements of fact such as, “That was tough for you.” Such statements demonstrate connection, not interrogation.

Talk less, do more. From a developmental perspective, full-on talk therapy isn’t the best fit for teens, especially for avoidantly attached ones who don’t want to engage in the first place. I suggest incorporating some no-talk approaches for building rapport and addressing therapeutic goals. The card games Exploding Kittens and Fluxx are excellent choices for building rapport. They are teen-friendly, easy to learn and filled with opportunities for making metaphors. Favorite therapeutically focused activities include collages, creative journaling and walk/talk sessions.

Be fully present. Being present means having your focus, attention, thoughts and feelings all fixed on the here and now — in this case, the current session with the current client. From my perspective, this requires more than a basic attentiveness. It requires being fully engaged, human to human, with no judgment or agenda. This level of presence can feel risky at times, for counselors and for avoidantly attached teens. However, the connectedness it brings makes the risk well worth taking.

Relationships are reciprocal

Imagine your response if a client reported being in a relationship in which the other person refuses to share personal information and frequently makes statements such as “I’m curious why you want to know that,” even when the question is fairly innocuous. Perhaps you’d amend this client’s treatment plan to include working on healthy relationships or building appropriate boundaries. I sure would. Yet, this is what we do all the time as counselors, based perhaps on an assumption that self-disclosure is inherently bad.

It seems to me that we shouldn’t expect teens, especially ones who are avoidantly attached, to be open with us if we aren’t open with them. I’m certainly not suggesting that we share every detail of our lives with teen clients, but I do believe we should be willing to disclose relevant information, answer questions asked out of true curiosity, and be as honest with clients as we expect them to be with us. By doing so, we model effective interpersonal skills, demonstrate healthy ways to connect with others, and solidify the therapeutic alliance.

When teen clients ask questions of a personal nature, some therapists view this as a form of resistance, as a way to avoid the topic at hand or as behavior that interferes with treatment. I disagree, at least sometimes. Perhaps the teen is making an initial attempt to cultivate a relationship with us. Perhaps these questions are a sign that we’re becoming a secure base for the teen. Perhaps we’re witnessing a little nugget of change. Why would we shut that down?

When we deflect all questions of a personal nature, maybe we aren’t reinforcing appropriate therapeutic boundaries or challenging client avoidance. Maybe we’re rejecting a tentative attempt at connection. Maybe we’re demonstrating that we aren’t a secure base. Maybe we’re reinforcing the client’s avoidant attachment style.

For the first several weeks, sessions with Ben were slow going. He often showed up late, sometimes refused to talk and frequently stated he didn’t need or want help. One day, I taught him Fluxx. He commented that the game was about unpredictability. “I hate that,” he said.

The next session, Ben brought his own game, Unstable Unicorns. “It’s a complicated game,” he said, “but I’m a complicated person, and you seem to understand me.”

I let that register, picked up my cards, and lost three games in a row. At the end of the session, for the first time ever, Ben said, “See you next week.”

John Bowlby (1969) described attachment as a “lasting connectedness between human beings” and stated that the earliest bonds formed by children with their primary caregivers have significant, lifelong impacts. When meeting with avoidantly attached teens, it’s essential that we remember the ghosts in the room with us. It’s essential that we intentionally earn marbles. It’s essential that we slowly, but steadily, create connectedness. When we do, we invite teens such as Ben to move toward a more securely attached way of being.

 

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David Flack is a licensed mental health counselor and substance use disorders professional located in Seattle. For 20 years, he has met with teens and emerging adults to address depression, trauma, co-occurring disorders and more. In addition to his clinical work, he regularly provides continuing education programs regionally and nationally. Contact him at david@davidflack.com.

Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Interventions for attachment and traumatic stress issues in young children

By Cirecie A. West-Olatunji, Jeff D. Wolfgang and Kimberly N. Frazier April 2, 2019

Although mental health professionals acknowledge that clinical issues often look different in young children, treatment practices continue to rely heavily on adult literature. These mostly miniaturized forms of adult treatment are often scaled down using more basic language and vocabulary, but they still depend on discovering ways to encourage the verbal communication of children. Furthermore, major deficiencies exist in the mental health care delivery system for children. General neglect and fragmentation of services create obstacles to effective service provision for this population.

Over the past decade, scholars have begun exploring early childhood development and effective counseling interventions, the role of traumatic stress in the presentation of emotional and behavioral symptoms, and the prevalence of attachment issues for young children. In this article, we aim to provide a brief overview of these key advances in what we have named “pediatric counseling.” We also offer 10 evidence-based counseling interventions that stem from our work with young children over several decades.

Early childhood development and counseling

Children are not miniature adults, meaning a paradigm shift and specialized skills approach are required to help them most effectively. Children also go through rapid developmental stages, strengthening the argument that therapy with children should be vastly different from therapy with adults. Thus, professional counselors and other mental health professionals must consider various concepts, issues, techniques and interventions that are cognitively, emotionally, psychologically and developmentally appropriate for children.

During early childhood, defined as birth to age 5, rapid development of gross motor skills (running, climbing, throwing) occurs. Fine motor skills (drawing, writing, manipulating small objects) are slower to develop at this stage, but children should be able to copy letters and small words sometime during the latter half of early childhood. Cognitive development at this stage is based primarily on preoperational thinking. Hence, children in this stage rely heavily on what they see. They can now recall past events and anticipate future experiences that may be similar. At this stage of development, children are very egocentric, commonly overestimate their abilities (e.g., thinking they can carry things that are too heavy for them), and gain increased control of their impulses.

Play is extremely important to social development during early childhood. At about 3 or 4 years old, children engage in associative play in which they learn how to share and interact with one another. During associative play, there are no clear goals for the play and the roles of those engaging in play are not assigned. At about age 5, children begin to create games, form groups and take turns. Children are expanding their vocabularies at this stage, but the words and phrases used to express feelings and emotions remain limited. Because of their limited emotional vocabulary at this stage, children are more prone to act out their emotions behaviorally.

Deficiencies in service delivery:
Some of the major deficiencies in the mental health care delivery system for children include:

  • How children are categorized (i.e., poor conceptualization of children within their ecological context, including culturally marginalized children being overrepresented in the most severe clinical categories)
  • Environmental factors (such as racism and poverty)
  • Lack of empirical data
  • Fragmentation of services

First, children are typically placed in categories of clinical, subclinical and at risk, and they are often in need of services such as remediation and prevention. However, they are largely neglected within the system. This is partly due to clinicians’ lack of training to provide developmentally appropriate clinical care for this age group. Lack of adequate funding and poor communication between providers (such as pediatricians, child care workers, parents/caregivers, social services personnel and professional counselors) are also factors.

Second, some environmental factors associated with higher rates of mental health problems include poverty, racism, abuse and familial problems. Systemic oppression is also linked to both behavioral and affective problems. However, insufficient research has been conducted with young children to provide adequate information about how these environmental factors affect them. 

Third, there is a lack of empirical data on effective treatment for young children. Although the literature is replete with community agency programs and hospital-affiliated programs designed for young children and their families, there is insufficient support for the effectiveness of the treatments and interventions provided.

Finally, there is fragmentation of the services that exist for this population. Mental health services for young children should be initialized by a social service agency or primary care physician. However, this rarely happens. Even when it does, it is unlikely that these professionals have included or interacted with counselors. Thus, many children slip through the cracks and remain unidentified until a crisis arises, meaning they are most likely to receive psychological first aid via psychiatric services.

Counselor training: Experts stress the need for counselor trainees to acquire foundational skills that serve as underpinnings for effective counseling of this population. The major challenge within the discipline of counseling is how to transform these base-level skills into effective techniques and interventions for young clients. Many beginning counselors feel ill-prepared and are often frustrated when they encounter child clients — and preschool-age children in particular. Most counselors begin their training by practicing their counseling skills on classmates and never encounter younger client populations until they are out in
the field. 

Traumatic stress issues

Researchers have suggested that symptoms of traumatic stress in early childhood include interrupted attachment displays of distress such as inconsolable crying, disorientation, diminished interest, aggression, withdrawing from peers, and thoughts or feelings that disrupt normal activities. Traumatic stress, a condition caused by pervasive, systemic external forces, can result in physiological, psychological and behavioral symptoms that negatively affect everyday functioning.

Symptoms of traumatic stress can include hyperarousal or hypoarousal, avoidance and re-experiencing. Hyperarousal in early childhood is often observed through displays of inconsolable crying, flailing about, arching the back and biting. Hypoarousal involves emotional numbing that may be observed as a child who sleeps excessively, displays a dazed expression or averts his or her eyes. Avoidance is characterized by withdrawal, which is often demonstrated as displaying less affection, consistently looking away or avoiding facial contact. Other observable features of avoidance include a fear of being separated from caregivers, refusal to follow directions, disorientation and extreme sadness.

Re-experiencing is often the most subtle of the three symptoms, but it can be observed through the presence of rigid and repetitive patterns. These patterns can include common play leading to outbursts or withdrawal if the pattern is changed or interrupted. The play or reenactments have a noticeable anxious quality to them, or the child appears to space out when engaged in these patterns. One of the most consistent observations of re-experiencing is the presence of nightmares.

Neurological responses to traumatic stress include:

  • Increased levels of adrenaline (activation of the sympathetic nervous system)
  • Decreased levels of cortisol and serotonin (a reduced ability to moderate the sympathetic nervous system or emotional reactivity)
  • Increased levels of endogenous opioids (which result in pain reduction, emotional blunting and memory impairment)

In addition, chronic stress can interrupt cognitive functions such as planning, working memory and mental flexibility. Hence, it is important to systematically assess how children use relationships, interact with others and interact with their environment. Furthermore, when traumatic stressors deplete the coping resources of caregivers, they can become neglectful or show signs of chronic danger, leading to the potential disruption of the attachment system for young children.

Attachment issues

Attachment research describes children’s behaviors along a wellness spectrum from secure attachment (most well) to insecure attachment (where children are at highest risk). With secure attachments, caregivers display relaxed, warm and positive interactions involving some form of direct expression of feelings or desires and the ability to negotiate conflict or disagreement. In this manner, caregivers are encouraging, sensitive, consistent and responsive. With insecure attachments, the child loses confidence to varying degrees in the caregiving system, believing that the caregiver lacks responsiveness and availability during times of distress or trauma.

Securely attached children typically display the following healthy behaviors during the different phases of growth:

  • Phase I (0 to 3 months): Newborns often seek out connection (eye contact and touch) and respond to familiar smells, sights and sounds.
  • Phase II (3 to 6 months): Infants begin to orient to familiar people (preferring those who are familiar to them while avoiding those who are not familiar) and are emotionally expressive, responding to others’ emotional signals.
  • Phase III (6 months on): Infants become wary of strangers and actively seek out familiar caregivers. Additionally, they begin practicing verbal and nonverbal displays of happiness, sadness, anger and fear.
  • Phase IV (from the second to third year on): These young children notably gain increased abilities to negotiate with caregivers (sometimes resulting in short-lived tantrums), are better able to coordinate goals with others (showing adaptable and responsive goals), display increasingly empathic responses to others, and progressively develop greater walking and complex verbal communication skills.

Insecure attachments styles are divided into three categories: avoidant, resistant and disorganized-disoriented. Avoidant attachment styles often can be associated with caregivers who minimize the perceptions of young children, are emotionally unavailable, and assign care of the child to others. This results in young children becoming indifferent to the presence of the caregiver, displaying detached/neutral responses to others, and minimizing opportunities for interaction with others.

Resistant attachment styles are associated with caregivers who resist distress (showing avoidance verbally or physically) and often wait for the child to get highly upset before attempting to sooth. This conditions young children to maximize distress, to resist or display difficultly in being soothed, and to under-regulate their emotions (e.g., responding dramatically to change and acting out dramatically when expectations are not met). Additionally, these children readily perceive experiences as threatening, get frustrated easily, and often approach life anxiously or as if helpless. These children initiate their interactions with others through their distress.

The third and most unhealthy attachment style is disorganized-disoriented. It is associated with caregivers who are often confrontational, helpless, frightened or disengaged (avoidant). These caregivers often passively place children at risk due to the caregivers’ lack of involvement or preventive parenting skills. Their children respond by attempting to adapt to the caregivers’ emotional needs — either caretaking or avoiding. These adaptive behaviors are often observed as consistent displays of confusion, hostility, freezing responses or caregiving responses (e.g., reassuring, pleasing, cheering up).

Counselors’ role: As counselors, we are uniquely trained to meet the needs of young children because of our emphasis on human development, prevention, ecosystems and wellness. Counselors can use three main restorative skills to intervene with young children experiencing attachment issues related to traumatic stress. We can:

  • Set up a safe and warm environment in our clinical settings
  • Display trust through culturally sensitive gestures, tone of voice and facial expressions
  • Nurture a nonjudgmental understanding of young clients while focusing on exploration, empowerment and acceptance

By engaging in these three practices, professional counselors should be able to aid young children in working through a variety of social, emotional, behavioral and learning challenges. Counselors can foster warmth and vitality by employing mutuality and relational socio-dramatic play experiences. Additionally, counselors can create mediated learning so that young children can develop the ability to self-define, contextualize and transform their reality into healthy developmental journeys. This gentle, nonthreatening rebalancing of the energy can create restorative opportunities.

Ten evidence-based interventions

In 2000, Cirecie A. West-Olatunji (one of the co-authors of this article) and a colleague created a program called the Children’s Crisis Unit, in partnership with a local YWCA rape crisis unit, to provide clinical services to young children in a five-county area when referred for allegations of child sexual abuse. Over a four-year period, the Children’s Crisis Unit provided assessment and intervention for children and provided consultation to clinicians, law enforcement, medical professionals and legal professionals, both locally and nationally. During this time, training was provided for counseling, psychology and social work graduate students who learned how to work specifically with clients from birth to age 5.

The following techniques were used systematically with hundreds of clients. Although these interventions may be similar to those used with nonsymptomatic children, in working with young children, there are several unique features, including:

  • Assessment for degree of severity
  • Remediation
  • Involvement of the caregiver
  • Bookmarking for interventions at later developmental periods

1) Popsicle sticks: This intervention can be introduced in the first session with the primary caregiver and the child. One of the appealing things about the use of Popsicle sticks is that they are very inexpensive, meaning nearly any family can afford them. Counselors can use nontoxic crayons or markers and other craft tools such as glitter, buttons, yarn and nontoxic glue. Counselors direct the caregiver-child dyad to use the Popsicle sticks to create individual members of their family as dolls. This activity can be continued at home between sessions. This intervention facilitates bonding and trust, decreases anxiety, is client-centered and culturally appropriate, and allows children to tell their story.

2) Feeling faces: This activity provides easy access for the counselor because various versions can be downloaded from the internet. Use of the feeling faces allows children to identify with other children and their facial expressions. In the exercise, the counselor directs the child to select those faces to which he or she is drawn to determine thematic links between the selected faces. The counselor then hypothesizes and contextualizes the presenting problem. This activity is useful in remediating flattened affect, with the counselor directing the child to mimic faces that match a range of emotions.

3) Storytelling: Narrative activities allow children to tell stories of their own choosing or give a particular recounting as directed by the counselor. Storytelling also allows the caregiver to recount or read the child a story that represents some resolution to the problem. Additionally, this activity permits the counselor to a) read the child a story representing some resolution to the problem and then engage in dialogue about feelings or b) collect pre- and post-observational data regarding the child’s responses.

4) Puppets: This intervention is helpful in allowing children to use dramatic play to express their feelings, recount a story or “restory” prior negative events. It can be particularly useful when the caregiver is actively involved in the puppet intervention. Puppets can be of the caregivers’ own making or ones that are available in the clinical room. Smaller and isomorphic puppets work better with infants and toddlers, whereas 3- and 4-year-old children are more likely to respond to animal-shaped and larger puppets.

5) Anatomically and culturally correct figurines: These figurines can be useful in cases of physical and sexual abuse because children are more likely to provide an accurate accounting when directed to engage in dramatic play. This intervention allows children to reenact situations that they have experienced. Additionally, it offers opportunities for children to point to parts of the body on the figurines as well as on themselves. This activity can provide the counselor with an assessment of the child’s developmentally appropriate knowledge about sexuality.

6) Dollhouse: This intervention offers a physical example of the home that can be used to explain what happens in the home from the child’s perspective. Use of a dollhouse can aid in accessing the child’s memories more easily based on familiarity with household items rather than starting from scratch. This activity allows counselors to be either:

  • Directive with the child, using prompts such as, “Tell me what happens in this room” (while pointing to a specific room in the dollhouse)
  • Nondirective with the child, permitting the child to have free-flowing play with the items in the dollhouse (while making observational notes)

7) Play dough (modeling clay): Modeling clay provides a kinesthetic, moldable medium that children can use to contextualize and express feelings involving sensory experiences. This intervention permits children to create representations of their family members by providing definition to body parts and facial expressions, and thus connecting emotions, experiences and people to the critical event. Play dough activities allow counselors to direct children to mold important people (both family members and nonfamily members) in their lives.

8) Freehand drawing: This activity offers children the opportunity to creatively express what is happening for them in the moment. Tools for this activity are based on the child’s developmental level and might include crayons, markers, pens, pencils or chalk, depending on the child’s age and motor skills. Counselors can use this activity to promote comfort, connection, nurturance and fun for children.

9) Kinetic family/human figure drawing: Kinetic family drawing is a more directive technique that allows children to articulate how they see themselves in relation to other family members. This activity allows for dialogue between the parent and child in terms of perspectives of the family. The counselor offers paper and drawing instruments and directs the child to draw a picture of her or his family. (Note: Try to avoid stick figures, depending on the age of the child.)

10) In vivo parent-child observation and feedback: This intervention permits the counselor to assume an observer role as the parent and child interact. It can be either directive or nondirective. This activity allows for a real-time view of the interaction quality between the parent and child, providing insight into parenting style and skills as well as attachment issues. In vivo observations afford counselors the opportunity to prepare the clinical room with play materials and direct the parent to engage with the child (or, in a nondirective way, allow the parent and child to interact without instructions). Thus, the counselor can step back to observe (either in the clinical room or in an adjoining room with a one-way mirror). If the counselor is in the room, she or he can provide instant feedback and redirection, if necessary.

It should be noted that when working with preverbal children, counselors should rely on nonverbals such as body language, facial expressions, physiological responses and the child’s attention and focus. Also, be aware that children’s comprehension develops earlier than their language abilities. It is important to remember that children understand more than they can communicate.

Extending our reach

The counseling profession is poised to serve as a leading provider of much-needed services to young children. Our focus on prevention, environmental context, development and wellness makes us uniquely trained to assess, intervene with and investigate clinical issues in early childhood. The benefits for us as a profession are numerous and extensive.

First, by incorporating a focus on young children, we can increase our role definition by providing psychological consultation to children, parents, and child care providers in day care centers (such as Head Start) and preschools. Second, we move from the implicit to the explicit. Many practicing counselors are already working with young children in their agencies, schools and private practices. However, without counselor educators and policymakers explicating guidelines for practice, the profession lacks a systematic response to ensure application of evidence-based interventions. Third, we can expand our involvement in addressing the needs of this clinical population by securing grants from federal agencies and private foundations; attending think tanks and conventions where other health professionals are gathering to discuss the needs of young children; and advocating for increased coordination of service providers across all service delivery platforms and agencies. Finally, we can advocate for ourselves by becoming more visible within the larger health care community.

Recommendations: Existing courses in counselor education need to incorporate a paradigm that includes training specifically geared toward clinical populations from birth to age 5. The major challenge within this discipline is how to transform base-level skills into effective techniques and interventions for young clients.

School counselors especially need to have specialized skills and training so they are equipped with tools that acknowledge characteristics and cultural nuances that are specific to child populations. Allowing graduate students to become familiar with the pediatric population early in their training begins the process of conceptualizing young children in the context of a holistic, strength-based and culture-centered approach.

Some professionals have offered a solution to this dilemma by suggesting a framework that incorporates exposure to a variety of populations or the use of various subspecialties. In such a framework, counselor educators systematically incorporate broad content knowledge of specialized populations that is applied throughout the curriculum. Family courses could focus on the specific issues that pediatric members of the family system face and how these issues affect the entire family’s functioning. In addition, family courses could focus on interventions geared toward young children that incorporate the entire family, hence aiding the family to function more effectively. Counseling courses on theory and technique might add discussions on how to incorporate young child development and issues into concepts and interventions that are specific to various counseling theories.

Finally, to further develop our understanding of what practicing counselors actually do when working with young children, it is important to perform additional counseling research. One way of advancing our knowledge in this area might be the use of a Delphi study. This systematic approach, which would gather a panel of experts through a nominations process, could be used to generate ideas, gain consensus and identify opinions of a wide range of counseling professionals without face-to-face interaction. This method could provide a means of bridging research and practice to reach a common understanding of what steps can be taken to explore our conceptualization and assessment of and intervention with young children.

In sum, counselors have the ideal training to work closely with young clients and to provide culturally appropriate interventions to address the unique needs of this client population. Use of developmentally informed and ecosystemic frameworks will allow counselors to be accurate in their conceptualization and treatment of young children.

 

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Cirecie A. West-Olatunji serves as associate professor in counseling at Xavier University of Louisiana (XULA) and as director of the XULA Center for Traumatic Stress Research. She is a past president of the American Counseling Association and the Association for Multicultural Counseling and Development (AMCD). Internationally, she has provided consultation and training in southern Africa, the Pacific Rim and Europe. Contact her at colatunj@xula.edu.

Jeff D. Wolfgang is an assistant professor in the Department of Counseling in the College of Education at North Carolina A&T State University. His research focuses on multigenerational effects of trauma on young children and their families. Contact him at jdwolfgang@ncat.edu.

Kimberly N. Frazier is an associate professor in the Department of Clinical Rehabilitation and Counseling at the Louisiana State University Health Sciences Center-New Orleans. Her research focuses on counseling pediatric populations, cultured-centered counseling interventions and training, systemic oppression and trauma. She is a past president of AMCD and has served as an ACA Governing Council representative. Contact her at kfraz1@lsuhsc.edu.

 

Letters to the editor: ct@counseling.org

Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Standing in the shadow of addiction

By Lindsey Phillips October 30, 2018

Theresa Eschmann, a licensed professional counselor (LPC) and addiction family specialist in private practice in St. Louis, experienced firsthand the power of denial in adult children of parents with alcohol use disorders. All her life, Eschmann had witnessed her mother struggle with this disorder, yet upon finding her mother dead with a bottle of alcohol in her hand, Eschmann’s first response was denial. She couldn’t believe that her mother’s alcohol use disorder had caused her death, initially insisting that someone must have poisoned her.

“I … took a chemical dependency proficiency certification to try to get some understanding of what killed her because it couldn’t have just been alcohol,” Eschmann says, explaining her thinking at the time. “Alcohol made you sick. It made you have delirium tremens. It made you see things. But it couldn’t have killed you.”

Denial is often a strong coping mechanism for adult children of parents with alcohol use disorders, says Lisa Kruger, an LPC and psychotherapist and the owner of Stepping Stone Psychotherapy in the Washington, D.C., metro area. “They have to deny any feelings of sadness or anger that they might have in order to survive,” she says.

This denial extends to adult children’s own potential struggles with substance use disorders. Keith Klostermann, an assistant professor in the Department of Counseling and Clinical Psychology and the director of clinical training for the marriage and family therapy program at Medaille College, had a female client whose father chronically abused alcohol, and her own drinking often led to fights with her boyfriend. One of these drunken fights resulted in her breaking her foot. Even so, she maintained a permissive attitude toward drinking and brushed it off as a recreational activity.

The client was firmly in denial and not yet ready to address either her experience of growing up around substance abuse issues or her own drinking habits, says Klostermann, a licensed marriage and family therapist and licensed mental health counselor who maintains an active practice in New York. Counselors may be eager to push clients to explore these issues, but Klostermann warns that discussing the implications of this childhood experience before clients are ready is a recipe for disaster. Taking that approach may lead to problems establishing a therapeutic alliance or cause clients to end counseling prematurely, he explains. Instead, he advises, counselors can help clients connect the dots and arrive at an understanding that their behavior makes sense based on their experiences growing up.

Asking the right questions

Being an adult child of a parent with a substance use disorder is not uncommon. According to the National Association for Children of Addiction, 1 in 4 children in the United States (or approximately 18.25 million children) live in a family with a parent who is addicted to drugs or alcohol. Yet, Eschmann, a certified master addiction counselor and a member of the American Counseling Association, says it’s her sense that asking whether clients grew up in homes where addiction was present is often skipped over in clinical assessments.

In addition, because these individuals have frequently learned to minimize, discount or deny the implications of growing up in a home with substance abuse, they aren’t particularly likely to seek counseling for those issues.

Being a child of a parent who abused substances “may be the elephant in the room, but that may not be what brings them in. They may not recognize it,” says Klostermann, an ACA member. “The stuff that happens to us when we were younger, a lot of times we carry with us, [but] we don’t even realize why we do the stuff we do. We just sort of do it out of inertia.”

Klostermann and Kruger say that many of their clients present with relationship problems, anxiety, stress, depression and substance use. Often, the counselors note, these issues result from growing up with a parent who had a substance use disorder.

The environment of walking on eggshells around a parent who is under the influence of a substance creates and breeds anxiety for the child, Klostermann explains. When the child becomes an adult and engages in stressful situations in college (e.g., exams) or at work (e.g., deadlines), the person’s anxiety can snowball, he adds. Likewise, they may struggle with adversity and withdraw socially because they find it difficult to navigate relationships. This isolation can lead to depression, which is a real challenge, Klostermann says.

Counselors can look for possible warning signs that their adult clients were exposed to substance abuse issues in the home as children, Klostermann says. For instance, clients might engage in avoidant strategies (e.g., using alcohol as a way to cope with stress) or have a permissive attitude about substance use (e.g., “I don’t drink much. I only have a 12-pack a day.”).

Kruger, an ACA member who specializes in the areas of depression, anxiety, posttraumatic stress disorder, trauma and addiction, had a male client who came to see her for help with relationship issues and high anxiety. In his intake paperwork, the client wrote that he drank nightly, so she asked him how many drinks he had in a week. “It was 50 to 60 a week,” he replied, “but now it’s only 20 or 30.” This response was a big red flag, yet he didn’t realize that his drinking was a problem, she says.

To help clients recognize unhealthy behaviors, Kruger often uses motivational interviewing techniques. For example, with this client, a counselor might ask, “How is drinking 20 or 30 drinks a week working out for you?”

If counselors see potential warning signs, Klostermann advises asking questions about current substance use patterns, previous substance use, parental substance use and family attitudes around drinking. For example, counselors might ask the following questions: What was it like growing up in your home? What does drinking a lot or having a good time mean to you? What does that look like? What are the holidays and celebrations like in your family? What is a typical family dinner or birthday party like?

“Substance use is built around so many family functions and gatherings and celebrations,” Klostermann says. So, if a client comments, “My parents liked to party,” counselors could follow up by asking the client to explain what that means and what the implications are for the client’s life (e.g., increased violence after a parent drank, embarrassment when a parent became intoxicated at a social event). Klostermann explains that these types of questions help clinicians gain a better understanding of not just the acute nature of growing up in an environment with substance abuse but also the context of it — for instance, whether parental drug use led to a more permissive attitude at home or whether the child adopted unhealthy coping strategies.

In addition, adult children often find it easier to talk about others rather than themselves, Klostermann says. By asking these types of nonjudgmental questions (e.g., “Did drinking like that seem to work out for your mom?”), counselors can help clients create insight and awareness by changing the frame of reference, he explains. This technique helps clients gain an understanding about not only the severity of their parents’ alcohol or substance use but also the emotional implications of that behavior, he adds.

After counselors establish that awareness, Klostermann says, they can connect it to the client’s present situation (e.g., “Does drinking affect your relationships or grades?”). He suggests that counselors could also try to educate clients by saying something along the following lines: “Given what you described about your [parent’s] history, it’s not uncommon for people that grow up in these homes to sometimes exhibit certain behaviors. Sounds like that might be happening for you.”

Counselors are “planting the seed [and] leaving the door open but also helping [clients] to connect the dots and understand this is what’s going on and here’s why,” he explains.

In addition to asking about clients’ personal and family substance use histories, Kruger often focuses her questions on clients’ relationships with their parents. These questions can help bring out emotions such as shame, guilt or anxiety that stem from being a child of a parent with a substance use disorder, she says.

Emotional and attachment wounds

“Adult children of alcoholics … have difficulty identifying and expressing emotions,” Kruger explains, “because when they were kids, they had to set aside their own emotions — maybe they had to care for their parents. … They didn’t understand what their emotions were because what they saw in their parents’ relationship was inconsistent presentation or organization of emotions between them and maybe even between the parent and child too.”

To help clients who are having difficulty expressing their emotions, Kruger provides a sheet that shows 50 visual representations of emotions and asks clients to name the emotions that describe how they are feeling. She says this activity, which she refers to as an “emotional cheat sheet,” is “a good springboard … for clients who really don’t have the language [for their emotions].”

Kruger and Eschmann find that codependency is another common issue for adult children of parents with alcohol use disorders. Because these adult children grow up being sensitive to the needs of their parents — even to the point of ignoring their own needs — they often engage in approval seeking, which leads to codependency, Kruger explains. This need for approval and to avoid conflict can result in these individuals seeking acceptance from others who do not treat them well, which causes lower self-esteem, she says.

Often, clients who are codependent will assume they are OK because they are not the ones causing problems, Eschmann observes. She questions clients on codependent behavior by asking about their controlling behaviors, approval-seeking behaviors, anxiety, and distortion around intimacy and separation.

For Kruger, it all comes back to attachment — how bonds are created and broken. Parents who struggle with alcohol use disorders are typically inconsistent in their parenting and in their show of emotion toward their children. As she points out, this can create attachment wounds and be stressful for children growing up under these circumstances. Children may be doubly affected because they still depend on parents for care and for getting many of their emotional needs met. At the same time, these children often aren’t in a position to fight or to flee elsewhere, she adds.

Counselors can help adult clients gain awareness of how their current relationship patterns are affected by their childhood experiences, Kruger says. One technique she finds helpful involves taking the client’s experiences and imagining how those experiences would be perceived on The Brady Bunch. As a member of The Brady Bunch family, Kruger explains, the client would notice instantly if a partner or spouse were abusive because of the contrast with the sitcom family. However, growing up in a stressful environment with one or both parents suffering from an alcohol use disorder tends to distort a person’s perceptions of what is “normal” or acceptable.

For example, having a parent who drank and was inconsistently present when the client was a child would affect the client’s ability to evaluate his or her current relationships. If the client has a partner who sometimes withholds affection or emotion, is manipulative and comes around only when he or she wants something, the client won’t necessarily notice any red flags because those are the circumstances and relationship patterns the client knows from growing up, Kruger explains.

Kruger also gives short attachment assessments and finds that these clients often present with anxious attachments. “In relationships, [they cater] to the other person because that attachment anxiety comes up and that need for approval keeps them in relationships” — including bad ones, she says.

To help clients see the connection between their view of themselves and their relationships with others, Kruger will have clients write out how they view themselves, how they view other people and how they view the world. Then, they will discuss how these views are created, how clients are perpetuating these views and how they would like to see themselves in relationships.

The exercise is particularly helpful for clients who find themselves in toxic relationships, Kruger adds. “It’s really rare [for] somebody in a toxic relationship [who is] being manipulated to say, ‘I see myself in high regard, and I think I’m great.’ It’s usually the opposite,” she says.

Making meaning of conflicted feelings

Another crucial part of adult children’s recovery is sorting through their conflicted feelings of love, disappointment, anger and shame. In fact, both Eschmann and Kruger find that shame and guilt are common presenting issues.

Children often feel that a parent’s situation is their fault, and they find it difficult to process these multilayered emotions, Kruger notes. They simultaneously feel disappointment in and love for their parent. For adult children, processing and making sense of these feelings is a substantial part of recovery, she explains. Counselors should acknowledge that shame piece and how clients have “put that burden on themselves and carried that burden with them throughout adulthood,” Kruger advises. 

“Shames translates to I am bad,” Kruger points out. “Even if [clients] don’t present it on the outside, they’re usually coming in with some pretty damaged self-esteem and are already judging themselves.” In part for that reason, she emphasizes the importance of creating a nonjudgmental atmosphere in counseling.

When self-esteem, thoughts and feelings are involved, Kruger uses cognitive behavior therapy techniques. She says she has experienced a good deal of success with an exercise that blends cognitive restructuring and emotion identification. In the exercise, clients look at a triggering event and then identify their negative self-talk and automatic thought, the feeling that this thought creates, evidence to strengthen this thought, evidence against this thought and a new thought that they can believe.

The exercise allows clients to recognize their negative self-talk and its consequences and enables them to reconfigure these self-demeaning thoughts in a way that is believable to them, Kruger explains. For example, clients might think that they are “bad” and list all of the evidence they have for that thought. Next, they could counter that thought with the fact that they recently got a raise at work. Finally, they could create a new thought that sometimes they do good things, Kruger says.

“These clients need validation,” Eschmann emphasizes. “They didn’t get it growing up.” Instead, she explains, the parent who was abusing alcohol or other substances has often discounted the adult child’s feelings and experiences.

Klostermann also stresses the importance of normalizing these clients’ emotions and experiences. These clients may not realize — or, in some cases, perhaps don’t want to realize — the impact on them of their parents’ drug or alcohol use, he says. He notes how difficult it can be for clients to verbalize that their parents had or have a drinking problem, especially if they maintain a glorified version of their parents. For this reason, counselors need to help clients understand that it is possible for them to love their parents while still recognizing that their parents made mistakes.

Kathleen Brown-Rice, department chair and associate professor in the Department of Counselor Education at Sam Houston State University, agrees. Counselors must keep in mind that the family member is someone whom the client still loves and cares about, she says. Counselors can give clients the “space to say that you can love somebody and also be disappointed by their behaviors. You can love someone, and they can love you, and they can still hurt you,” she says. “[It’s] helpful for clients to understand that it’s more complicated than just [their parents are] bad or they don’t love [them].”

Eschmann helps clients focus on unresolved grief, which is common for adult children who grew up with parental substance abuse. Adult children are often hesitant to admit that their mom left them alone all night with a stranger or that their father came home drunk and had violent arguments with their mother, Eschmann says. They might not want to admit that these past events are why they get triggered today during certain situations.

“[Clients] have to accuse before [they] can excuse,” Eschmann asserts. “They have to go back and [ask], ‘What happened to me?’ This isn’t about [the parents] anymore. It’s about [the client].” If clients become more aware of what happened to them and what kind of environment they lived in that made them fearful and anxious today, then they can start healing, she adds. 

Mindful resilience 

Adult children who grew up in the same environment with substance abuse can respond very differently. One person may be angry, whereas another may be empathetic, and still another may end up also struggling with a substance use disorder. This raises the question of why some adult children of parents with alcohol use disorders are more resilient than others.

Resilience is “critical in terms of shaping kids’ development as they transcend into adulthood in terms of the choices that they make and the way that they deal with stress and conflict,” Klostermann points out. Based on his clinical experience, Klostermann suggests that having other healthy outlets (e.g., extracurricular activities such as sports, positive role models such as grandparents) and an ability to contextualize what is happening help to foster resilience.

Brown-Rice, an LPC and a member of ACA, acknowledges that there is more than simple genetics at play with resiliency. “Resiliency is not a moral characteristic. It’s a function of our brain,” she says. It’s “how our brain controls for those genetics … how that resiliency comes in and how we support that.”

Recently, she, along with Gina Forster (a lecturer in the Department of Anatomy at the University of Otago) and several other colleagues, conducted a study funded partly by a grant from the Center for Brain and Behavior Research at the University of South Dakota on college students who had similar experiences of being adult children of parents with substance use disorders. The participants identified as either engaging in risky substance use (the vulnerable group) or not engaging in risky substance use (the resilient group).

“Overall, their experience being raised by a parent who met the criteria for having a substance use disorder appeared similar,” says Brown-Rice, who presented the findings at the ACA 2017 Conference in San Francisco. However, “vulnerable individuals had lower scholastic performance … [and] reported poor overall psychological, physical and social health and more polysubstance use.”

The study also revealed another difference: The vulnerable group had a short allele of the serotonin transporter gene, which meant they were more likely to react to stressful events. “[This group] had a reduced uptake of their serotonin, which can increase depression and stressful life events,” explains Brown-Rice, associate editor of the Journal of Addictions & Offender Counseling.

Brown-Rice and the other researchers also measured brain activity while the participants viewed positive images (e.g., a cuddly bear), negative images (e.g., a crying baby) and neutral images (e.g., a chair). They found that the vulnerable group had altered brain activity when processing negative images. This group recognized the negative image but refused to store it, Brown-Rice explains.

Brown-Rice hypothesizes that this refusal to store negative images is an important factor in resiliency levels. To illustrate, imagine that you are walking outside and see a stick. Initially, your brain may think that the stick is a snake, so you jump back. As Brown-Rice explains, when you first see the stick, the amygdala activates and warns you because it looks like something that the brain remembers could hurt you. But after taking a closer look (i.e., storing the image), you realize it is just a stick, so you relax.

Resiliency depends on our ability to realize that the stick is not a snake. Some people, however, may be more likely because of brain functioning or genetic variations to see the stick and just react by running, Brown-Rice says. Thus, counselors can help certain clients by nurturing the parts of the brain that activate during stressful situations, she explains.

Brown-Rice incorporates this research into her clinical practice. She tells her clients that they have a resilient part of the brain — the prefrontal cortex — and that in session, they can work on controlling their brain and building their optimism and resiliency. She suggests that counselors use mindfulness techniques, such as guiding clients in breathing exercises and finding a safe place to go when triggered, because mindfulness is effective in calming the amygdala, which activates during stressful events.

Consistency also helps promote clients’ resiliency, Brown-Rice notes. If counselors are inconsistent, she says, that will put clients on edge.

Klostermann agrees. He finds that having a clear agenda helps to create a sense of safety and build rapport with clients. He informs them about his clinical approach and what to expect during the session and tells them there is no assumption on his part that they will schedule another appointment.

Kruger recommends using clients’ resiliency to help strengthen their internal sense of self. After all, she points out, adult children of parents with alcohol use disorders have already developed survival strategies, such as caring for siblings in areas in which the parent was lacking.

Instead of simply telling clients that they have strengths, Kruger uses motivational interviewing, which allows clients to identify and recognize their strengths themselves. For example, rather than telling a client, “You seem to be good at your job,” she might ask, “In what ways are you praised at your job?” This question helps clients reach the conclusion themselves, which builds their internal positive regard.

One more piece of advice for working with adult children of parents with substance use disorders: Counselors shouldn’t be afraid to change their approach if it’s not working. For example, Brown-Rice says, research has shown that people who have a short allele for serotonin may be resistant to cognitive behavior treatment. “If clients are not responding, we have to think maybe we need to change,” she says. “Maybe we need to move. Maybe we need to [incorporate] some of these mindfulness techniques. Maybe we need to do something else.”

Sometimes, it may be the counselor, not the client, who is being resistant, she stresses.

Halting the domino effect

The desire to get treatment for someone with a substance use disorder often overshadows the way that addiction affects the person’s family and others who care about the person. It shouldn’t.

In her educational video on addiction in the family, Claudia Black, an expert in addiction, highlights a child’s drawing of his experience living in a home where substance abuse is present. The child draws images of dominoes and writes, “Alcohol and drugs are like dominoes. They knock down the person, who knocks down everyone, including themselves.” The child’s words illustrate the way that addiction permeates and affects the entire family, not just the person with the substance use disorder.

For the first two years after her mother died from alcohol-related causes, Eschmann found herself crying repeatedly. Her grief and denial led her to learn more about chemical dependency, addiction and adult children of parents with alcohol use disorders. Counselors need to understand that the family has an emotional illness as well, Eschmann emphasizes. This illness is just as progressive as what the person with the substance use disorder is facing, she adds.

Brown-Rice reminds clients that they are not responsible for their substance use issues, but they are responsible for how they respond to these issues. For adult children of parents with substance use disorders, this means learning how their childhood experiences affect their current behaviors and choices.

Adult children of parents with substance use issues often feel isolated. Support groups such as Al-Anon and Adult Children of Alcoholics are helpful because they provide opportunities for people with similar experiences to share their stories and come to the realization that they’re not alone, Kruger says.

Counselors should also help clients understand that their parents’ substance use is not their shame to carry and substance abuse is not a legacy that they have to repeat, Brown-Rice says. Then, clients will realize that choosing a different path doesn’t mean that they are being disrespectful or dishonoring their parents, she explains.

The hope is that this different path will stop the domino effect of addiction, shame, depression and pain.

 

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Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist living in Northern Virginia. Contact her at consulting@lindseynphillips.com or through her website at lindseynphillips.com.

Letters to the editorct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Working with foster and adoptive families through the lens of attachment

By Somer George October 4, 2018

“He just got kicked out of his second preschool program! We’re nearing the end of our options here. What do we do?” I could hear the desperation in the mother’s voice as she described the past few months with the 5-year-old she and her family were fostering and would soon be adopting.

“He threw a chair at the teacher and punched a little girl, and nothing we do seems to make it better,” the father explained, describing the detailed behavior plan on which they had collaborated with a well-meaning social worker.

“And it’s not just at school,” the mother continued. “Even when he’s home with us, he often gets out of control. He even peed on his dad’s lap” — her voice lowered to a whisper — “on purpose!”

I nodded my head, empathetic to the immense strain this family had been under for the past several months. The mother and father were friendly and confident, well-educated and sincere. They had wanted to do something good for the world by fostering and adopting children in need. They had so much to offer. And yet here they were, barely surviving each day and feeling the shreds of normalcy slip through their fingers as this little boy pushed every emotional button they had, leaving them exhausted and discouraged.

My years of experience working with the Secure Child In-Home Program and the Virginia Child and Family Attachment Center helped me to frame their experience in terms of attachment. The situation they were in was not unique among parents who had adopted a child or made the decision to provide foster care, the initial good intention and early excitement slowly turning to exhaustion and sometimes regret. Often, these children who need it the most push away every offer of help and comfort that is provided to them.

Where healing happens

So, what do we do when parents who have adopted a child or are providing foster care come to us, asking for advice or counseling for their troubled child? Certainly, there is benefit in providing these children with play therapy, giving them a chance to form a new relationship and to express themselves through their own language of play.

And yet, that strategy speaks to only one side of the coin. Attachment theory tells us that children heal best in the context of secure caregiving relationships. And parents are the ones who provide the day in, day out caregiving, wielding the most influence on the development of new patterns in the child’s relationships and behaviors.

According to attachment theory, a child is biologically wired to turn toward a caregiver in times of distress. When the child’s emotional needs are met, the child develops patterns of soothing and regulation that are essential for healthy development. When these emotional needs are denied or rebuffed, however, or if the child experiences the caregiver as frightening, the child learns dramatically different adaptive strategies. The child may become withdrawn and inhibited or bossy and aggressive. These patterns aren’t quick to change when a new caregiver comes along. Add to this the trauma of abuse and the loss of a biological parent, and you have a situation full of misunderstanding and relational strain.

New caregivers often come into their role with little awareness of the child’s experiences and the patterns necessary for surviving a young life filled with turmoil, anguish and uncertainties. When these coping strategies show up in the new relationship, parents are (understandably) distressed and often seek help to “fix” the child’s confusing and challenging behavior.

What these parents may not realize is that their own ability to read through the confusing signals and meet the child’s emotional need is the place where most of the healing will happen. If the parents can provide both a secure base from which the child can explore the world and a safe haven for the child to return to, the deeply rooted patterns of behavior and interaction will begin to shift. This is not a quick and easy process. It is messy to be sure, often following a pattern of one step forward, two steps back. However, if parents are given the support they need, it is certainly an attainable and worthy goal.

The counselor’s role

So, what is the counselor’s role in helping form new patterns of interaction, leading to more emotional stability and better child behavior? How can we help move these relationships toward greater security, helping each family to become a haven of safety for children who have experienced significant neglect, rejection, fear and loss?

I’d like to offer some suggestions for counselors who desire to help these parents form stronger relationships with their children and experience a reduction in the difficult behaviors that create such chaos.

  • Provide empathy and understanding to parents. Often, by the time parents seek out a counselor, they have already been through a great deal of distress, frustration and turmoil. Yes, they are coming to receive help, but first they need to feel heard and understood without being judged. Parenting is extraordinarily difficult, and parenting a child with extensive emotional needs is even harder. Take the time to empathetically hear these parents’ concerns and welcome their expressions of distress.
  • Educate parents about normal development and the impact of trauma/loss. Sometimes foster and adoptive parents have already successfully raised biological children, so these difficult behaviors on the part of the child they are adopting or fostering don’t make sense to them. What they did with their other kids doesn’t seem to work with this child. Spend time teaching these parents about how their child’s brain may have developed in a dramatically different way due to the impact of neglect, trauma and loss. Talk about the fact that forming new secure relationships takes time and how important their role is in this process.
  • Help parents to practice observation skills. We human beings so naturally take in information and draw conclusions without even realizing we are doing it. Unfortunately, we aren’t always right. Parents who are living in highly stressful situations may have trouble stepping back and paying attention to what is happening in the moment. Help them to slow down and notice their child’s body language, facial expressions and tone of voice before making assumptions about what the behavior means or how to stop it. With foster and adoptive children, parents often say they don’t know what is going on inside the child; this is often the most important place to help them learn. It is essential that they obtain a developmentally accurate view of the child’s inner experience, feelings and thoughts in the context of the child’s earlier experience and relationship patterns.
  • Invite parents to pay attention to their own experience. How does mom feel when the child is screaming that he hates her? What is dad’s experience when his request to come for supper is repeatedly ignored? As parents become better at observing their child, it is important that they also attend to themselves. What are they feeling in these moments, and what is their body language and tone of voice communicating to the child? Help them to consider their own needs and to find ways to regulate their own strong emotions that are activated when the child is pushing them away.
  • Encourage parents to think about what the child is feeling in these difficult moments. So often, the focus of parents is on how to manage the child’s behavior. Traditional strategies that use rewards and punishment are rarely successful with children who have experienced neglect, trauma and loss. Although the child’s behavior doesn’t make sense at first glance, there is often much to be learned if we slow down and pay close attention.

Have the parents set aside quick assumptions and, instead, help them to observe carefully, giving consideration to what the child might be feeling. The child might look and sound angry at first glance, but might he or she instead be feeling scared or sad? The child already has emotional and behavioral sequences established that, once activated, run automatically. These unintentional and automatic patterns need to be shaped into healthier ones.

  • Ask parents to think about what the child needs from them. Does the child need to feel heard and validated? Does the child need comfort, protection and co-regulation of automatic well-learned patterns? Does the child need the parent to stay close by and help him calm down because he feels out of control? If the child is anxious, might she need the parent to provide soothing rather than correction?
  • Encourage parents to try new strategies aimed at fostering connection. Instead of putting the child in timeout, try bringing him in close for a cuddle and some conversation. Instead of sending the child to her bedroom to calm down, try going with her and staying close by. Remind parents that new approaches may not work right away, but with persistence and practice, they can begin to make a significant difference.
  • Facilitate parents’ exploration of their own attachment histories and how this influences interaction with the child. We know from research that a foster child’s initial relationship patterns are often a mismatch for a parent’s natural caregiving patterns. We also recognize that parental patterns of attachment have a strong influence on the child’s patterns. Increased reflection on these experiences can help us become better caregivers.

Invite parents to think about how their own experiences with caregivers have influenced the way that they react and respond to their child. What expectations do they hold? What automatic reactions are happening outside of their awareness? What automatic reactions happen outside of the child’s awareness?

  • Celebrate small (and large) victories. The little moments are the big moments. Provide plenty of affirmation and support for parents as they try new approaches and persevere in the day-to-day tasks of parenting. Acknowledging their efforts and celebrating successes, however small, can go a long way toward giving them the courage to continue through the hard times.

Working with these families can be immensely rewarding. They are often highly motivated and desperate for support. As counselors, we need to be aware of our impulse to provide a “quick fix” to try and make things better. We can make concrete suggestions, but we also need to recognize that the process of building stronger relationships and changing behavior takes time.

The type of relationship that we build with the child’s parents can itself be a catalyst for change. We can provide a place where the parents feel safe expressing their distress and their shortcomings, knowing that we will support them in their efforts to help guide their child on the path to healing.

A different path

As I continued working with the family mentioned at the beginning of this article, I could see the changes taking place. They began having more positive interactions with their child and seeing new qualities in him that they hadn’t noticed before; they were thinking about him in a different way. Their own self-reflection helped them to catch themselves before they reacted and think more about what he needed from each of them.

“I noticed that the collar of his shirt was often wet from him chewing on it. I stopped reprimanding him for this and realized that it meant he was feeling really anxious,” the mother told me one day.

“Yeah, and this was a sign that we needed to pick him up and give him some reassurance,” the father quickly added. “It really seems to calm him down.”

The mother continued: “I think that before when he was anxious, his behavior would spiral out of control. And the behavior chart was part of what contributed to his anxiety, which just made things worse instead of better. I don’t think we need it anymore.” As she spoke, she glanced at dad and noted his nodding head.

“They still use one at school,” she said, “but we’ve been talking to his new teacher about how to connect with him and what helps relieve his anxiety. Also, I stuck a picture in his book bag of the three of us together so he can get it out and look at it when he is at school. I think it helps him feel more secure. It’s a way for him to carry us with him.”

As I listened to them share these stories, I couldn’t help but smile. They still had a long road ahead of them, but they were headed down a very different path than the one they were on originally. We celebrated each of these moments together and reflected further on their experiences with their child.

I continued to come alongside them to support them in this journey for a little while longer, serving as a secure base and safe haven for them. Soon, however, they decided that they no longer needed counseling. Through a lens of attachment, they saw that their relationship with their son was much stronger, and although his behavior was still challenging at times, they possessed the confidence that they could handle it, moving forward together as a family. Once again, the experience of a healthy attachment proved itself to be a powerful force, propelling another family toward greater health and healing.

 

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Somer George is an adjunct professor at James Madison University and is currently completing her doctorate in counseling and supervision. She also works for the Virginia Child and Family Attachment Center and the Secure Child In-Home Program, where she helps to provide comprehensive attachment assessments, intensive in-home therapy and research-based parent courses. Contact her at somer@george.net.

 

Letters to the editor: ct@counseling.org

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.

 

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Related reading, from Counseling Today:

Fostering a brighter future

Through the child welfare kaleidoscope

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

 

When panic attacks

By Bethany Bray July 30, 2018

Kellie Collins, a licensed professional counselor (LPC) who runs a group private practice in Lake Oswego, Oregon, experienced her first panic attack when she was 14. She remembers suddenly feeling cold, losing sensation in her hands and her heart beating so rapidly that it felt like it was going to leap out of her chest — all for no readily apparent reason.

“I thought I was dying. That’s what it felt like,” Collins says. “It was the worst experience of my life up to that point. It felt like it lasted forever, even though it was just a few minutes. Afterward, I was left with a feeling that I had no control.”

When Collins subsequently experienced more panic attacks, the situation was exacerbated by a close family member who didn’t understand what was happening. The family member suggested that Collins might be having the panic attacks on purpose, to get attention.

Collins’ life changed for the better in high school, when she began seeing a counselor. She learned not only that her panic attacks were manageable but also that she wasn’t to blame for their occurrence.

“Hearing that I didn’t cause this and that it wasn’t my fault set me on the path to get better. It made all the difference,” says Collins, a member of the American Counseling Association. “The biggest thing [counselors can do] is to validate the client’s experience. What they experience is real and not under their control in that moment — and it’s terrifying.”

‘Fear of the fear’

In addition to overwhelming feelings of fear, panic attacks are usually marked by shortness of breath or trouble breathing and a rapid heartbeat. Other physical symptoms can include sweating (without physical exertion), a tingling sensation throughout the body, feeling like your throat is closing up or feeling that you’re about to pass out, explains Zachary Taylor, an LPC and behavioral health director at a health center in Lexington, Virginia. Symptoms vary, however. “I’ve never had two patients describe it the same way,” he says. (Taylor refers to patients instead of clients because he works at a medical health center.)

According to the National Institute of Mental Health (NIMH), an estimated 4.7 percent of adults in the United States experience panic disorder at some point in their lives. The past-year prevalence was higher among females (3.8 percent) than among males (1.6 percent).

Panic disorder is marked by recurring, unexpected panic attacks (or, as NIMH describes, “episodes of intense fear” that are “not in conjunction with a known fear or stressor”). People who experience panic disorder typically worry about having subsequent attacks, even to the point of changing behavior to avoid situations that might cause an episode.

“It’s such a jarring and uncomfortable experience, and it feels so much like a real medical emergency, that they begin to fear the sensations themselves. This fear of the fear is what drives panic disorder,” explains Taylor, a member of ACA. “If it gets too bad, they begin to arrange their life around trying not to experience anything that might resemble or trigger any of those feelings that are associated with a panic attack, and it becomes a vicious cycle.”

At the same time, panic attacks can occur in people who do not have a panic disorder diagnosis. Although panic attacks are often coupled with stress, trauma or anxiety-related issues, they can also occur in clients without complicating factors, says Collins, who notes that she has seen clients who experienced their first panic attack in their 50s or 60s.

“They can happen even when life is going well and have no apparent reason. … Some people have them for a period of time in life and then never have them again, while others will have them throughout life,” she says. In addition, significant life changes, such as getting married, starting retirement or having a child, can trigger recurrences in clients who previously were able to manage their panic attacks, Collins adds.

Among clients with mental illness, panic attacks can co-occur with depression, anxiety, bipolar disorder, posttraumatic stress disorder, obsessive-compulsive disorder, specific phobias (particularly emetophobia, or fear of vomiting) and other diagnoses. Taylor says they can also be associated with a medical or physical issue.

“One of the most overlooked problems that can lead to developing panic is chronic sleep deprivation or insomnia,” he says, explaining that a lack of sleep can overexaggerate the fearful thoughts related to panic. When treating panic attacks, counselors should ask clients about their sleep habits within the first few sessions, Taylor advises. Counselors can also remember the acronym CATS and ask clients about their consumption of caffeine, alcohol, tobacco and sugar — all of which can worsen the feelings associated with panic attacks, he adds.

Learning coping skills and identifying triggers

Clients who come to counseling after experiencing a panic attack may start therapy without understanding the complexity of panic attacks or harbor feelings of shame or embarrassment about succumbing to panic seemingly out of the blue, Collins says.

It is sometimes helpful to explain to clients that during a panic attack, their body is launching into the fight-or-flight mode that is part of their biological wiring, Collins says. However, in this case, there is no tiger chasing them.

“I like to say that [a panic attack] is tripping the sensor, like when a leaf falls on your car and the alarm goes off. It trips the sensor, but your car doesn’t know” that there isn’t any actual danger, she explains. Collins says it also can be helpful to assure clients that “it will never be as bad as those first few times when you didn’t know what was happening to you.”

To identify triggers, Collins suggests walking clients through the months, days and hours that led up to their first panic attack — but only when the individual is ready to relive the experience, she adds. Some triggers can be easily identifiable, such as a spike in work-related stress or the loss of a loved one. Other triggers may be less obvious, meaning more work will need to be done to unpack the experience later in therapy.

“I like to make sure clients have really solid coping skills before they work on the underlying stuff that might be contributing” to their panic attacks, such as trauma, Collins says. “Spend the first few sessions identifying what’s been going on. Once they’re confident and capable of managing and getting through an attack, then ask about what might be contributing” to the attacks occurring.

Outside of session, counselors can encourage clients to devote time to journaling, relaxation, deep breathing and counting exercises that can boost self-reflection and change negative thought processes, Collins suggests.

Counselors can also equip clients with coping mechanisms such as mindfulness to help them remain calm and feel more in control in the event of a panic attack. Collins often gives her clients a small stone to carry with them and hold in their hand when a panic attack strikes. She tells them to focus on the stone and describe it to themselves — is it rough, smooth, cold, heavy? This can help divert their attention from the panicky sensations, she explains. The same technique can be followed using car keys, a coffee mug or whatever else clients can hold in their hands that wouldn’t readily draw undue attention from others, she adds.

Clients can also develop mantras to remind themselves in the moment that even though a panic attack feels all-consuming, it is a finite experience. Among the phrases Collins suggests as being helpful:

  • “I’ve gotten through this before.”
  • “This is only temporary.”
  • “Even though this feels like it’s going to last forever, it will end; it always does.”

Collins acknowledges, however, that “once it gets to a certain point, these things don’t work. You have to accept it for what it is when you’re in the middle of an attack. You have to ride the wave, accepting that it will be temporary and it will go away.”

“Sometimes, even getting angry at the panic attack can help,” she adds. “When [people] allow themselves to accept that anger, it takes away some of the power of the attack itself. Admit that it stinks but it’s something you can get through.”

Uncomfortable but not dangerous

Thinking that a panic attack can be halted or avoided by using breathing or relaxation techniques is a misconception, according to Taylor. Those methods are often the first choice of well-meaning practitioners, but Taylor argues that “it sends a subtle message to the patient that what you’re experiencing is dangerous and we need to do something to prevent it.”

“The first thing you need to do is teach [clients] that what [they are] experiencing is uncomfortable but not dangerous,” he says. “It’s your avoidance of the uncomfortable feelings, and trying to stop it, that has unintentionally made it worse. When it comes to symptoms of panic, trying to suppress or avoid those symptoms is the exact opposite of what you want to do.”

Diaphragmatic breathing and other relaxation techniques can be helpful to manage anxiety, Taylor clarifies, but they won’t stop the symptoms of a panic attack altogether. “The only way to truly stop it is to become accustomed to the feelings” and to understand that a panic attack is not dangerous, he adds.

Taylor finds the DARE method developed by author Barry McDonagh particularly helpful. The technique focuses on overcoming panic with confidence rather than employing futile attempts to calm down, Taylor says. The four tenets of DARE are:

  • Diffuse: Using cognitive diffusion, counselors can teach clients to deflect and disarm the fearful thoughts that accompany panic attacks. The thoughts that flood people’s minds during these episodes are just that — thoughts — and are not dangerous, Taylor explains. “Teach them to say ‘so what?’ to their thoughts: ‘What if I embarrass myself or pass out or throw up? So what?’ Take the edge off that thought by not only demoting it but separating ourselves from the thought: ‘It’s not me. I didn’t put it there.’ Teach patients to say to themselves, over and over, ‘This sensation is uncomfortable but not dangerous.’ Think of it like a hiccup. It’s uncomfortable but not dangerous. There’s nothing medically wrong. The more you focus on it, the more uncomfortable it gets.”
  • Allow for psychological flexibility: It is more important that individuals allow and become comfortable with their negative associations than it is to try to get rid of them, Taylor says.
  • Run toward the symptoms: Moving toward feelings of discomfort is antithetical to human instinct, but in the case of panic attacks, it can actually be an effective tactic. Taylor teaches people who deal with panic attacks to tell their bodies to “bring it on. Ask your heart: ‘Give me more. Let’s see how fast you can beat.’ One of the fastest ways to stop a panic attack, ironically, is to ask for more and try and make it worse. It’s the resistance to the sensations that makes it stick around.”
  • Engage: Teach clients to engage in the moment once the panic attack has peaked and is starting to wind down. This is when grounding and mindful exercises can be helpful, Taylor says. “What’s important is to focus on right here and right now. That will help you continue to move forward and get unstuck,” he adds.

An attachment approach

All of the counselors interviewed for this article noted that cognitive behavior therapy (CBT) is an effective, tried-and-true method to support clients who experience panic attacks by helping them refocus the fearful and overexaggerated thoughts that accompany the experience.

Linda Thompson, an LPC and licensed marriage and family therapist in Florida, finds that using CBT through the lens of attachment theory can be particularly helpful in addressing panic attacks. That holds especially true for clients who struggle with feelings of abandonment or rejection or have experienced attachment trauma, including the loss of a loved one or caretaker. Counselors can identify clients who might benefit from attachment work by asking questions at intake regarding past relationships and loss, Thompson says.

“If they are the kind of person who is very relationship-oriented and attachment is very important to them or there is trauma there, that has to be brought into the conversation,” says Thompson, an associate professor at Argosy University with a private practice in the Tampa area.

Thompson suggests that counselors invite someone to whom the client is attached, such as a partner or a spouse, into the therapy sessions (with the client’s consent). The practitioner can prompt discussion that helps the client share some of the inherent fears that he or she is harboring. Often, Thompson says, the partner’s response to this sharing is “I had no idea you felt that way. How can I help?”

From there, counselors can introduce techniques that the client and the client’s attachment figure can use together when the client is feeling anxious, Thompson says. Eye contact, hand holding and other physical connections can be particularly helpful. “It’s making it about connecting,” she explains.

Once they understand that their loved one’s worry and panic are spurred by issues related to relationships or a fear of isolation, friends and family members can be better prepared to respond differently when the person begins to struggle. If the client is willing, counselors can play a role in training the individual’s support system to help with attachment-oriented responses. For example, if a client wakes up in the middle of the night feeling panicked, a spouse or partner could respond by rubbing the person’s back or whispering affirmations such as “You’re not alone,” “I’m here” or “We’re going to get through this together,” Thompson says.

Attachment-oriented clients may also benefit from learning to do breathing techniques with someone to whom they are attached, Thompson adds. For example, a client may start to feel the symptoms of a panic attack while driving. Relying on techniques learned in session, the client would pull the car over and focus on their child in the backseat — holding the child’s hand, making eye contact and breathing together. The physical touch will boost oxytocin, a hormone connected to social bonding and maternal behavior, Thompson explains.

Thompson also suggests that these clients try yoga to help with relaxation and self-control. She says the practice is more beneficial if it involves a social aspect, so she recommends that clients practice yoga in a class with other people instead of alone at home.

Similarly, Thompson suggests helping attachment-oriented clients build a “tribe” or circle of support beyond the counselor. This is especially important for those who have lost a spouse or partner and those who are more susceptible to isolating themselves. Counselors can guide clients in finding connections that are personally meaningful to them, whether that is through participation in spiritual or religious activities, volunteer work or other community groups such as a book club. Focusing on relationships rather than the physical symptoms of a potential panic attack can help these clients feel less vulnerable, says Thompson, a past president of both the Pennsylvania Counseling Association and the International Association of Addictions and Offender Counselors, a division of ACA.

Thompson recalls one client who struggled so acutely with panic attacks and a fear of losing her loved ones that it kept her from leaving the house for two years. CBT alone wasn’t helping, so Thompson added attachment techniques to their therapy work together.

After a substantial amount of in-session exploration, Thompson discovered that the client’s panic attacks were tied to family-of-origin issues. The physical feelings the client experienced during her panic attacks were in the same part of the body where one of her parents had experienced a significant health problem.

In addition to conducting one-on-one therapy, Thompson included the client’s husband in sessions. They worked together on attachment-focused techniques, and, eventually, the couple was able to go outside of the home for the first time in a long while to celebrate their anniversary.

To prepare, they created notecards with attachment-focused feelings and reminders, such as what their first date felt like. They referred to the notecards throughout the evening and connected consistently via holding hands and making eye contact.

After the date, the client reported to Thompson that instead of thinking of where the exits were in the restaurant, as she would have done previously, she remained focused on the man — her husband — in front of her.

Thompson urges counselors to remain open to adding attachment theory or other complementary methods on top of go-to techniques such as CBT to reach clients who are experiencing panic attacks. “Expand your toolbox,” she says. “A person’s fear, the fear that is triggering panic, can have multiple origins. Help the client to find the source of their fear, and work on that. … Broaden your perspective to recognize that human beings have to be attached with people, no matter what the disorder. Ask, ‘How do I make sure the social needs of my client are being met?’”

Controlled exposure

Taylor knows firsthand how terrifying a panic attack can feel. He began experiencing anxiety in his teens and early 20s that intensified to the point of daily panic attacks.

When things were at their worst, he would often go to the emergency room of his local hospital. He wouldn’t register as a patient but would simply sit in the waiting room, knowing that those uncomfortable, uncontrollable feelings would eventually overtake him again. “Sometimes [I would go] because I was having a panic attack, or other times it was just because I felt I might have a panic attack,” Taylor recalls.

Eventually, Taylor did check himself into the hospital, and a doctor explained that he was going to be OK. That was the life-changing encounter that put him on the path to getting help; he credits medication and therapy for helping him overcome his panic attacks. The experience also inspired him to become a counselor.

This personal history plays into his work with clients. As a specialist in treating chronic anxiety and panic, he often emphasizes to clients that feelings of fear and excitement share the same neurological pathways. “It’s just our perception that makes them different. … You have to be able to ride the waves of panic without resisting it,” he says.

In addition to teaching clients to tolerate and deflect the invasive thoughts and physical symptoms that accompany panic attacks, Taylor finds exposure therapy to be a powerful treatment for panic. In fact, Taylor believes that exposure, or intentionally bringing on a panic attack in a controlled setting (such as the counselor’s office), must necessarily play a large role in overcoming the episodes.

“Patients are not moved by information; they’re moved by what they believe is possible, and they’re moved by new experiences. Just giving them the information [that panic attacks are survivable] is about as good as baptizing a cat,” he says. “If you give them the experience of exposure work in your office, they walk out a changed person. The focus should not be on staying calm but [on knowing] that no matter how hard their heart beats or [how much] they feel a sense of doom, they’re actually safe. It’s just a brain hiccup.”

Inducing a panic attack in the safety of a counselor’s office can prove to clients that what they might experience is uncomfortable but far from fatal, Taylor says. “When a counselor is doing exposure therapy with a patient and inducing panic-like symptoms in the office with them, we as counselors need first to be confident that a panic attack truly is not dangerous to the patient,” he explains. “If they start to panic and then we get scared and try to calm them down, the exposure will fail. We have to be able to stay with it, let the panic attack fully develop and subside on its own, so the patient learns that their fear of having a heart attack, passing out or losing control won’t happen. And unless we can really allow them to go all the way through a panic attack and come out the other side, the exposure just won’t work. They will continue to believe that a panic attack is dangerous and continue to try to suppress and avoid them.”

A good amount of therapeutic work may be required before clients are ready for exposure techniques, Taylor says. Once they are, counselors should begin the experience by asking clients to verbalize the worst thing they can imagine happening to them as the result of a panic attack, he says. Fears that clients typically voice include passing out, vomiting or even having a heart attack.

Taylor says the counselor’s response could be, “OK, are you ready to test that out” in the safety of the counselor’s office?

To induce the elevated heart rate and rapid breathing that accompany panic attacks, the counselor might suggest that the client do jumping jacks, run up and down the stairs or breathe through a straw for an extended period of time. As the panic symptoms swell and peak, the counselor will remain close by to remind the client of the cognitive diffusion and other techniques previously mentioned by Taylor.

Afterward, the counselor can talk about how the things the client feared happening as the result of a panic attack did not actually come to pass. The moment clients realize that they can endure panic attacks without their worst fears materializing is the moment they can begin to overcome the attacks, Taylor says.

Conquering avoidance

Individuals who have experienced panic attacks will sometimes start avoiding situations or places where a prior attack occurred. Often, this includes public places such as shopping malls. If this inclination is left unchecked, it can spiral into the person missing work and social engagements or engaging in other isolating behaviors, Collins says. On top of that, avoidance will serve only to make things worse, she notes.

“That fear of having another panic attack can be crippling,” she says. “One of the fears a lot of people have is having an attack in front of people or being in a place where they can’t escape, such as an airplane or a meeting at work.”

When Collins broaches this subject with clients, she frames it as taking their power back and not letting panic attacks control their lives. “We talk about starting small and [taking] baby steps, especially if they’ve been terrified of a place for a while,” she says.

Counselors can begin by having clients visualize in session the place they have been avoiding. Ask them to describe it and talk about how their body feels as they think about that location, Collins suggests. This process may need to be repeated several times before clients feel comfortable and confident enough to make a plan to actually go to the places they have been avoiding, she adds.

When they do go, make sure the client takes a friend or other trusted person with them for support. Clients should also be directed to stick to the plan they have created and talked through in their counseling sessions, Collins says.

For example, if a client has been avoiding going to a shopping mall out of fear of having a panic attack, a first step in the client’s plan might be simply driving to the mall, parking the car and sitting inside it for five minutes before leaving. The client might even need to repeat that step of the process multiple times, Collins says.

After that, the client can move on to walking through the doors of the mall and then leaving immediately. On the next visit, the client might enter the mall and go into a store, and so on. The idea is to continue going until the client no longer associates that place with feelings of fear.

Often, after repeated visits, “people will say, ‘OK, I don’t need baby steps. I want to go now,’” Collins says.

Above all, compassion

Counselors can provide a holistic approach to addressing panic attacks that clients might not have experienced previously with medical professionals or other mental health practitioners. Most of all, Collins says, counselors should offer empathy to clients who are confronting such a distressing, overwhelming and, often, seemingly unexplainable experience.

“That validation is the most powerful thing I’ve seen that helps people,” she says. “Clients get better with the relationship, the validation, the compassion. Compassion: That’s the No. 1 thing to remember.”

 

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Contact the counselors interviewed for this article:

 

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Learn more:

ACA Practice Brief on panic disorder: counseling.org/knowledge-center/practice-briefs

 

Zachary Taylor recommends these resources for counselors who want to learn more about the treatment of panic attacks:

  • DARE: The New Way to End Anxiety and Stop Panic Attacks by Barry McDonagh
  • Anxious Kids, Anxious Parents: Seven Ways to Stop the Worry Cycle and Raise Courageous and Independent Children by Reid Wilson and Lynn Lyons
  • Interview, “Maximizing Exposure Therapy for Anxiety Disorders” with Michelle Craske, professor of Psychology, Psychiatry and Biobehavioral Sciences and director of the Anxiety and Depression Research Center at the University of California, Los Angeles: sscpweb.org/craske
  • Article, “Get Excited: Reappraising Pre-Performance Anxiety as Excitement” by Allison Brooks, assistant professor, Harvard Business School: apa.org/pubs/journals/releases/xge-a0035325.pdf
  • Dr. Andrew Weil’s 4-7-8 Breathing Method: drweil.com/videos-features/videos/the-4-7-8-breath-health-benefits-demonstration/

Linda Thompson recommends these resources for counselors wanting to learn more about attachment-focused responses:

 

 

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Bethany Bray is a staff writer and social media coordinator for Counseling Today. Contact her
at bbray@counseling.org.

Letters to the editorct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.