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Building a foundation in premarital counseling

By Bethany Bray January 31, 2022

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For many people, the phrase “premarital counseling” may conjure the image of a young, starry-eyed couple doing short-term work with a counselor or religious leader to discuss issues such as whether they’d like to have children or who will be responsible for cooking and taking out the trash.

While that scenario can and does still happen, more U.S. adults are delaying marriage. According to the U.S. Census Bureau, the median age for first-time marriage was 28.6 for women and 30.4 for men in early 2021. In 2000 and 1980, those statistics were 25.1 and 22 years for women and 26.8 and 24.7 years for men, respectively.

In addition, fewer American adults are choosing to say “I do” at all. The Pew Research Center estimates that roughly half (53%) of all U.S. adults are married, which is down from 58% in 1995 and 72% in 1960. Between 1995 and 2019, the number of unmarried Americans who were cohabiting rose from 3% to 7%.

These gradual but notable changes have led professional counselors to evolve their approaches to meet the needs of today’s premarital couples, regardless of whether they have a wedding date marked on the calendar. For Stacy Notaras Murphy, a licensed professional counselor (LPC) with a private practice in the Georgetown section of Washington, D.C., premarital counseling includes the couples on her caseload who are planning a wedding as well as those who are in unmarried yet long-term relationships.

In the two decades that Murphy has done premarital counseling, she has shifted from a top-down, topic-focused approach to a bottom-up approach that addresses attachment style and other deeper issues. This is not only because couples’ needs have shifted over the years, Murphy says, but also because recent research indicates the meaningful role that attachment plays in human relationships across the life span.

It is still important to prompt couples to talk through “big-ticket items” such as their expectations about finances, children, sex and intimacy, and the role that family and extended family will play in their lives, Murphy says. But premarital counseling should also build a foundation for couples to engage in these types of deep discussions — and navigate conflict when it inevitably arises — on their own in a healthy way, she stresses.

“All of these topics are grist for the mill,” says Murphy, an American Counseling Association member. “At the end of the day, couples want to understand themselves more deeply, and you don’t get there on your own by talking about what your goals are for retirement [and other topics]. … More so, it’s focusing on the steps that partners take to get their needs met and how those conflict and dovetail. It can be a beautiful dance.”

Getting started

Murphy thinks that in many ways, premarital counseling is couples counseling and uses similar tools and approaches. Premarital counseling has a more preventive focus, however, whereas couples counseling with married clients is often focused on repair work and undoing unhealthy patterns.

Tyler Rogers, an LPC and licensed marriage and family therapist who owns a private practice in Chattanooga, Tennessee, begins work with premarital couples by asking some straightforward questions: “Why do you want to do this?” and “What are you hoping to gain by getting married?”

Hearing couples’ perspectives on the why can help a practitioner understand more about the two partners, their relationship and their expectations, he says. If their answers tend to be more surface level, such as “this person makes me happy,” it opens the door to ask other questions and explore deeper with the couple, including offering psychoeducation about how attraction and liking someone are not the same as being “relationally competent,” Rogers notes. These discussions sometimes involve talking through why and how marriage requires “an entirely different skill set” than dating or living together, he says.

This work is still beneficial for couples who are getting married later in life or who have been living together for a while. Counselors will just need to tailor their approach to meet the couple’s experience.

“Sometimes counselors will need to help [more established] couples have a merger marriage, like the merging of two companies,” says Rogers, an associate professor of counseling at Richmont Graduate University. “Older couples [who are getting married] have less idealistic issues clouding what they think is coming [or] are more aware of each other’s problems. They might say, ‘We are really not good at talking about X’ or ‘This is how our conflicts go.’ … It’s a hybrid place of doing some marriage counseling along with premarital work. Couples may already have patterns or habits that aren’t great, but not to a breaking point.”

Practitioners may also work with couples where one or both partners have been divorced or experienced a painful breakup previously, and they come to therapy wanting to “get it right this time,” Murphy says. “These couples know a lot about themselves but also [know that they] need this partner to be very different than the one who hurt them in the prior relationship. We do a lot of unpacking what their needs are. I also acknowledge that it can be triggering for the other partner to hear a lot about someone’s ex.”

Beatriz Lloret, an LPC with a couples counseling private practice in College Station, Texas, takes a two-pronged approach to premarital counseling: One part involves psychoeducation on the components of a healthy relationship, and the other part explores the couple’s attachment style and patterns. In psychoeducation discussions with couples, particularly those who don’t have a healthy example to follow from their parents or family of origin, she often pulls from the Gottman method’s “sound relationship house theory,” including its components of trust and commitment.

“Couples often feel hopeful because they’re about to get married but sometimes mixed and apprehensive about periods of disagreement. The premarital [counseling] becomes couples therapy a little bit to address those issues,” says Lloret, an ACA member. “The beauty of it is that when [clients] are willing to come and dive into it a little, things [improvements] happen fast, especially because the issues are fresh and there is not too much rigidity built up yet.”

In addition to psychoeducation, Rogers and Lloret both say that initial work with premarital couples includes weaving in questions to cover necessary topics such as family of origin, finances and money management, children, and the roles they expect to have within the relationship.

Lloret says some of the clients who seek her out for premarital counseling do so as an alternative or in addition to premarital programs in their faith communities. These couples sometimes want to discuss issues — often those that have connotations of shame, such as sexuality — that they aren’t comfortable discussing with a religious leader or in programs that use a group setting. 

Although Lloret typically sees premarital couples together for the initial intake session, she splits the couple up for the second session to work with each person individually. This helps her get to know and build rapport and trust with each partner, as well as screen for domestic violence, she says. However, beyond issues such as abuse that require sensitivity, she has a “no secrets” policy for these sessions. Clients sometimes reveal that they haven’t told their partner about a chronic illness, a financial problem or a past affair; Lloret stresses the importance of disclosing and working through these issues with their future spouse.

Ellen Schrier, an LPC with a solo private practice in North Wales, Pennsylvania, has several assessment tools she uses to begin work with premarital couples. She says underlying distress — often involving frequent conflict, trust issues, personality clashes or infidelity — is revealed through this process in roughly 90% of the couples she sees. With distressed couples, it is often the case that one partner is pursuing the other, and the other partner is pulling away, withdrawing or avoiding conflict, she notes.

Schrier considers premarital counseling to include all of the unmarried couples she counsels, including those who aren’t engaged or looking to get married. She estimates this work is 30% of her caseload. Like Lloret, Schrier often sees premarital couples individually for a session early on to get to know them and help tailor her work to their needs.

“Often the case is they come in to strengthen the relationship, but there’s more to it,” Schrier says. “As you begin to talk, you realize there are deeper issues or past infidelity. They come in looking for a little boost but actually are struggling with a big problem.”

Addressing attachment

Initial assessment and discussion about content topics (finances, children, sexuality, etc.) in premarital counseling serve a couple of different purposes. One, they provide the practitioner with information about a couple’s personalities and background and, two, they open the door for deeper discussions and work on challenges that underlie those topics, including addressing attachment, repairing broken trust or breaking cycles of conflict and blame.

“The big-ticket-item conversations have to happen, and they can be very triggering, so it’s good to have them in couples therapy,” Murphy says. “My role is to let them talk about that content but then put it into the context of how they’re talking about it. … It’s absolutely critical to teach them about their own attachment style and how that interacts with their partner’s. Across the board, teaching them how to have healthy disagreements is my main agenda. We have such stereotypes that a ‘good marriage’ is one where you don’t have any conflicts, but that is so untrue. Demystifying that process is my job more than anything else.”

Murphy and Lloret use emotionally focused therapy (EFT) with premarital couples and find it useful for helping clients explore and dig into patterns and attachment issues. Throughout this work, the counselor guides the couple as they talk through deep issues that they wouldn’t necessarily recognize or know how to address on their own. Lloret says some premarital couples choose to work with her because she specializes in EFT and attachment.

“The counselor is a moderator to prompt deeper exploration, diving into what’s really inside of you and what’s really inside the other person,” Lloret says. “I don’t give solutions — what do I know [about what] they should do? — but they do.”

Having couples talk about their family of origin and the examples of marriage and relationships they’ve seen in their lives can be a good starting point for attachment-focused work with couples. Research shows that attachment patterns that humans form in early life repeat in romantic relationships, Lloret notes.

Murphy says, “I repeat over and over: ‘I’m not asking questions about your childhood to vilify your parents. They did the best they could. [And] it’s actually a good sign that you’re asking for help. But it’s important to talk through what you have experienced and what you believe.’ We want to get very clear about those expectations and desires and how to talk about them.”

Rogers believes it is important to relay a message to premarital clients who haven’t had healthy or stable examples of relationships in their life that “it’s not your fault; you didn’t choose that.” A counselor can help couples focus on the fact that they don’t have to repeat those experiences in the family they create.

Couples can also seek out other couples that they would like to emulate. Rogers sometimes asks clients to think of people they know whose relationships they admire and then to connect with them as “marriage mentors.”

“Ask them to have dinner with you, and pick their brain and learn from them,” suggests Rogers, an ACA member who previously worked as a Protestant pastor.

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At its core, premarital counseling should help clients explore and learn about themselves and “the process of couplehood,” Murphy says. Relationship education is some of the most important ground to cover, she emphasizes. The crux, Murphy says, is helping clients understand that human attachment draws us to want connection and support from others. Counselors can then help teach clients how to give and receive that with a partner in a healthy way.

“At the end of the day, [couples] need to really know each other deeply and take care of each other. … It all comes down to ‘is there someone in this world that has my back?’ That’s the basis of attachment: to be secure, to know that there is someone in this world who thinks we are special, a home base,” Murphy says. “Premarital couples don’t always have a lived experience of worrying about that, and my job is to establish that that’s why we’re here or [to] remind experienced couples [of that]. At the end of the day, it’s the same lecture [both in premarital counseling and couples counseling] about the role of attachment in our lives.”

But sometimes partners can become too attached. Some couples who are in the early stages of their relationship have an attachment that Lloret describes as two hands with interlaced fingers. It’s very hard to move one hand independently when the fingers are so tightly interwoven, she explains.

“They need to [learn to] feel comfortable with a certain amount of emotional distance. They need to find patterns of interaction that are healthy while feeling supported, but also maintaining their own independence,” Lloret says. “It’s common to see these issues in premarital counseling, including communication issues, arguing and misunderstanding. They often label it as a communication issue, but it’s really trying to differentiate while maintaining a bond [and] feeling seen and heard and understood while keeping connection.”

Bridging differences

The number of Americans marrying someone with a different cultural background than their own is increasing with each generation. In 1967, 3% of married U.S. adults had a spouse who was a different race or ethnicity. That number has since grown to 11% of adults being intermarried in 2019, and the percentage is even higher (19%) among newlywed couples, according to the Pew Research Center.

Murphy says discussions about culture and cultural differences between a couple — and the friction, misunderstandings or other challenges that may arise from these differences — can fit naturally into conversations about family of origin and relationship expectations. Here, as with other topics, it’s important for counselors to dig into why clients feel the way they do.

“The goal has to be to keep it curious instead of feeling that your partner’s family does it ‘weird’ or ‘wrong,’” Murphy notes.

Prompting premarital clients to share about how their family celebrates holidays can be a good way to introduce these topics, delve into client expectations and uncover potential sticking points that the couple hasn’t addressed yet, Rogers says. It can also be an opportunity to talk with the couple about how holidays — and other aspects of marriage and long-term relationships — can involve a blend of preferences from the two partners instead of being all one way or the other.

Another important aspect of these discussions involves asking couples how they think their partner views their culture, adds Rogers, who leads trainings on premarital counseling through the Prepare/Enrich program. He sometimes prompts clients by asking, “What aspects of your culture are important to you? What would you like your partner to embrace a little more or understand a little more?” 

“Generally, it’s a conversation they’ve had already without realizing they were having it, in the form of disagreements about things such as family, money or traditions, [and] without realizing that it’s tied to their identity and feeling that their partner’s objection to their stance is a rejection of their culture,” he says. 

Culture ties into how people express love and relate to those they love in many ways, Lloret notes. This includes everything from expectations about gender roles in marriage to a person’s comfort level around discussing sex or displaying affection in public. For example, in Latin American culture, a male partner may be taught that showing possessive behavior and jealousy can be a way to express care and love. But a female partner from an American background might find these expressions overly controlling.

A counselor’s role is to guide clients as they break down the meaning behind feelings and behaviors and explore why aspects of their culture and traditions are important to them, Lloret says.

“When they take the time to clarify what the expectation means, break it down and explore how they make sense of it, and then find ways to compromise and give and take [with their partner], that’s when the beauty comes,” she says. “It’s either explaining, ‘I can’t give this thing up, but it doesn’t mean that I don’t love you,’ or ‘I will compromise because I love you.’ It’s deeper conversations that create connection rather than getting stuck on the differences.”

Building a firm foundation

Premarital counseling should always aim to provide couples with the tools they need to navigate future disagreements and differences on their own. This includes learning to compromise and respond to each other in ways that are not reactive, judgmental or assumptive, Rogers says.

For example, perhaps one partner wants to live close to their parents and have them involved in the couple’s life, whereas the other partner would prefer to maintain some distance from the in-laws. A counselor can serve as a moderator as the couple talks through why they are in favor of or opposed to something and what compromises they are willing to make. Rogers suggests having clients identify specific solutions such as not allowing the in-laws to have a key to the couple’s home or agreeing to limit dinners at the in-laws’ home to twice per month. That approach is more tangible, he says, than one partner saying something vague such as “Don’t worry, my parents won’t be over all the time.” 

“In premarital counseling, I’m trying to help them learn the process of being a patient, curious person to find out why their partner doesn’t think the way that they think when they don’t agree,” Rogers explains. “A lot of that is teaching them how to communicate why they have the position that they do and encouraging them to do some digging without judgment. … Whatever the issue is, there is a deep why, a reason why they hold these feelings close. The counselor’s role is to help them understand their own why and explain it to their partner, while at the same time being open and accepting [of] their partner’s why.”

Schrier says that couples in premarital counseling often need to learn how to fully listen and acknowledge their partner. “A lot of people don’t have that important skill of listening to someone without reacting … [and] understanding each other’s position and validating it, valuing it, without escalating, getting overwhelmed or angry,” Schrier says.

“Sometimes they need to learn how to have one person speaking at a time without the other person interrupting or adding on to what the partner is saying,” she says.

Schrier uses various activities to help couples practice these skills, including one that has the partners take turns being the “speaker” and the “listener” as they respond to prompts such as:

  • Name three strengths and three challenges in your relationship.
  • What would you like to have more of and less of in your relationship?

Schrier says these conversations help clients with skill building and help her identify things to focus on with the couple. In the process, couples often find things they agree on such as needing to work on communication or making time to have fun together, she adds.

Equipping couples with an expanded emotional vocabulary can help in this realm as well. Clients often fail to realize or fully describe their feelings when in conflict with their partner, Schrier notes. For example, a client who wants more connection from their partner may express that as blame: “You don’t spend enough time with me.”

Schrier has a detailed list of “feeling words” that she gives clients to help prompt more constructive and respectful dialogue. She also sometimes suggests that during disagreements, clients ask their partner (using a nonaggressive tone), “Can you say that in a different way?”

Perhaps a towel left on the bathroom floor triggers an argument between a couple. Initially, the person who discovers the towel may feel intense anger toward their partner, who dropped the towel. But skills learned in counseling can help the person realize what they are feeling beyond anger, she explains.

“Saying ‘I feel disrespected or devalued’ is a better way to talk about it and less reactive. It’s more empowering to say that than to say, ‘You make me angry.’ It gives their partner more to understand and change,” Schrier says. “It’s a way to slow the conversation down a little bit so they can better understand their partner instead of assuming they know what [their partner is] feeling.”

Couples who aren’t able to do this sometimes get “stuck on a hamster wheel” of arguing over the content (in this case, a dropped towel) rather than the feelings of a disagreement, she adds. When this happens repeatedly over time, it can lead to contempt, resentment and distance in relationships.

“It’s so much easier to work on problems when you’re coming in [to premarital counseling] with a spirit of friendship, instead of years later coming in as adversaries with years of misunderstandings and hurt feelings,” Schrier says. “It’s better to do it on the front end and be preventive.”

Premarital counseling can also open the door for couples who need deeper long-term work, Murphy notes. Premarital clients who are not able to fully resolve challenges before their wedding date may need to return for further counseling after they are married or when a life change, such as having a child, upsets the couple’s equilibrium.

“Premarital counseling can be the appetizer to a later full meal of deep couples work that is needed, sometimes years later or with a different clinician,” Murphy says. “It’s important [for counselors] to normalize getting input from different sources throughout the life span.”

Preventive care

Although premarital counseling often covers some of the same ground as couples counseling, there is one major difference: clients’ attitudes. The counselors interviewed for this article said that premarital work is rewarding because most clients are optimistic, enthusiastic and willing to strive to make changes to strengthen their relationship. In addition, growth and improvement often occur quickly.

“Premarital counseling is preventive care in a lot of ways,” Rogers says. “It can be some of the most rewarding, fun work to do with couples. … So many other mental health issues could be helped if we can help people have healthy relationships. We can be instrumental in pushing the ball forward to start marriage off on the right foot rather than addressing things only when they’re in a bad situation.”

 

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Let’s talk about sex

One of the most important “musts” to discuss with couples in premarital counseling is sexuality. This is an area that couples who are older or who have lived together for a while may think they have figured out and don’t need to cover, says licensed professional counselor (LPC) Tyler Rogers.

Rogers sometimes jokes with premarital couples, saying, “John Lennon was wrong. Love is not all you need.”

Couples may have “the basics” of sexual intimacy mastered but need psychoeducation about how a healthy sex life will need to evolve and change over the course of a marriage. There will be times in life when sex isn’t easy and effort has to be made to foster intimacy, Rogers says. It’s important for practitioners to ask premarital couples about their sexual history and expectations regarding sex and, if they are sexually active together, to ask questions to ascertain their level of sexual wellness. Manipulative behavior such as withholding sex can indicate an area that needs more attention in therapy. Factors such as past sexual trauma or pornography use can complicate this issue, Rogers notes, especially when it is undisclosed between partners.

“There can be feelings of shame or guilt, especially if things are not disclosed until after they are married,” he says.

Tensions or misunderstandings regarding sex can cause distress that spills into other areas of the relationship for couples who otherwise have healthy connection, notes Beatriz Lloret, an LPC with a couples counseling practice in Texas.

Lloret says that where she lives, many premarital couples choose to delay sexual experiences — and important related discussions — until after marriage. Clients who fall into this category, many of whom are in their 20s and come from conservative, Christian backgrounds, often explore feelings and judgments regarding sexuality, she says. For some, discovering that their partner has certain sexual preferences or expectations carries a negative meaning or assumption for them. As with learning how to handle conflict in premarital counseling, practitioners may need to equip clients with tools to listen and respond to their partner about intimacy without being reactive or accusatory, Lloret says.

“For couples who don’t get to explore their sexuality until they’re married, once they open the door to this whole universe of sexuality, there’s a chance for a huge mismatch. Sometimes people have very different ways of expressing themselves and relating to pleasure, and it can create a big disconnection,” Lloret says. “They often need to explore judgment in a way to open their heart to the human being they’re in love with and the wiring that is sexual pleasure for that person. [It’s] getting judgment out of the way. There’s no one technique or easy way to do that, but the focus should be on being open and nonjudgmental.”

 

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

Healing attachment wounds by being cared for and caring for others

By Adele Baruch and Ashley Higgins October 29, 2020

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Those who work with individuals who have been traumatized have noted the need for these clients to reestablish connection to their own internal worlds. In these cases, clients often become frozen or, depending on the depth of trauma and the immediate response to that trauma, have an outwardly focused, hypervigilant, fight-or-flight approach to their experiences.

Cases of troubled attachment are based in this kind of fight-or-flight response, whether it is rooted in large T trauma (i.e., catastrophic accident or abuse) or small t trauma (i.e., multiple experiences with neglect or mistreatment). This leads to an inability for these clients to securely attach to others.

Building safety via action-based attunement

In cases of troubled attachment, the first task in counseling is to build safety through a focus on empathic, attuned responses associated with the client’s primary pathway of learning (for more, see David Mars and the Center for Transformative Therapy Training Center).

In a chapter titled “The creative connection: A Holistic expressive arts process” in the book Foundations of Expressive Arts Therapy (1999), Natalie Rogers defined empathy as “perceiving the world through the other person’s eyes, ears, and heart.” She noted that this understanding is conveyed through both our words and body language: “The body language, although usually unconsciously given and received … offers a sense of safety and comfort.” As we offer this opportunity for empathic co-regulation, we concurrently engage grounding approaches to enable a return to safety if anxiety is too high.

Along with grounding approaches, it is often useful to initiate action-based responses that are shared by the counselor to promote collaboration and attunement. These can range from the very simple to the more complex.

The following are offered as examples:

  • Expressive arts: Both the client and counselor respond to a piece of music with line and color. Then each person can respond to the other person’s artwork through line and color. Notice that there is no interpreting of the art experience, only the sharing of a visual response to music, and then sharing one’s experience of that response.
  • Breathwork: The counselor may model and practice basic and simple breathwork alongside the client to help the client access more internal quiet and space.
  • Role-plays: Engaging in simple role-plays can offer alternative action-based responses to challenging interpersonal situations

The choice of action-based approaches will depend on the needs and inclinations of the client, but these approaches are all in the service of conveying empathy and expanding interpersonal resonance. As Allan Schore (2013), a neuroscientist who has looked at brain activity during attachment experiences, would describe it, these approaches create opportunities for right brain to right brain communication (the foundation of attachment experiences).

As the client and counselor create together with these practices, the client builds a repertoire of action-based responses. The client may then begin to engage some of these action-based responses when triggered by a reminder of a traumatic event. This increases the client’s sense of internal safety.

Building resilience via attachment rupture and repair

Once safety is developed along with basic attunement and the capacity to choose constructive action, there is an opportunity to build a more robust and mature attachment via the counseling relationship. This can be achieved through a process of both intentional and unintentional rupture and repair of that attachment bond developed in counseling.

In her book chapter “Dyadic Regulation and Experiential Work With Emotion and Relatedness in Trauma and Disorganized Attachment” (originally published in Healing Trauma: Attachment, Trauma, the Brain, and the Mind, 2003), Diana Fosha articulated the way that counselors may, with great care, begin to interpret and confront with the expectation that this may create temporary ruptures in empathy. This empathy can be carefully repaired and restored in session through the articulation of feeling and the expression of understanding. A hypothetical example:

Counselor: “I wonder if you returned to your medical books with such great fervor last week because your partner has been asking for increased intimacy, and that is scary for you.”

This confrontation may be experienced as a temporary break in empathy, but if the counselor and client can sense and articulate the client’s immediate experience during that break, it can lead to a deeper understanding of that experience. That deeper understanding may lead to a more mature connection and, potentially, to the experience of a return to empathic attunement. These experiences, over and over again, may become internalized, leading to a more empathic connection to the client’s internal self.

Client: “When you say that, I feel like you are trying to push me to experience things I am not ready to experience after my last horrible relationship. You don’t really care about me. … You just want to see me move on.”

Counselor: “I hear you saying that my view about using your studies to keep a distance feels as if I am pushing you, and that feels as if I don’t understand how scary that is. Do I have that right?”

Client: “Yes, that’s right. You don’t really understand how scary it is.”

Counselor: “Can you tell me more about how scary it is?”

The repair may not occur immediately, but with careful listening, engagement and articulation, the feelings of fear and vulnerability may become more accessible. That experience makes a repair of empathic breaks caused (both intentionally and unintentionally) in a mature relationship inevitable. As Fosha explained, the experience of repair, in the context of confrontation and deeper understanding, provides evidence that differences or misunderstandings may eventually result in deeper connection.

This experience can lay the groundwork for both a greater capacity and patience for real-world attachments, as well as greater internalized empathy. Through this, the client experiences more ruptures and the relational commitment necessary for repair. 

Building self-regulation via emotional flexibility

In addition to internalized empathy, resilience in attachment ruptures and repair also creates a sense of safety — safety to dwell near emotions and to work to translate vague sensations to words. This requires the development of a sense of “unconditional friendliness,” as John Welwood has described it (Toward a Psychology of Awakening), toward the emotions that come up during rupture and repair. As counselors, we model this friendliness to emotions when they come, both during periods of attunement and during experiences of rupture.

As clients become more experienced with the naming of feelings in both easy and difficult interpersonal situations, this encourages greater self-reflection. With practice, this leads to a “self” system capable of modulating a range of affects, with emotions that may be integrated into adaptive responses.

Schore noted in Affect Regulation and the Repair of Self (2003) that through this process of self-regulation, the client “develops the ability to flexibly regulate emotional states through interactions with other people.” It is through this increased flexibility in the expression of emotion that the client can productively practice emotional regulation in the real world.

Building agency via helping others

It is very useful for clients to see themselves not only as the one who is helped but also as one who helps others. George Vaillant reminds us that it is not so helpful to give into the understandable wish to “mother” or “father” our clients, as it is important for them to develop and internalize their own “parenting” capacities with others.

Often, clients who have been traumatized multiple times become frozen in the role of “helpee,” but by helping, they are developing an active response to others, often in the face of anxiety. Action in the face of triggered anxiety creates new neural pathways for responses to triggering events (as detailed in “A call to action” Overcoming anxiety through active coping” by Joseph LeDoux and Jack Gorman).

Additionally, as clients listen to and fashion adaptive responses to others, they further practice emotional flexibility and regulation. It is wonderful to exercise a developing sense of self with an empathic counselor; it can be even more rewarding to exercise these abilities with someone who may not have as much to give and who might challenge and stretch our adaptive responses — within reason. Early entry into the community as helpers and participants is often best done in a supportive environment, such as a peer support group or a well-structured community initiative or a learning environment.

Helping and prosocial behaviors foster more confidence in helping. Ervin Staub cites multiple studies that show that children and adults become more helpful once they start helping. This increased comfort with helping is generally positively received in peer milieus, and the person helping experiences a sense of being valued — and, if all goes well, a sense of community.

We suggest that the ability to practice responding, in a helpful, emotionally regulated way in the real world, is as important as counseling is on the path toward mature attachment.

Four examples of helping opportunities

The following are four brief examples of milieu settings that provide opportunities to help and observe others, as well as to articulate feelings that develop while participating. 

Example 1: Roots of Empathy

Schools in Canada and New Zealand have developed a program for young children called the Roots of Empathy. In this program, a group of children is selected to host a parent-baby dyad in their room each month. Before each visit, the class prepares for the new developmental stage of the baby and the dyad. During each visit, children are encouraged to closely observe the way that the baby communicates, almost always with an open-hearted curiosity to their surroundings, and how the parent reads their baby’s needs.

After the visit, the children participate in discussions, artwork, drama and journal writing about what was learned. The natural generosity of children is expressed when they use art, music and drama to present gifts to the baby and parent. The visits continue one time per month throughout the year.

In this context, difficult questions arise, such as, “What if you were once a bully?” and “If no one ever really loved you, can you still be a good father?” As the children discuss observations of the parent-child dyad, they gain insight into their own emotions and those of others, leading to greater empathy.

David was 9 years old and had a form of autism. His parents shared with the program leader that David had never been invited to a birthday party by any of his classmates until the year that Roots of Empathy came to his classroom. That year, he was invited to three birthday parties. (For more, read Roots of Empathy: Changing the World Child by Child by Mary Gordon.) 

Example 2: The Courage and Moral Choice Project

A program focused on the cultivation of empathy for older adolescents is the Courage and Moral Choice Project, developed in our Maine schools. With this project, students listened to stories of helping under catastrophic conditions, such as during Hurricane Katrina. They participated in group discussion after hearing these stories, where they were able to share their own stories of times when they, or someone in their neighborhood or family, took a risk to help someone.

Students were encouraged to express their own stories, and the stories of others, through art, song, essays and poetry. Those works were shared with the larger community at a school board meeting and a university conference. After presenting at a conference, one student approached a second student involved in the presentation and apologized for harassing and bullying her during her earlier years of school. The second student forgave the first student and expressed understanding that those years were rough ones for both of them.

Example 3: Active bystander training

Many student life programs have established active bystander training to support university students in preparing to step up when they see a peer harassed or bullied. Ervin Staub originally developed active bystander training for schools and government agencies to prevent a sense of isolation should an individual experience a violation.

The training promotes a sense of awareness on the part of community members, but more powerfully, it suggests a pathway to a sense of agency should a person experience the pain of knowing a friend or community member is being targeted.

Example 4: Transformative Couples Therapy

One final example of integrating attachment cultivated in counseling work and connection in natural support systems is David Mars’ transformative couples therapy (TCT). TCT is an approach to couples work in which partners may deepen their attachment to each other by providing empathic support as they work through the unexpressed feelings from experiences that may have left them in fight-or-flight mode. TCT offers examples of how prior individual counseling work may be augmented in a collaborative environment.

These opportunities are mentioned to provide examples of the kinds of programs that encourage empathic connections, self-expression, listening and a sense of agency. These integrated experiences support the work done in counseling toward the development of the capacity for mature attachment.

Conclusion

When working with individuals who have experienced either “small t” or “large T” trauma, it is essential to engage them in action-based responses that provide a healing alternative to the fight, flight or freeze reaction. Building agency in the form of fostering connections to their inner world (via safety developed through grounding and attunement) and outer world (via repaired ruptures in therapeutic alliance, and engaging as the “helper”) is critical.

For the client to establish connection to their inner world, safety is built in a therapeutic alliance focused on empathic, attuned responses and action-based grounding techniques. This allows for the clinician to challenge the client, creating mild ruptures in empathy that can be repaired to build a more mature attachment through the return to empathic attunement. These breaks and repairs provide practice for a greater capacity and patience in real-world situations. Greater patience increases clients’ empathy and connection to their internal world and an internalized safety to sit with uncomfortable sensations and experiences, thus increasing both internal and external resilience and agency.

In tandem to building internal resolve, balance provides the client the ability to further increase their agency. This is best accomplished by encouraging the client (the person originally helped) to help others in the context of a well-structured environment. With the balance of being “the one helped” and “the helper,” the client develops and internalizes their “parenting” ability, allowing individuation from being the “parented.”

Greater internal and external connection and competence heals attachment wounds both inside and outside of the clinician’s office.

 

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Adele Baruch chairs and is an associate professor in the University of Southern Maine’s counselor education department. She practiced couples and individual counseling for 15 years before starting to teach. She has focused her scholarship on healthy adaptation and has developed an action research project on courage and moral choice in Maine. Contact her at adele.baruchrunyon@maine.edu.

Ashley Higgins is a clinical counselor at the Glickman Family Center for Child and Adolescent Psychiatry at Spring Harbor Hospital in southern Maine. As a licensed professional counselor, her primary areas of clinical interest include integrative and strengths-based modalities for treating attachment trauma; family systems; and wilderness therapies. Contact her at amhiggins@mainebehavioralhealthcare.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.

Identifying and addressing competing attachments with couples

By Anabelle Bugatti August 6, 2020

5 Comments

Couples come to counseling for a variety of reasons, and therapists are tasked with understanding the nature of couples’ concerns and offering helpful tools. Sometimes, as therapists, we might hear one partner complain about the things the other partner is doing and, often, these things may seem very trivial. We might also hear clients complain of conflict that centers on a lack of emotional availability on the part of their partner, coupled with their partner escaping or turning elsewhere to de-stress, to get needs met or for emotional sharing.

For example, one person might say, “My partner is always on their phone” or “My husband always takes work calls even during family time” or “My wife shares our fights with her friends” or “My partner would rather play video games than be with me.” Then there are statements that are less trivial, such as, “I think my spouse is having an affair.”

Anything that erodes the security of the bond between partners and creates distress can be seen as a threat to the relationship. The resulting distress must not be viewed as trivial, regardless of how small and harmless the situation may appear on the surface.

A rival to the relationship

A competing attachment is a threat to secure bonding in which one person in a relationship turns away from the relationship and toward someone or something else to get their emotional or attachment needs met. This is often experienced by their partner as a rival to their relationship — someone or something with which they have to compete for their sweetheart’s time
and attention.

Some of these emotional investments or activities on the part of one of the partners may actually be counterfeit attachments. These attachments are an attempt to mimic the fulfillment of comfort, soothing and belonging needs that a secure relationship would typically provide. It is usually the other partner (not the partner engaging in the competing attachment) who initially complains of distress.

The person participating in the competing attachment may or may not be aware that they are turning elsewhere to get their emotional and attachment needs met. This may largely depend on their own attachment style and level of emotional intelligence. Those engaging in the competing attachment are sometimes aware of what they are doing but may try to deny the impact this has on their partner or relationship. 

Depending on the type of competing attachment (what or whom a person turns out to) and the frequency (how often they’re turning out), their partner can be left feeling frustrated, jealous, hurt and disconnected. The more often this occurs, the more distressed the relationship may become. The attachment bond may then start to shift from secure to insecure, or a romantic attachment bond that was already insecure can have that insecurity amplified. Additionally, relationship satisfaction decreases as a relationship becomes distressed by a competing attachment.

Research currently shows a connection between competing attachments and insecure attachment relationships. However, it is unknown whether one causes the other or if an already insecure bond or insecurely attached person might be more vulnerable to developing or experiencing a competing attachment.

While different types of competing attachments tend to pose different levels of threat to a relationship, there is a clear connection between a partner’s concern of competing attachment and their romantic attachment security and relationship satisfaction. In a study conducted for my dissertation research, it was revealed that the more a competing attachment increases, the more the attachment security within the relationship decreases. As attachment security decreases, the more relationship satisfaction also decreases.

Competing attachments constitute a counterfeit attachment in which one partner turns outside of the marriage or relationship and toward something or someone else for escape, soothing, comfort or attention as a substitute for unmet attachment needs. Competing attachments can include addictions, affairs, gaming systems, smart phones, family members or anything else that might lead a spouse or partner to feel it necessary to compete with this “other” for the attachment bond with their partner.

Competing attachments vs. hobbies

It is important to distinguish the difference between a competing attachment and a hobby. Obviously, not everything that someone turns to outside of a relationship will constitute a competing attachment. Clients may have healthy attachments with other people or things that do not violate the boundaries of the romantic attachment relationship between two people and that do not create a feeling of competition for emotional time, attention or affection.

In general, hobbies do not threaten relationships because there are some emotional boundaries involved. Typically, hobbies are engaged in for general enjoyment rather than as an escape or as an alternative to the benefits of their romantic partner. Hobbies do hold the potential of turning into a competing attachment, although this doesn’t usually happen in securely attached people or relationships.

In my clinical practice, I have often heard female partners voice feeling the threat of competing attachment because their partners come home from work most nights and neglect to spend even a little bit of quality time connecting. Instead, they go straight to their gaming systems and play for hours until it’s time to put the children to bed or turn in for the night. Part of what contributes to the sense of a competing attachment is if one partner regularly turns to this “other” before they turn to their own partner or more frequently than they turn to their own partner.

Types of competing attachments

Research has yet to explore every type of competing attachment individually or their respective impact on relationship security and satisfaction, in part because new forms of competing attachment pop up and develop over time. In addition, competing attachments and their impacts can vary culturally. However, a few specific types of competing attachment have been linked to decreases in relationship security and satisfaction.

Addiction

Research on addiction and attachment helps explain how disrupted early life attachment bonds and adaptive mechanisms can, if left untreated, become barriers to emotional flexibility and bonding in adult romantic relationships. When emotional regulation and soothing have not been taught in the context of attachment bonds with a loved one, it can leave the individual more vulnerable to turning to a substance as a means of soothing and escape. On a fundamental level, failed attachment to a primary attachment figure creates alternative attachment to survival mechanisms and defenses. This eventually transitions into attachments to substances or other compulsive behaviors in an attempt to find comfort, soothing, safety, protection and security.

Substances are shown to have analgesic (pain blocking) effects that aid in the numbing out of emotionally painful experiences and situations. Individuals with addiction lack the ability to internally self-regulate their emotions. They frequently turn to substances or compulsions to regulate their feelings of pain or distressing emotional experiences. Nonchemical processes such as pornography and gambling are demonstrated to have similar effects to chemical substances on the brain and can be used by a person to achieve the same effect.

The more frequently someone turns to addictive behaviors to meet their attachment needs, the less often they will seek connection with others. The addiction eventually starts to become a substitute for human connection. Over time, this builds into a false sense of connection, or a counterfeit attachment, because a true and secure attachment bond involves a reciprocal relationship.

In romantic relationships, the consequences for the partner who is not addicted is that they are left emotionally (and, often, physically) alone to deal with emotional distress and the stresses of daily living. Additionally, it is hard to build a secure and satisfying connection with a partner who is not emotionally present, engaged or accessible because of their addiction, especially if the addiction negatively alters the person’s mood. The result is a relationship that is higher in conflict, less emotionally engaged, more unstable or insecure, and less satisfying.

Social media, gaming, smart phones

With the advancement and availability of new technology, the types and frequency of competing attachments have also changed. Internet addiction is a general term used to encompass a wide variety of online behaviors that are problematic for individuals and relationships. For example, addiction to Facebook, Twitter or Instagram has been cited as being intrusive in relationships and is associated with relationship dissatisfaction. Technoference is a term applied to the interference of technology in relationships, including romantic relationships. Another trending term is phubbing, or phone snubbing. This describes when a person turns their attention to a smart phone instead of to their romantic partner or others in a social or personal setting.

As cell phones and gaming systems have morphed from simple electronic devices to devices that encourage participation and interaction online, live human interactions have decreased. Online adult gamers have described sacrificing major aspects of their lives to maintain their online gaming status. Romantic partners report that technologies such as gaming and smart phones frequently interrupt quality time and connection, reduce instances of going to bed together at night, and affect the amount of time spent together on leisure activities. In other words, these partners feel that their relationship has taken a back seat to online gaming activity.

Those who have been phubbed report feeling that their romantic partner favors a virtual world over time and connection with them, thus sending an implicit message about what their partner values most. This has become so problematic in romantic relationships that support groups have been created for “gaming widows” suffering from technoference. Additionally, interviews have revealed that technoference lowers relationship satisfaction and increases conflict between romantic partners.

Pornography

Pornography is unique in that it can encompass two different types of competing attachments: addiction and infidelity (since many romantic partners view pornography as a form of infidelity). Often, the partner who is addicted turns to pornography as a source of stress release or to soothe feelings of shame and disconnection in the romantic relationship.

Research into the experiences of those partners who are not addicted to pornography shows that they often feel in competition with the pornography or the actors in the pornographic material. The turning outside of the relationship to an addiction has also been shown to have a negative effect on the security of the relationship bond and the level of relationship satisfaction.

Affairs and infidelity

Being unfaithful in a romantic relationship (infidelity) is considered one of the most potent threats to romantic attachment security and relationship satisfaction. Infidelity is one of the leading causes of divorce and one of the leading threats of competing attachment.

Unlike other forms of competing attachment, this particular form may need to occur only once for the partner to consider it a competing attachment. What constitutes appropriate or inappropriate behavior with someone outside of the relationship can take on different meanings for different people. For some, a one-time nonsexual encounter in which their partner turns to another may be acceptable, whereas others may find small flirtations that do not result in sexual intercourse unacceptable. For others, finding inappropriate, provocative or sexual pictures or messages exchanged between their partner and someone else may constitute infidelity. The definition of infidelity depends on how the couple delineates the boundaries of their relationship and how they define cheating.

Infidelity, even if only perceived, has the power to undermine the trust, security and satisfaction of the love relationship. Behaviors on social media that violate relational boundaries are also associated with relational insecurity and lower levels of relationship satisfaction.

Factors such as attachment security and satisfaction have been demonstrated to be both consequences and causes of infidelity. Those with secure attachment are less likely to engage in infidelity-related behaviors. There is also a link between attachment avoidance and interest in other partners, as well as strong associations between attachment insecurity and infidelity in relationships. Unmet attachment needs and low levels of relationship satisfaction may contribute to people seeking connection and sex outside of their primary love relationship. 

Rival relationships

Outside or “rival” relationships may not constitute or result in infidelity, but they can still be experienced as competing attachments to the romantic bond. A rival relationship may be any nonromantic relationship that a partner has with another person outside of their love relationship, especially if the outside person is perceived as being attractive. This could be a friend of the opposite sex. Even family members can become competing attachments in some relationships.

In rival relationships, one partner may consistently turn out to a friend or family member to discuss private emotional topics, seek comfort or validation, or share friendly connections that are not shared with their partner or spouse within the love relationship. Another example may be a partner who exchanges text messages, emails or phone calls or engages in private get-togethers with another person outside of the love relationship, particularly if their romantic partner is not invited to take part. The romantic partner may feel like they are being left out of or are on the outside of a friendship or relationship that their partner has.

In therapy, clients might complain about their partner’s closest friend of the opposite gender or an intrusive in-law whom their spouse frequently turns to for advice and emotional support. Rival relationships that involve family members, usually described by clients as “intrusive” family members, are associated with a weaker couple identity and are demonstrated to predict the quality of the couple’s bond.

Interestingly, even in cultures in which men are expected to maintain a strong alliance with their mothers after getting married, wives in these marriages often complain about feeling like they are competing with their mothers-in-law for their place in the family unit. An example might be a husband who frequently puts his mother first by meeting her every need, even after he marries. This type of competing attachment often goes unnoticed. Society tends to dismiss enmeshed mother-son relationships as being potentially problematic, despite the consequences to the son’s marriage or romantic relationship. I am not referring here to a healthy attachment bond between a mother and a son but rather to an unhealthy form of attachment (insecure bonding) that results in the failure of either person to securely and appropriately transition parts of their attachment role when necessary.

Importance to clinical practice

In each of these types of competing attachment, there exists a common link with attachment security (or lack thereof) and relationship satisfaction. As professional therapists, we know that science is clear about the importance of human attachment bonds across the life span. Primary attachment figures were initially considered important for infants and children. However, these roles were later recognized as being important for all humans at all stages, including those with whom we formulate strong romantic attachment relationships as adults.

Each person will have a different attachment style that is classified as either secure or insecure. These attachment strategies are typically stable over time. However, attachment relationship bonds can be defined separately from individuals, also as either secure or insecure. Additionally, there is plasticity in adult attachment relationships. They can shift from secure to insecure and vice versa. In romantic relationships, distress can occur when the security of the attachment relationship is threatened. This is important for therapists to understand as they work with their clients to help them shift from insecure to secure bonding and to build safe and satisfying relationships.

Competing attachments threaten the security and satisfaction of romantic attachment relationships and can become pivotal moments that redefine a couple’s relationship as unsafe. This can additionally create an impasse to relational trust and stability, both of which can negatively affect relational satisfaction. Anything that threatens the stability and satisfaction of an attachment bond is important for clinicians to know about so that they can be prepared to intervene.

Not all things that someone turns to outside of the love relationship qualify as competing attachments. To constitute a competing attachment, it must cross certain boundaries or thresholds that result in distress. If a competing attachment does exist in a relationship and is causing distress, then the relationship satisfaction will start to go down. The less secure the bond becomes between the couple and the less satisfying the relationship is, the more risk exists of the relationship becoming broken. Attachment security is strongly associated with relationship satisfaction. Both attachment security and relationship satisfaction are also important factors in relationship longevity and personal health. Relational satisfaction should remain relatively high and stable over time for most couples in securely attached relationships.

Attachment science offers a guidepost for treatment strategies and interventions for couples who come to therapy reporting the presence of competing attachment.

Treatment recommendations

If a couple comes to your practice complaining of a competing attachment or hinting at the possibility of one, consider asking a few assessment questions. These questions are based off of the Competing Attachment Scale that I created with emotionally focused therapy trainer Rebecca Jorgensen and UCLA professor Rory Reid in 2015 for my dissertation study.

1) Have you experienced in the past or do you currently experience a sense of competition with the activities or relationships in which your partner engages?

2) Do you feel like your partner turns elsewhere outside of the relationship to have their needs met rather than turning to you?

3) Do you feel hurt, bothered or upset by this?

4) Do you feel like this has been a problem in your relationship, created a lot of conflict or affected your ability to get close with or have a healthy bond with your partner?

Also consider the following treatment recommendations for couples reporting distress due to a competing attachment:

  • Clearly identify and understand how the competing attachment is part of a couple’s relational system (their negative interaction pattern or cycle).
  • Identify the competing attachment as an alternative (and ineffective) way of coping with/not dealing with emotional distress or not getting needs met (maladaptive behavior).
  • Help couples turn toward each other as secure bases/safe havens to help co-regulate moments of emotional distress.
  • Help couples find alternative ways of coping with emotional dysregulation that don’t create relational distress or violate relationship boundaries.
  • Help couples identify their emotional/attachment needs and be able to ask for these needs to be met in their relationship.

 

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For more information on adult attachment research, or to find clinical training in your area, visit the websites of the International Center for Excellence in Emotionally Focused Therapy and its founder, Sue Johnson.

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Anabelle Bugatti is a licensed marriage and family therapist with a private practice in Las Vegas. She is a certified emotionally focused supervisor and therapist and is the president of the Southern Nevada Community for Emotionally Focused Therapy. She has a doctorate in marriage and family therapy from Northcentral University. Her new book, Using Relentless Empathy in Therapeutic Relationships: Connecting With Challenging and Resistant Clients, is slated for release at the end of the year. Contact her at anabellebugattimft@gmail.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.

Engaging avoidant teens

By David Flack May 4, 2020

12 Comments

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

3 Comments

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.