Hello. Welcome to episode 3 of the “Be A Neff” podcast. Today were going visit this months theme Attachment as it pertains to the population of Adolescents ages 13-18.
DIAGNOSIS AND RULE OUT:
It’s easy to start with the diagnosis of Reactive Attachment(F94.1) or Disinhibited Social Engagement Disorder. Both are a result of a failure of attachment, merely RAD is when a child/adolescent refuses to be consoled by another adult, with Disinhibited we see more traditional behaviors associated with RAD prior to DSM 5. Disinhibited will present that a client doesn’t appear to distinguish between whether they have a relationship with a person that they barely know they attach. This could present like a teen saying “were as close as sisters.” Though with some probing, you will find out that they have met within a short time(like a week.) Also do your best to rule out PTSD and Acute Stress Disorder, which while they can appear comorbid with RAD or Disinhibited, they do rule each other out.
Adolescence is a critical time for attachment, finding safety and attachment at this time is the last major milestone before adulthood. Without achieving a secure base during this stage, you can expect the attachment trauma to develop into a myriad of potential personality disorders based on the maladaptive coping mechanisms used to meet the clients needs. I cannot restate this enough in therapy, that forming a safe attachment base at this time is critical in developing healthy relationships with themselves and the world around them.
Lets shift now to where we begin...
IN THE OFFICE
So what does this look like in the office? When a teen arrives in my office who is struggling with attachment issues we’ve reviewed their early social history and see that there was some severe interruption of engagement, either through divorce, loss and grief, or incarceration, there are several reasons. The primary complaint in my experience is “attitude” “lack of respect” “at risk or sexual behaviors,” “depression and anxiety”. During this time parents will identify several reasons “why” that have nothing to do with the attachment. A key point at this moment is to listen to the client discuss the problem from their perspective. When you complete grounding work, they will describe the empty, and hollow feelings, or lack of range of feelings. They often will evoke a sense of loss just in their inability to communicate what it is they want in therapy, mostly just that they not “feel” this anymore. There are some instances of suicidal thoughts that must be explored and when needed, develop and address a safety plan.
Adam --For the purpose of our work I’m going to discuss a case study, Adam. Adam came to the office a freshman in high school needing therapy. Highly motivated, intelligent, and resourceful, he found his therapists profile on psychology today and gave my number to his parent to call. The first session without a parent visiting, he alternated between discussing how he hated and loved his foster parent, alternating weekly, and reporting a sense of bleak lack of feelings and emptiness. His tone and verbal skills always identified intellectually, though when we discussed his trauma he dropped his voice and regressed to one syllable words. Through family therapy we processed the empty parts of his life story, and established a more secure base of trust with his foster mother. We also addressed the false front of utilizing his large vocabulary to present a mask between myself and him, as though he could distract me enough with words that we would avoid holding him accountable in his avoidance of both his dbt skill homework and talking through his part in his daily struggles with his foster family. He identified he didn’t want to engage with his family, the most appropriate source for secure attachment, but through his peers. As the treatment progressed, Adam’s biggest challenge is to reduce his black and white thinking and accept that others around him cannot exist in all or nothing perspective.
The concerns the parent may be looking at are finding moments to connect, even when valid connection drives the client away. Engaging with a teen on these terms is engaging in a losing power struggle. The best course of action is to present two choices during interactions, and not to be overly emotional at the choice selected. I would refer again to the “illusion of choice” method in last week, presenting two choices that ultimately lead to the same destination. Failing that, choices with a natural consequences that you both can live with. When it comes to motivating change, I offer 2 tips. First positive experiences need to outweigh negative at a 2 to 1 ratio, if possible 3 or 4 to 1. When ever engagement or conversation isn’t about a chore or task, we gradually begin to associate engagement with positive feelings. Don’t presume that will feel natural or welcome with a child with RAD. In session, I’ve heard it best described as “really scary” whenever something good is happening, because that sense of something fear based happening at an engagement is a learned behavior not easily dropped. What this means is that if you’ve been screamed at every day for any length of time, your not going to feel safe at someone shouting from the bottom of the stairs that we’re going out to eat tonight. Your going to have a general sense that something bad needs to happen, your going to drag your feet if you come down at all. All because shouting is followed by something painful, and you want to avoid that. Secondly once you engage in a power struggle, you have lost. Digging your feet in only assures that you may win, but the relationship loses, as you prove again that adults can’t be trusted, and their might will always win.
Lets shift now, away from how to break something, but onto how we can fix it...
SO our main interest here with teens is building positive experiences. At home our homework is all going to be about reframing our daily conflicts into prosocial statements that ask for the needs instead of behavior that we don’t want to see. Entire family sessions may be breaking down conflicts and seeing what triggers what, and how we can address the needs of HALT(hungry angry lonely tired) before we ask of anything of each other. This provides a major benefit, as we stop seeing attacks as personal and attribute them to situations. Were shifting our behavior to recognize our internal cognition that a person wants to hurt us fundamentally and replacing it with positive self talk that they may in that moment not be meeting their needs, and focusing not just on ourselves but meeting that need before we ask for the same respect in return.
So Kenisha asked this week for more DBT. High Kenisha! So for this week I’m going to review some DBT skills. In the office I have purchased a really excellent card game called the “DBT Deck”. I will lay them out fan style and ask a client weekly to choose 4 cards. The deck itself lists different ways to use them in sessions, but this is my chosen activity. As each card is read, I then tell the client to sort the card lowest to highest based on difficulty. This is really important because completes two tasks that are often missing in therapy, manifesting the homework into tasks the client can complete in real life, and then also shifts the client from emotion based to rational mind, or wise mind, as they engage in right brain thinking and numerically order the cards. After they client completes this task I ask them to teach me the skill, in their own words. I read the card and let the client know if I “understand it differently” and then we discuss it. At the end I always encourage the client to pick one card, and I pick the other. Take out their phone and take a photo of the card, turning the card into a transition object to “take home”. Their assignemtn often directly comes from the card, and I have a data tracking sheet I’ll enclose that tracks the card 3x, showing skill was introduced, reviewed, then mastered or at least exposed to 3 times.
So i’m goingto engage in this activity now and review a few cards.
Dealing with Distractions: This card talks about how distractions are ever present. Getting frustrated doesn’t serve you except as a reminder to return to mindfulness. I would ask a client if they’ve felt like this recently, that they are easily distracted. Most people are. I would ask the client in this room to check in at this point, are they feeling distracted now? By what? What does it take for them to return to being present here.
FAST: Be Fair: This card talks about being fair to yourself and others. Thinking about your expectations, do you hold yourself or others more accountable? How would if be for you to ease that up or raise the bar until they were closer to being equal. This I would process with my client about their self talk, are they mean to them selves? I would have a general sense of a persons self talk at this point in session, but sometimes I’m surprised.
Opposite to Emotion(O2E) for Anger: This card asks you to assess whether you are angry at a person and can do better to avoid them until you calm down into a more rational state of mind. As with all O2E cards, this one encourages you to behave the opposite of your gut reaction and be mindful of whether this changes your feelings towards this person. Personally I’ve always found that that ability to remain kind is a bit like acid for both parties trying to do so when someone is just vinegar on an open wound. It helps me to reflect back if my actions at this time were something I would want to be judged by in a court of law. I might share a personal story at this point where the point of the parable is to win it out in the end by maintaining control of yourself while another person obviously has lost control and acts out in anger.
IMPROVE: Prayer: This card is one I approach very carefully, though I believe so strongly in its power. My faith isn’t the majority popular faith, but daily prayer is an important aspect of it. I like to present different cultures and how they pray, mine included, and encourage the client to reflect on prayer itself. We all have inner self talk, especially in times of stress, and who do we feel we are talking to? When “hearing voices” is associated with mental health, sometimes its nice to educate kids that the “inner voice” in all of us exists, and its there to help us.
Depending on the client, I would suggest a card and they choose one, or suggest both and assign them for the week. We might “manifest this” at this point, by talking about how it would physically be practiced for the next week. Increasing this skill is so beneficial to the client, as this is a great take away to do for themselves when your time has ended.
This week we have just a few points on integrating technology, and this all includes increasing positive experiences.
Again using apps could include looking for and sharing with positive images and quotes on social media, even just sitting together and going through “ifunny” quotes and memes and sharing a laugh together. The key aspect in this is doing something that is usually isolative together.
Secondly, have the teen teach the parent a video game they like for up to 1 hour a day for the next week. Its confidence building to put the teen in charge of the adult, and as the adult progresses they may continue the practice, increasing the prosocial aspects. A client actually suggested this once when I engaged in a discussion about problems parents face in connecting with kids, about things they don’t know anything about. “Why not ask him(my son) to teach you?” the client suggested. Brilliant in its simplicity, because the worse I was the more time we spent together.
Finally engaging in an exergame such as pokemon go or ghostbusters. This uses smartphones and requires walking around the home, parks, or local places. The most interesting part in the design for me is how prosocial these games are designed, with parks and other local landmarks as “power up” places you need to get to to level up in some way. I’m actually really a big harry potter fan, and excitedly await the arrival of the harry potter version of an exergame, where I can see some of my favorite characters and creatures from the HP world and “catch” them to stop them from exposing themselves to muggles like myself.
SHIFTING NOW TO THE END OF OUR SHOW TODAY:
I appreciate you joining me today and look forward to interacting on instagram and facebook @mytherapies or through the hashtags #topeka #anxiety #therapist and strive to respond to every post. Thank you for joining us. Interested in meeting with us live? This months podcast is sponsored in part by the 2019 KACAP Conference on Poverty. The Kansas Conference on Poverty brings together direct service workers, agency/department management, agency Boards of Directors, volunteers and anti-poverty advocates from Kansas’ non-profit organizations, faith-based agencies and government offices. Join us at the Capital Plaza Hotel in Topeka, Kansas on July 17th and 18th in our live workshops. This year’s conference theme is “Working Towards Prosperity”. I really enjoy this conference, it will be my 3rd year attending and 2nd year speaking. Each year I discover new resources to add to my referral list, and make friends with excellent people doing great things in my state. When you are in the business of solving problems and making change, you sometimes need to recharge your batteries and give back to other workers. We hope to see you live and in real life, and welcome you to our community of change makers!