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Dual Relationships and Attachment Therapy
by Liz Sikora, M.A., C.A.G.S., C.P.C., N.C.C.

Do we really have to discuss, think about, consider dual relationships? Yes, as professionals in this field this issue must be considered. Although the ATTACh professional standards do not address dual relationships we are called upon to meet state and other ethical guidelines. Given the unique situation the attachment therapist often finds her/himslf in when dealing with children or adults with attachment difficulties, a review of the guidelines regarding dual relationships is appropriate. The American Association of Marriage and Family Therapists (AAMFT), American Counselors Association (ACA), American Association for Counseling and Development (AACD), American Psychological Association (APA), and National Association of Social Workers (NASW) all have clear guidelines about dual relationships. In general Corey, Corey and Callanan (1993) summarize these guidelines to include "blending a professional relationship with a client with another kind of relationship" (p.141). They go on to note that specifically the standards include limitations in the following areas:

teaching and providing therapy, bartering, providing therapy to family and friends,

socializing outside of therapy, and given the nature of intensive therapeutic interventions over extended periods of time, the limited number of trainers in the field of holding therapy, the requirement in some programs that a trainee participate as a client in a holding, the travel often required with a client to a treatment facility as well as the individual and family therapeutic interventions there are frequent times in the therapeutic process we must assess and limit the development of dual relationships. Cory, Cory and Callanan (1993) offer professionals the following when considering dual relationship situations:

1. Consider whose needs are being met. In evaluating this consider the following questions: Whose needs are being met, the client and trainee or the therapist and trainer? Is there any covert manipulation by the therapist or trainer? Would you feel comfortable addressing an ethics panel or state board to explain how the client or trainees needs were being met?

2. Have you considered through an honest self-searching, the impact of a dual relationship on the client/trainee? Is there a personal gain or motive behind the dual relationship for you? Could there be a detrimental impact upon the client or trainee? Although they may be approaching you for the expansion of the relationship it is incumbent upon the therapist to evaluate these issues.

3. Is it possible your clinical judgment will be affected by the dual relationship? Can you state in all honesty your judgment will not be affected by this relationship? For instance, if you are the trainer and require a trainee be held by you during the training, are you clear that your role as therapist will not affect how you treat the client later as a trainee. Are you clear the trainee is participating willingly and with full awareness of the potential negative implications of combining roles?

As therapists, it is extremely critical we continue to be aware of and address the area of dual relationships with clients. The fact we work with children and adults who have already suffered major distress from a lack of safe and trustworthy relationships makes it that much more important we act to protect our clients in every6 way in this regard. We must strive to review our interactions with clients and their families on a regular basis to ascertain our client is best being served. And as trainers we must be clear we are always acting in ways that benefit our students. Dual relationship boundary violations are often secrets that don't get reported. Don't add to the burden of your clients or trainees--keep it clean and simple. And keep the flow of healthy, secure attachment growing!

References: Corey, G., Corey, M., and Callanan, P. (1993). Issues and ethics in the helping professions. Pacific Grove, CA: Brooks/Cole Publishing Company.



Trauma and Attachment
by Rebecca Perbix Mallos, MSW

As the adoption of special needs children rises in this country, so does the need for adequate post adoption services. The current condition of post adoption services in most states still reflects the old adage of "just give them enough love and they'll be fine." This was probably true during the last era of special needs adoptions, which was before World War II. Before that war, the average age of children being placed for adoption in the U.S. was 4 years old. Most of the children being placed then were available because their families were not able to financially care for them or because a single parent could not provide adequate resources. After World War II, the world of adoption changed with the dramatic increase in infants available for adoption. This trend lasted into the 1960's when adoption again began to change with the advent of birth control. Once again, older children came to dominate the landscape of adoption. Our current dilemma in older child adoption, now called special needs adoption, is the level of trauma children have experienced prior to placement. While prenatal exposure to alcohol was a possibility before World War II, prenatal exposure to drugs was virtually non-existent. In addition, current special needs children, if not prenatally exposed, typically have lived in their original family where drugs and alcohol are the driving force behind the chaos, abuse and neglect these children suffer. The availability of relevant post-adoption services has not kept pace with the need to help families raising traumatized children. I have worked in social services and mental health for over 22 years and I cannot remember a child I have met who has not been exposed to a family setting that included drugs and alcohol. This may be due to the fact that I have worked in community mental health, domestic violence, foster care and post adoption, all areas in which children who have experienced trauma are likely to be seen. Parents who have adopted children with special needs know that a child who has previously experienced trauma from having lived in chaos, abuse and neglect is affected in all of the child's functioning systems. The child's cognitive emotional, behavioral and physical systems have all been impacted by early trauma. Consider how many of the following traumatic experiences your child has endured:

*Parental Alcoholism

*Parental Substance Abuse

*Group Care/Out of Home Care

*Mental Illness in Parent(s)

*Sexual Abuse

*Emotional Abuse

*Physical Abuse

*Neglect

*Poverty

*Abandonment

*Divorce

*Loss of Family

*Malnutrition

*Physical Illness

Our kids have suffered much trauma. My foster son experienced 11 things on this list before age eight. Traditionally, mental health practitioners have diagnosed children with behavioral symptoms subsequent to trauma with diagnoses such as Reactive Attachment Disorder, Attention Deficit Disorder, Oppositional Defiant Disorder, Conduct Disorder, etc. These symptoms could also be called Post Traumatic Stress Disorder (PTSD.) This is not to say that those first disorders do not exist-obviously they do. However, my question is, to what degree are the behavioral symptoms presented by a child symptoms of traumatic stress? If so, we then have a basis for understanding the symptom rather then simply the behavioral description the other diagnoses provide. For instance, is it possible that what has traditionally been called Attachment Disorder is more effectively called Post Traumatic Stress Disorder? A child experiences disorders in their ability to successfully attach because the trauma symptoms the child presents in the new family are based on the child's previous traumatic experiences and are not useful. I came to this way of thinking by many routes, one being through the research on adults with Post Traumatic Stress Disorder, primarily Vietnam War Veterans. This research describes how difficult it is for the family of the veteran with PTSD to live with the behavioral symptoms of the vet re-experiencing the trauma of the war on a daily basis. This does not necessarily mean flashbacks. It can mean mood swings, hypervigilance, unpredictable anger, despair and a strong need to control every situation. Another way I understand the correlation of behavioral disorders to PTSD is the way in which trauma is stored in the brain. For instance, memories are encoded in the brain in different ways. Declarative memory contains facts-explicit details about events that can be verbalized. Non-declarative memory, or implicit memory, is experienced viscerally and is not immediately available for verbalization. Recent experiments with adult victims of trauma have shown that when an event is perceived to be traumatic, i.e. life threatening, that part of the brain that gives language to the experience stops working. Instead, the traumatic event gets stored in the sensorymotor domain of the brain. Another way to think about this is to understand that each of our brains has an extensive filing and storage system for details and experiences. Like all memory, traumatic memory gets stored too. This is useful for us when we can make use of memory as a way to protect us from further trauma. It is helpful to be able to call out of memory that a particular situation is potentially threatening and our response needs to be protective. However, for those of us who have not experienced trauma as a daily event, we are selective in our understanding of what is threatening because we believe we are generally safe. Our children with special needs do not have that advantage. Their experience has been that the world is a dangerous, threatening, hostile and uncaring place and that potential danger is always present. That means that the filing system in their brain is stored with memories that indicate that even seemingly benign situations can carry some hidden threat. When a person is responding to their environment out of fear of a potential threat, they become hypervigilant, their heart rate is often higher than normal, even at rest, and their adrenalin system is always pumped up ready for "fight or flight." This "fight or flight" phenomenon is evident in children who are often defensive, or ready to blame others, are in need of controlling each situation they encounter, are usually ready to fight back when there is nothing to fight about, or seem to "check out" and become non-responsive to any requests. Children who are suffering from some form of PTSD or traumatic stress are both emotionally and neurophysiologically "alert" to potential danger. What is very hard for both parents and professionals to understand is that simply telling the traumatized child that this new family will not hurt them in the ways they have been hurt before is not enough to change the filing system in the brain. The way the filing system got filled up was by experience with trauma and highly emotional situations. Once way to change what the filing system has assigned to a particular situation is to re-do the situation emotionally. There are many ways to re-do the emotional experience. But because traumatized children operate at a higher level of adrenalin functioning, the new emotional experience is going to have to be highly charged. Some of the ways to evoke new emotions therapeutically is through movement, art, music, drama and through holding therapy. This last intervention is the most controversial for many people. I use many different interventions in my work with children but the one that appears to make the most difference for the most shut down, controlling and angry kid I know is holding therapy.

There is much misunderstanding in the general population and in the professional world about what holding therapy is or isn't. In my practice with colleagues at the Attachment Center Northwest outside Seattle, what holding therapy isn't is violent or abusive. When seen on TV, the part of the therapy that is shown is the catharsis. It is dramatic. That is just a segment of what really goes on. Holding therapy is nudging, cajoling, challenging and for the most part nurturing. Holding therapy allows for re-experiencing of a traumatic event, within an emotionally charged situation; but this time the outcome of the trauma is different. The child gets taken care of rather than neglected; comforted rather than abandoned. The child shares his rage; fear and grief with nurturing adults who are in control and keeping the child safe. Parents who are safe, trustworthy and predictable are the most significant part of the therapy because they comfort the child at a time when the child is most vulnerable. For the traumatized and neglected child, this comfort is a new experience because most children from chaotic backgrounds have learned to take care of themselves. They have not allowed themselves to be comforted or nurtured because they don't know how. Finding a therapist who understands trauma is critical when seeking services for a child with a traumatic past. The family needs to be an integral part of the therapy. The resolution of trauma, decrease in trauma-based behavior and increase in ability to be vulnerable and nurtured is what will lead the attachment disordered child to risk attachment. There are two national organizations that are available to help families find therapists in their communities who understand trauma and/or attachment. Those organizations are: ATTACh and The International Society for Traumatic Stress Studies 60 Revere Drive, Ste. 500 Northbrook, IL 60062 PH: 847-480-9028

Taking care of our traumatized children requires that we take good care of ourselves. Finding the right help is the first step.

Rebecca Perbix Mallos, MSW, is in private practice at the Attachment Center Northwest. She is a parent by birth, adoption, and fostering. This article was reprinted with permission from the author and from "Family Matters: Oregon's Special Needs Adoption Newsletter," June/July 1997 issue.



Families: Major Channel for Change and Healing
by Regina M. Kupecky, L.S.W.

Reprinted with Permission from Attachments, the quarterly newsletter of the Attachment Center at Evergreen, P.O. Box 2764, Evergreen, CO 80437.


Children with attachment disorder have suffered greatly, usually at the hands of those who are supposed to care of them, love them, support them, and even die to protect them - their birth families, and usually more specifically their birth mom. It sometimes seems easier, safer, and less chaotic to raise these children in institutional care, allowing them to avoid the close attachments they fear and react to with such vehemence. The problem with that philosophy is that they never learn the skills needed to achieve family living. Once emancipated, they form families of their own, and thus perpetuate the cycle of neglect, abuse, and out of home care so familiar to us all. Family living is the best place for children with attachment disorder to learn, heal, and change. It is only through experiential day-to-day living that a child can learn that families can be safe and nurturing, and can meet his needs. It is a place to practice being a good spouse and parent. Traditional training in mental health and social work often produces professionals who empower the child rather than the family. A view of the apparently dysfunctional substitute family who is parenting a child with attachment disorder can lead professionals to look for abuse, poor parenting, anger, and control issues in the adults. Blaming parents is often the response which is not helpful. Support for the family must come from caring professionals forming an alliance with the adults, trusting what they say, and not minimizing their pain. Finding a professional who believes them, acknowledges the reality of their experience, and offers hope for change is often an added challenge to the family. They do not need another professional telling them to "love the child more and it will be all right." Love is not the cure - it only helps facilitate the cure.

Although stereotypes are dangerous, the typical scenario for a family parenting a child with attachment disorder is an exhausted, controlling, angry mother with a more relaxed father (remember these children attack moms). The mother is often armed with reams of notes, sometimes chronicling) life moment to moment in order to "prove" her reality. She and the child are in a battle of control. Often other siblings have been ignored, the marital and sexual life of the parents has been threatened as the child takes over control of the family. It is not unusual to find couples who have not been on a night out alone in years. All the family resources (time, money, energy) have been absorbed by the child with attachment disorder.

If infertility is an issue in the adoption, the sense of loss, betrayal, and pain can intensify. Once the child begins to heal, often other issues are spotlighted in the family. Smaller issues can grow quite large from benign neglect, and need to be tenderly addressed. Respite, time away from family, to give child, siblings, and parents a chance to relax, is the most often requested support. Most available in the community to children with physical disabilities, this is a vital piece of support to keep families healthy. Respite can be creatively supplied by:

- family members

- paid formalized care in an approved home

- agreement among adoptive families to offer casual babysitting

- weekend retreats for moms or parents with child care provided

- part of training for preadoptive or foster parents while waiting for a child

- a day activity for children (recreation) to provide a rest for parents

- parents taking turns having an evening off

Parents should realize respite is not a "cure" or a punishment. It is simply time off to energize.

Parents need to be encouraged to take care of themselves. Mothers especially can suffer fatigue, stress, and even signs of depression. Encouraging them to begin a hobby, go for a walk, take a bubble bath, or whatever, making them feel capable, loved, and whole again is important. Just as important, the marriage needs to be taken care of by the spouses. Sometimes even encouraging a fifteen-minute break (go to day-care 15 minutes later and go for a walk, get up 15 minutes earlier with spouse and talk, go to bed 15 minutes later and read a book) can revitalize a person. Parent support groups suggest the best support is saying, "You aren't imagining it, you aren't alone, there is a reality and name for what you experience, and there is hope and help." These are the most positive statements a parent can hear from anyone. Support groups can be beneficial as parents can be validated by others. Often these families have been abandoned by family and friends who can't understand the issues. Isolated and alone, they suffer. Buddy families, pairing a couple with someone who has been there, can be invaluable. Parents need a safe place to vent anger, speak without judgement, and be given helpful suggestions regarding parenting. Recently a mothers' weekend retreat helped moms talk to other moms. "What a delight," said one, "to be able to say sometimes I hate my child, and no one is shocked. They all understand the roller coaster I am on." These support groups can also share in celebrating the often miniscule gains that families parenting attached children do not appreciate. Behaviors seen as normal, i.e., the child telling the truth about a minor infraction, needs to be celebrated in a child who have never done it before in his life. Other moms of children with attachment disorders understand this. Traditional therapy developed out of a belief that: 1) a client can develop a relationship, 2) a client can trust another, and 3) a client can feel internal discomfort, which is why it is generally ineffective with children who do not trust. Therapy needs to include parents either by their observation or presence in the treatment room. Parents can learn new management skills by modeling the therapist, and as parents learn to trust the therapist, they can hear parenting tips as a team suggestion, not a criticism. Children learn that adults communicate and help each other. The alliance with the parents must be lively, fun, and clear to the child. The child then needs to choose to join in the family or remain in isolation. Parents need to learn to let go of what they can't control and heal from their destructive cycle of anger and control. Most children get better (maybe not perfect) in families. Families are a tremendous resource for these children, and need to be nourished, not criticized by professionals and society. The family's needs should be met in order to keep the parents emotionally, physically, and spiritually healthy. These supports education, respite, support groups, weekend retreats, appropriate therapy, to name a few - need to be monetarily supported, available, and nurtured by the agencies who place the children. In this work, I am not discouraged by a few disruptions. I am rather awed by the commitment, love, perseverance, and healing that most families offer. These families need to be honored, nourished, cherished, and appreciated for the work that they do.

[fonte: attach.org]