Concurrent Disorders

Week 4: Attachment, Empathy & Counselling: The 1st Session

Key Points from Last Week Level 1 Screening:

To help us decide if further assessment is necessary

Clients will report inaccurate information Certain questions elicit good information

Screening Tools Cage-Aid RAPS4 Mental Status Exam

1. Attachment: ‘Through A Needle, A Warm, Soft Hug’

Defined: Drive for physical, emotional closeness with people

Failed childhood attachments are common in clients with Concurrent Disorders

Broken families, physical, sexual abuse, substance use by parents, placement in foster homes…leads to high incidence of failed attachment

What is Attachment?file://F:\2010 concurrent Disorders\Attachment Disorders Experts- Psychological Services

“Attachment is the deep and enduring connection established between a child and caregiver in the first several years of life. It profoundly influences every component of the human condition - mind, body, emotions, relationships and values.” Attachment is not something that parents do to

their children; rather, it is something that children and parents create together, in an ongoing reciprocal relationship.

Core Beliefs(CBT)

Secure attachment Self. "I am good, wanted, worthwhile, competent, and lovable." Caregivers. "They are appropriately responsive to my needs,

sensitive, dependable, caring, trustworthy." Life. "My world feels safe; life is worth living."

Compromised attachment Self. "I am bad, unwanted, worthless, helpless, and

unlovable." Caregivers. "They are unresponsive to my needs,

insensitive, hurtful, and untrustworthy." Life. "My world feels unsafe; life is painful and

burdensome."

Attachment Disorder

“Disrupted and anxious attachment not only leads to emotional and social problems, but also results in biochemical consequences in the developing brain. Infants raised without loving touch and security have abnormally high levels of stress hormones, which can impair the growth and development of their brains and bodies. The neurobiological consequences of emotional neglect can leave children behaviorally disordered, depressed, apathetic, slow to learn, and prone to chronic illness. Compared to securely attached children, attachment disordered children are significantly more likely to be aggressive, disruptive and antisocial.”

Risks

Behavior: oppositional and defiant, impulsive, destructive, lie and steal, aggressive and abusive, hyperactive, self-destructive, cruel to animals, irresponsible, fire setting.

Emotions: intense anger and temper, sad, depressed and hopeless, moody, fearful and anxious (although often hidden), irritable, inappropriate emotional reactions.

Thoughts: negative beliefs about self, relationships, and life in general ("negative working model"), lack of cause-and-effect thinking, attention and learning problems.

Relationships: lacks trust, controlling ("bossy"), manipulative, does not give or receive genuine affection and love, indiscriminately affectionate with strangers, unstable peer relationships, blames others for own mistakes or problems, victimizes others/victimized.

Physical: poor hygiene, tactilely defensive, enuresis and encopresis, accident prone, high pain tolerance, genetic predispositions (e.g., depression, hyperactivity).

Moral/Spiritual: lack of faith, compassion, remorse, meaning and other prosocial values, identification with evil and the dark side of life.

Foundation of Attachment

Only mammal that needs parental love to survive for such a long period

Love, attachment to child is driven by our own ‘chemical substances

Opioids drive Attachment

“Nurturing mothers experience major endorphin (opioid) surges as they interact lovingly with their babies – endorphin highs can be one of the natural rewards of motherhood.”

Gabor Mate: ‘In the Realm of Hungry , Ghosts’ , 2008

The soothing cycle…

Infant feels emotional pain, uses crying to bring parent…

Cuddling triggers the release of endorphins in child’s brain, and feels soothed…parent also feels soothed

Self-regulation of mood…

“A child’s capacity to handle psychological and physiological stress is completely dependent on the relationship with his parents.

Infants have no ability to regulation their own stress apparatus…will stress themselves to death if not picked up.” Mate

‘No cuddle = raised risk for addiction’

“Children who have not received the attentive presence of the parent are at greater risk for seeking chemical satisfaction from external sources later in life.”Gabor Mate

“The first time I did heroin, it felt like a warm, soft hug.” 27 yr.old sex trade worker

Problematic Attachment in Adults

Avoidant: 15-23% of children

and adults

Anxious about strong emotion Wary of close relationships Over-reliance on self

Failed attachment… Ambivalent:

8-12% of children and adults

Low self-esteem

Anxious: am I loveable?

Seek intense involvement with others to boost self-worth

Failed attachment… Disorganized

15% of young children Suffered serious trauma in childhood

(abuse, many foster homes) Have not resolved losses or traumas

2. Attachment & Counselling

C.D. clients bring broken attachments to counselling

1st session is key: we need them to form attachments to us, and return over long term

What contributes to successful counselling outcome?

Therapeutic Alliance

30%

TherapeuticTechnique

15%

Client Expectations 15%

Client’s personal strengths & supports

40%

MicroskillsHierarchy

Skinner: Treating Concurrent Disorders

“Evidence suggests that the client-counsellor relationship has more influence on engagement and improved outcomes than the methods, tools & instruments we employ.”

Ch. 1: ‘The Client-Counsellor Relationship’

Applies to all Social Work…

“The value of the working alliance has been demonstrated not only in individual therapies, but in couples, family treatment, group therapy…it’s a common factor across many helping situations.”

Adam Horvath, ‘The Therapeutic Relationship’ 2000

Skinner: Phases of Treatment 1. Engagement

2. Persuasion

3. Active Treatment

4. Relapse Prevention

Engagement in 1st Session

“Clients coming into treatment facilities for assessment indicate that the warmth and welcoming attitudes of the staff – not their perception of how skilled we are – are the most important factors in making clients want to return to use the service again.”

Key Characteristics Required for Successful 1st Session

Warmth

Acceptance

Empathy: Critical!

Caring

Genuineness

Empathy means… Valuing and understanding your client’s

reality….

And knowing yourself intimately

What have you learned about yourself since starting SSW program?

Empathy…

A way of being, not just a ‘skill’

What is the client’s point of view?

Can we set judgments & biases aside?

Verbal and non-verbals messages

Use tentative language

Move gradually towards sensitive issues

Note signs of client stress

Should help clients see their issues more clearly

Some questions to ask yourself…

How do you express anger?

What kind of person would you want in a social worker?

What are the differences between man and women?

What relationships have been really important to you in your life?

Have you experienced intimate group sharing with other men or women?

Research on Positive Outcomes lots of ‘helping’, protecting responses

lots of ‘affirming’ (cheerleading) and understanding responses

Clients disclose and express themselves

Clients perceive that the session was ‘busy’ & they got to tell their story

Final Thoughts… Attachment history makes connecting with

CD clients more challenging

Successful 1st session key to engaging client over long term

And remember: ‘The weight of a problem is the significance it has for the person who carries it.’