There are some real challenges with finding a safe and effective attachment-based therapist. You may have heard the horror stories or you may have survived them. And still, your family needs help! How can you sort through the self-proclaimed "attachment experts" and find someone safe, someone who can really help?
First off, definitely make sure that any potential therapist has at least a Master's Degree and also a license to practice in your state. Make sure that this person works primarily with children and families. Call this person for a consultation (or sit down in person if possible) and really check in with your instincts as you listen. Write down a handful of your own questions before the consultation and be sure to ask them.
The world of attachment therapy can be treacherous. There are some "old school" attachment therapies which can be really corrosive to relationships, flirting the line between unhelpful and abusive. And there are also some really amazing professionals out there who will know just how to help your family. Knowing this attachment therapy terrain as a therapist, here are the questions I would write down and ask if I were looking for someone to help my child:
1. "What specific trainings do you have for working with traumatized children? Can you explain the duration of the trainings you have received, including any supervision specific to those models?"
What I would be looking for is extensive, hands-on training in models that are widely supported by the general research community. To check a model out for yourself and see if it is evidence-based, you can look it up on SAMSHA and/or the CEBC.
For example, let's consider the Theraplay® model, which I use in my practice. It's recognized as evidence-based by both organizations I just shared, and it has an intensive training process. To become fully certified, you must complete 7 full days of hands-on training, as well as submitting 24 videotaped sessions of your work to a supervisor for review. This process usually takes several years. At this point, I have been training for over 3 years and have almost achieved Level 2 out of 3. The difference in the quality of my work between just after my first 4-day training versus today is remarkable.
Let's look at another example: Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). There is free online training for TF-CBT which takes just a handful of hours to complete and has no supervision component. Anyone can take the course and say that they use elements of TF-CBT in their practice. However, the full training for TF-CBT takes many months and includes massive amounts of supervision and feedback. A fully rostered TF-CBT clinician will be much more effective and skillful than one who has only done the free online training.
These two examples illustrate why it is so very important to ask specifics about the therapist's level of training and supervision, not simply which models they use. I would view the therapist's answer here in the context of their other 4 answers: Just because a therapist doesn't have extensive training, doesn't mean they aren't "safe." But because children with severe attachment problems tend to be so challenging (for parents and therapists alike), I wouldn't bring my theoretical child to anyone who wasn't highly trained.
2. "When working with attachment problems, do you work with children and parents together, just parents, or just children?"
Therapists who do attachment-oriented work should be primarily working with children and parents together, and sometimes with parents alone. Attachment problems are relationship problems, not child problems. And parents have the most power and resources within that relationship. As a parent, you are the center of your child's emotional world. A therapist who excludes you from the process of change will not be as effective as one who partners with you.
Some models, such as Trust-Based Relational Intervention (TBRI), have parent training and education as an important component. Parent-only sessions support parents in learning new strategies to support their children at home. The parent-child relationship is still at center stage, even though the child is not in the room.
In Theraplay® we use a combination of mostly parent-child sessions and some parent-only sessions. In the parent-only sessions, we watch videotaped parent-child sessions to better understand the relational dynamics at play and to learn how to read the nonverbal cues of the child. Even though we are doing parent-only work, we are looking directly at the parent-child relationship.
Models of therapy like Cognitive Behavioral Therapy or Child-Centered Play Therapy, in which the child is seen alone and parents only receive occasional updates, will not be as effective in the treatment of attachment-related problems because they focus on the child, not the attachment relationship.
3. "Do you regularly recommend behavioral approaches such as sticker charts and time-outs? What is the most severe consequence you recommend to parents?"
Attachment related problems generally don't respond well to behavioral approaches on their own. This is because the foundation of behavioral change lies in the child's motivation to please the parent. If the child can't take in the parent's love or feels like a "bad kid" in the parent's eyes, the parent won't have much influence with the child. So generally, losing screen time won't work so well.
The danger here is when behaviorally-based therapists think that their approaches aren't working because they aren't intense enough. They might believe that severe consequences will work. They might not have any other therapeutic tools to draw upon. But it's dangerous. This is how we end up with therapists who recommend punishments for children such as: withholding food, sleep, touch, eye contact, affection, or social experiences outside the family; not allowing the child to sleep indoors or sit on furniture; forcing repetitive and demeaning manual labor; using time-outs lasting for hours; or sending the child to live elsewhere for minor misbehaviors. (Yes, these are all real "interventions" that real therapists have recommended in the past 5 years). If your child has attachment related problems, please approach any behaviorally-based therapy with great caution.
4. "What percentage of your caseload would you classify as having a true Reactive Attachment Disorder, as described in the DSM-V?"
This is an important question. Many therapists using controversial attachment therapies truly believe that most or all children who have suffered neglect or orphanage care go on to develop Reactive Attachment Disorder, or RAD. (Spoiler alert: they don't.) These folks sometimes talk about children as "RAD kids" or even, "RADishes." They might proclaim that their entire caseload is full of Reactive Attachment Disorder. There is a way that these professionals lump all "RAD kids" into a single personality type or presentation. There is a way they can pathologize and demonize these troubled kids. It's disturbing. It's also an easy trap for parents who are already feeling super frustrated with their child.
In reality, Reactive Attachment Disorder is an extremely, extremely, extremely (did I mention extremely?) rare condition. The majority of the most severely neglected children pulled from orphanage environments will never go on to develop RAD. To put it even further into context, in my 8 years of working with traumatized children, at times working in contexts that pulled in clients from all over the world, I have not met even ONE single child whom I would diagnose with a true Reactive Attachment Disorder. I have met a couple of kids with a relative of the disorder (Disinhibited Social Engagement Disorder) and a couple of kids that other professionals unfairly stamped with the "RAD kid" label. And many children I've worked with have had very troubled attachments- "insecure" or even "disorganized" attachments- but I've never seen a true Reactive Attachment Disorder.
So, unless this particular clinician is pulling in Reactive Attachment Disorder clients from all over the world, I would call major BS on any number over 5% of their lifetime caseload.
5. "Which therapists, thinkers and writers on attachment do you follow?"
This will give you an idea of what belief systems the therapist may be applying to their work. If they name names, write those down and do a quick Google search to check it out for yourself. Better yet, get your hands on some of the therapist's favorite books or videos. There are some fantastic thinkers on attachment out there, and there are also some very scary people. I'll let you be the judge of who's who.
Please let me know if you want my help sorting any of this out! Even if my practice is full, and I can't personally take you on as a client, I will try to help you find your way. There are many excellent therapists in the Asheville, NC area. I am passionate about helping families find the safe and effective attachment-based therapists we have in our community.
Danielle Maxon is a child therapist and Licensed Clinical Social Worker in the State of North Carolina. She has been strengthening families in North Carolina since 2011. In August of 2015 she created her private practice, Under Wing Therapeutic Services, PLLC, which offers parent-child play therapy, parenting support and individual counseling for children under 12. Danielle specializes in the treatment of complex trauma, including profound neglect, orphanage experiences and foster care. She especially loves helping defiant, aggressive little ones and exasperated parents.