Daily Archives: August 25, 2010

Somatoform Disorders



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Somatoform Disorders could be summed up in the following statement… “there are more questions than answers.”  (Blaney & Millon, 2009, p. 499)  As a collection of disorders, it appears as though they don’t belong under the same heading or classification.  Many have more in common with Obsessive-Compulsive Disorder (OCD) than they have with each other.

“The common feature of the somatoform disorders is the presence of physical symptoms that suggest a general medical condition and are not fully explained by a general medical condition, nor by the direct effects of substance, or by another mental disorder.”  (Blaney & Millon, 2009, p. 483)  Somatoform can only be diagnosed by the process of exclusion… which seems odd to me.  It represents a “curve ball” for medical and mental health professionals, because the underlying consensus is that the client “believes they have an ailment, but they don’t.”  I don’t use “very, very” very often, but this has to make it very, very difficult to diagnose.  It might give some explanation to the very low prevalence rates.

I would have expected a greater degree of stress or anxiety in a patient that presents with this disorder, as would be typical of someone who presents with symptoms that can’t be explained.  “Patients with these disorders typically experience little or no anxiety, whereas those with so-called preoccupation disorders are excessively concerned or anxious about the notion that there is something physically wrong with their bodies.”  (Blaney & Millon, 2009, p. 483)  Can we use this lack of anxiety as a “flag” for diagnosis?

The “sick role” seems to be an underlying sociological construct among all the somatoform disorders.  Sick role implies granted privileges (staying home from work) and avoidance of obligations because one has to comply with medical instructions.

I was particularly interested and enthralled with the cultural differences in the presentation of Conversion Disorder (CD).  Not only is it more prevalent among rural residents from low socioeconomic backgrounds, but there is remarkable differences between geographical areas.  The text cited frequent cases of “burning hands” in Asia, which are typically never reported in the Western world.  (Blaney & Millon, 2009, p. 487)

Pain disorder is another anomaly.  What surprised me is that typical clients don’t come to treatment because of the degree or intensity of the perceived pain, but are more likely to come seeking respite from the psychological costs of pain management.  I could anticipate that this would be one of the most debilitating somatoform disorders because of its ability to disconnect clients from family, friends, work, and recreation.  (Blaney & Millon, 2009, p. 487)

I was relatively familiar with the concept of hypochondriasis before reading the text, but I was wholly unaware of the underlying theoretical etiology.  The concept of increased sensitivity to innocuous bodily sensations is new to me.  I was aware that some clients have formed selective attention to illness formation, risk perception, and misinterpretation of benign symptoms.  The suggestion that it is triggered by critical incidents, and is predispositioned by parental attitudes rings true to me.  I was also suitably surprised by the transient nature of the disorder, since it can apparently go into full remission and then appear again when a stressor appears.

Body Dysmorphic Disorder (BDD) is fascinating, quite honestly I have never heard of it.  I think this probably has more to do with societal views of “what is beautiful” than we think.  I was not at all surprised by the suggestion that some believe it to be delusional in nature.  I am a “perfectionist type” myself, but I never in my life would have dreamed this could be one of the results of that predisposition.  The text suggests that it may be compounded by being teased or bullied as a teenager (during puberty), leading to a general lack of social skills and self conscious maladaptive behavior.

Factitious Disorder is when “physical symptoms are produced or feigned intentionally to assume the sick role.”  (Blaney & Millon, 2009, p. 492)  The concept of “hospital hopping” in effort to undergo medical procedures, even surgery, is amazing.  The fact that these patients frequently lie about the nature of their symptoms, and life circumstance in general, probably contribute to the difficulty of diagnosing and treating this disorder.  I mean, how can you believe them?  I would question everything that came out of their mouth, it might be increasingly difficult to sort out “real issues” from “fake ones.”

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Blaney, P. H., & Millon, T. (2009). Oxford textbook of psychopathology (2nd ed.). New York, New York: Oxford University Press.

A Personal Narrative on Burnout: PTSD, Balancing Risks and Rewards in the Profession of Counseling

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I have resisted the temptation to share this up until now because it is a very personal article I wrote some time ago… this one goes out to Rey, my only subscriber.

Counseling is a risky and rewarding business.  While counseling invites mental health counselors to participate with their clients in the awesome process of human growth and healing, it also may threaten their well being through exposure to their clients’ trauma and its painful consequences.  (Meyer & Ponton, 2006)  The consequences frequently manifest themselves in adverse and maladaptive reactions to ongoing stress; peaking as a condition we call “burnout.”  The symbolism involved with the word burnout relates to the extinguished flame, which is the motivational force in the caring professions.  Burnout can be defined as a syndrome of emotional exhaustion, depersonalization, and reduced accomplishment which can occur among individuals who do “people work” of some kind.  (Garske, 2007)  Although exact figures are unknown, it is estimated that approximately 10-15% of practicing mental health professionals will succumb to burnout during the course of their careers.  (Clark, 2009)  Due to the emotional stresses involved with caring for others, and my own personal history of dealing with stress and trauma, there is good reason for us to explore strategies to thwart the effects of professional burnout.

I anticipate that I will be particularly prone to what has been described as “vicarious traumatization.”  Vicarious traumatization is conceptually realized through “the development of empathic relationships with traumatized clients,” ultimately leading some therapists to become traumatized themselves.  The impact of this traumatization is not limited to the therapeutic environment and may trickle into other aspects of the therapist’s life.  (Meyer & Ponton, 2006)  Although I have not yet assumed a role as a professional counselor, on occasion I am called upon to be a shoulder to cry on when traumatic events unfold.  On one such occasion, it would suffice to say that my shoulder was soaked.

I wouldn’t describe my relationship with my cousin Josh as “close.”  I saw him a couple times a year, usually around the holidays or for a week or so on summer vacation.  Josh was 6 years younger than me.  I was one of the people he “looked up to” when he was growing up; I guess you could say I was one of his role models.  Josh always wanted to be in law enforcement, mostly because he enjoyed the “action.”  He, too, had an intense desire to help people.  Josh joined the Army Reserves to leverage the GI Bill and pay for college.  Specifically, he joined the 339th Military Police Company based in Davenport, IA.  When he joined, it had been 30 years since that company was activated.  After a short deployment to Cuba, officials activated the 339th once again in December 2003 and the company deployed to Iraq in February 2004.  His mission included guarding people and enemy munitions located at a “forward operating base.”  When he came back, he was a wreck.  Haunted by visions of Iraqi people he had killed, and plagued by Post Traumatic Stress Disorder (PTSD), he took his own life in front of his mother (my aunt) on December 22, 2005.  Because the depth and detail of the situation is beyond the scope of this essay, I would point the interested reader to the award winning essay by Dennis Magee of The Des Moines Register, reproduced on the following site… http://joshua-omvig.memory-of.com/legacy.aspx

Although it is difficult to assess how work as a mental health professional will affect me, I can infer that vicarious traumatization might cause me to react much like I reacted to the second hand accounts of Josh’s suicide.  I did my best to assume as much of the burden as I was able; in hindsight, I probably took too much.  My natural inclination to withdraw took root weeks after the funeral, mostly as a reaction to shouldering the weight of my family and their grieving process.  I couldn’t sleep.  I couldn’t eat.  It’s difficult even writing about this now, nearly 5 years later.  As a counselor, I believe second hand accounts of a traumatic nature have the potential to reproduce that effect in me.  As a result, I have a sense of urgency creating a plan to deal with it.

Inherent in my plan to prevent burnout is continually access my level of competency and adjust the scope of my practice accordingly.  It is imperative for my success as a practitioner that I know my limits.  Due to my traumatic experience with PTSD veterans, I don’t anticipate working with this population in the immediate future.  I bestow all due respect to the women and men who have fought and died for our country, but my personal experience would prevent me from being fully effective as a therapist for our veterans.  Someday I hope to overcome this.

In addition to suffering vicarious symptoms of traumatic stress, therapists have to struggle with the same disruptions in relationships as their patients.  (Canfield, 2005)  I have experienced a wide range of difficult situations in my life, and I have little reason to believe that it will be “clear sailing” from here.  Although I have grieved for the loss of both friends and family, I have yet to endure the loss of any member of my immediate family.  I am the eldest son of a mother thrice divorced, but thus far I have managed to avoid the missteps that could cause the collapse of my own marriage.  Raising my daughter has not been without trials, but in her 8 years she has never been sick or injured without reasonable expectation of full recovery.  In the end, any or all of the above is possible (hopefully not likely).  It would suffice to say that my ability to maintain balance in my personal life will continue to have direct effects on my ability to provide effective counsel.

To that end, I endeavor to continually invest in myself and my personal well being through my family life.  My personal life begins and ends with my family, and to what degree it is possible, I spend as much quality time as I can with them.  It’s as simple as taking the time to read to my daughter every night, or surprising my wife with flowers for no apparent reason.  My father once told me that I should “cherish every day like it was my last.”  That realization, that process, is at the core of my personal burnout plan.

Third and finally, I believe one area of significant vulnerability for me is my excessively preoccupation being successful.  Work tends to play a central role in people’s physical and psychological well-being, I am no exception. “Not only does it provide income and other tangible resources, but also it may be a source of status, social support, life satisfaction, and self-identity.”  (Garske, 2007, expression Nature)  No one likes to fail.  Too often, being anything less than the best is failure in my eyes.  Competitiveness is in my nature; the chase causes me a great deal of stress.

An integral part of my burnout plan involves individual therapy.  My persistent and unrelenting determination occasionally causes me a great deal of stress.  In the end, like our clients, it helps to talk about it.  Therapists cannot take clients any further than they have taken themselves; therefore ongoing self-exploration is important.  (Corey, Schneider-Corey, & Callanan, 2007, p. 73)  I am an advocate of counseling for counselors.  Without, I wouldn’t be writing this paper if not for my successes in individual therapy; I’d probably be burned out.

In closing, I believe we all struggle to balance the risks and rewards of life.  For every day I have spent grieving over a fallen solider, I should spend a reciprocal day defining my limits and reducing potential risks of transference.  For every hour I have spent mulling over the tragedies of yesterday and tomorrow, I should spend a reciprocal hour appreciating today.  For every minute I spend rushing to the destination, I should spend a reciprocal minute examining the road.  In the end, it’s all about achieving balance.  Balancing the risks and rewards could mean the difference between success and failure, not just for me as a clinician, but for the clients I endeavor to help.

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Canfield, J. (2005). Secondary traumatization, burnout, and vicarious traumatization: A review of the literature as it relates to therapists who treat trauma. Smith College Studies in Social Work, 75(2), 81-102. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1061959531&sid=3&Fmt=3&clientId=4683&RQT=309&VName=PQD

Clark, P. (2009, Apr). Resiliency in the practicing marriage and family therapist. Journal of Marital and Family Therapy, 35(2), 231-248. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1680596541&sid=3&Fmt=3&clientId=4683&RQT=309&VName=PQD

Corey, G., Schneider-Corey, M., & Callanan, P. (2007). Issues and ethics in the helping professions (8th  ed.). Belmont, CA: Brooks/Cole.

Garske, G. G. (2007, Winter). Managing occupational stress: A challenge for rehabilitation counselors. Journal of Applied Rehabilitation Counseling, 38(4), 34-42. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1418538171&sid=3&Fmt=4&clientId=4683&RQT=309&VName=PQD

Meyer, D., & Ponton, R. (2006, Jul). The healthy tree: A metaphorical perspective of counselor well-being. Journal of Mental Health Counseling, 28(3), 189-202. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1086418421&sid=3&Fmt=4&clientId=4683&RQT=309&VName=PQD

Skovholt, T. M., & Ronnestad, M. H. (2003, Fall). Struggles of the novice counselor and therapist. Journal of Career Development, 30(1), 45. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=420397201&sid=1&Fmt=2&clientId=4683&RQT=309&VName=PQD

Post Traumatic Stress Disorder (PTSD)

Because of my young age, I was wholly unaware of the political struggle that surrounded the Vietnam War (as it relates to the inclusion of PTSD).  I am confounded by the statement “PTSD was a normal response to an abnormal stressor that would evoke marked distress in nearly everyone, regardless of his or her preexisting vulnerabilities.”  (Blaney & Millon, 2009, p. 189)  The above statement is basically the reason it was included in the first place, and not 30 years later it has been refuted entirely.

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I was floored by the fact that “one epidemiological study of Michigan residents indicated that 89.6% of American adults now qualify as trauma survivors.”  (Blaney & Millon, 2009, p. 177)  I can’t believe that watching the evening news is considered trauma.  I could possibly comprehend assigning that status to someone who was directly involved in the 9-11 events, but if you had no connections (lost no immediate family members, etc) how can that be considered trauma?  Despite the fact that it is undoubtedly good for our profession (makes our market bigger), I can’t say I agree with this “bracket creep” that has been occurring.  To be quite honest, it’s approaching the “ridiculous.”

I am always drawn to the sex ratio comparisons for some reason, and I was especially drawn to the statement “men are exposed to traumatic events more often than women are, yet the rate of PTSD is twice as great in women as in men.”  (Blaney & Millon, 2009, p. 178)

The ongoing debate about the “definition of impairment” was really interesting since it had such a marked effect on the prevalence rates.  I really took this home as evidence that you really can “create the scenario you want to prove” if you manipulate the variables enough.

I can confirm the “reluctance to seek mental health care because of possible stigma” in the military community.

“The modal veteran in this cohort continued to deteriorate psychiatrically despite remaining in treatment, but then terminated treatment once 100% service-connected disability status had been achieved.”  All due respect to our veterans because they deserve that money in my opinion, but it’s the slightest bit amazing how much better $750/month can make me feel.  I am surprised that the VA Inspector General came to that conclusion; usually they sweep stuff like that “under the rug.”

Evidently it’s difficult to find someone who has pure PTSD, which I was wholly unaware of.  It’s not that it’s comorbid with that many different disorders (Major Depression, GAD, Alcohol/Substance Abuse), but it would appear that comorbidity is an issue in up to 84% of cases.  (Blaney & Millon, 2009, p. 181)  It really makes me question the validity of the diagnosis, given the current definition of “impairment,” and “trauma.”  While I am confident that this is a legitimate issue, I am inclined to align myself with the proponents of differential diagnosis on this one.

The Stroop Paradigm is ingenious.  I need to learn how to administer this test.  Is this commonly administered in private practice?

The suggestion that “being above average cognitively can protect you from the effects of PTSD” reminded me of my mother saying “your smarter than that” every time I got in trouble.  I called my mom tonight and told her she was right… she laughed.

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Blaney, P. H., & Millon, T. (2009). Oxford textbook of psychopathology (2nd ed.). New York, New York: Oxford University Press.

Obsessive Compulsive Disorder (OCD)

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Obsessions are unwanted/intrusive thoughts, impulses, or images and are “stress causing.”  Compulsions are constant repetitive behaviors or mental acts (rituals) that respond to obsessions, and are “stress relieving.”  Compulsions are a direct response to obsessions, representing an effort to reduce or otherwise avoid perceived consequences of the obsession.  1 in every 40 American’s is affected by varying degrees of Obsessive-Compulsive Disorder (OCD).  Dr. Jeffrey Schwartz believes “we all have a touch of this.”  I think we all have a natural inclination to identify stress and attempt to eliminate it, so I tend to agree with the final statement.  Dr. Jeffrey Schwartz, renown OCD expert, contends that people can change their own brain chemistry through his “biobehavioral” 4 step processes to remove “Brain Lock.”

1) Relabeling the thought, acknowledge it is an obsession or “false message”

2) Reattribute the compulsion to something else (a chemical imbalance, or OCD)

3) Refocus, concentrate on doing another activity

4) Revalue, determine that the obsession is meaningless

Comparing and contrasting the “biobehavioral” approach with more common clinical strategies, most clinicians would treat OCD with cognitive behavioral therapy (CBT), exposure and response prevention (ERP), and/or the use of pharmacological SSRI remedies.  (Podea, Suciu, Suciu, & Ardelean, 2009; Masi, Millepiedi, Perugi, & Pfanner, 2009)  CBT/ERP techniques can be implemented in a variety of different formats including individual, group, and self-controlled versions.  The latter study found the most effective SSRI to be clomipramine, although fluoxetine, paroxetine, sertaline, and fluvoxamine were all more effective than placebo.  On the whole, the general consensus is that a multimodal approach pairing SSRIs with CBT is the most effective treatment method, followed by therapist guided CBT and/or SSRIs alone.  Although his particular study found self-controlled versions to be significantly less effective than any combination of the above treatments,  (Masi et al., 2009, expression Background) some authors (including Dr. Jeffrey Schwartz) feel that self-directed in vivo ERP is just as effective clinically as therapist-controlled in vivo ERP.  In any event, it is more cost effective.  (Ben-Arush, Wexler, & Zohar, 2008)  It would suffice to say that there is general consensus that CBT/ERP is the preferred solution, although there is considerable disagreement in its implementation.

This cognitive based therapy is based on the assumption that what differentiates OCD patients from the rest of us is not that they experience intrusive thoughts, but the manner in which these thoughts are processed.  Unlike the general population, which would commonly dismiss intrusive thoughts, OCD patients consider them important and act on them.

In the traditional method, patients learn, with the help of a therapist, to expose themselves to certain stimuli (e.g., toilets, door knobs, public telephones) which intensify their obsessive thoughts and, also, how to resist responding to those thoughts in a compulsive manner (e.g. not washing their hands, not checking things repeatedly). Exposure can take place in real life, in vivo, (e.g. at home or in a public toilet) or in an imaginary form (e.g., in the case of patients with obsessions with religious content). The purpose of exposure is to teach the patient to tolerate anxious experiences, rather than avoiding them.  (Podea et al., 2009, expression Results and discussion)

So, what would I do if I was in the care a client of a classic case of ODC?  I would probably give them a copy of Dr. Schwartz’s book as soon as the diagnosis is made, in addition to starting to ramp the client up on an SSRI like clomipramine.  On the second session I would answer questions about the book, and begin some therapist led CBT/ERP procedures, while continuing to encourage the application of self-based interventions prescribed by Dr. Schwartz.  In the end, I would utilize all three options, because they are viable, and research has shown that a multi-modal approach is solution that delivers the best outcomes.

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Ben-Arush, O., Wexler, J. B., & Zohar, J. (2008). Intensive outpatient treatment for obsessive-compulsive spectrum disorders. The Israel Journal of Psychiatry and Related Sciences, 45(3), 193-201. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1667555491&sid=1&Fmt=3&clientId=4683&RQT=309&VName=PQD

Masi, G., Millepiedi, S., Perugi, G., & Pfanner, C. (2009). Pharmacotherapy in paediatric obsessive-compulsive disorder: A naturalistic, retrospective study. CNS Drugs, 23(3), 241-253. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1708241661&sid=1&Fmt=4&clientId=4683&RQT=309&VName=PQD

Podea, D., Suciu, R., Suciu, C., & Ardelean, M. (2009, Sep). An update on the cognitive behavior therapy of obsessive compulsive disorder in adults. Journal of Cognitive and Behavioral Psychotherapies, 9(2), 221-234. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1895143051&sid=1&Fmt=1&clientId=4683&RQT=309&VName=PQD

Reactive Attachment Disorder (RAD)

The profile of children diagnosed with Reactive Attachment Disorder (RAD) is disturbing.  Although the diagnostic criteria speak for themselves, I believe Cline’s (2008) account of life on a RAD unit is as insightful as one can find into some of the “typical profiles” of children diagnosed with RAD.

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The reactive part of RAD is certainly correct, as these children react immediately with rageful outbursts to any feelings of abandonment, slight, or limit setting.  The attachment aspect of the diagnosis is broad.  For whatever reason, children with RAD were unable to bond with anyone.  There was no stability in the relationships they formed from infancy on.  Trust was an issue.  Care, whether physical or emotional, was inconsistent.  There was nothing they could count on, except having nothing to count on.  There was no foundation to build on.  From day one they felt unattended, rejected.  They cried.  They hungered.  They hurt.  As infants, their stresses were not relieved.  Their needs were disregarded.  They were uncomfortable.  Many were hit, used.  They may have been ill at birth and suffered much in the name of medical treatment.  Perhaps they were not touched more than was necessary for basic care.  They may have been intentionally or unintentionally neglected.  They may have been abused physically, sexually, or emotionally.  They may have come from overcrowded orphanages in other parts of the world.  Their parents may have been drug addicts, alcoholics, economically disadvantaged, single parents, or mentally ill-parents who were unable to attach themselves.  (Cline, 2008, expression PROFILES OF RAD)

DSM-IV-TR diagnostic criteria for RAD include the following:  (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000, p. 130)

A)    Markedly disturbed and developmentally inappropriate social relatedness in most contexts, beginning before age 5 years, as evidenced by either (1) or (2):

  1. Persistent failure to initiate or respond in a developmentally appropriate fashion to most social interactions, as manifest by excessively inhibited, hyper-vigilant, or highly ambivalent and contradictory responses (e.g., the child may respond to caregivers with a mixture of approach, avoidance, and resistance to comforting, or may exhibit frozen watchfulness).
  2. Diffuse attachments as manifest by indiscriminate sociability with marked inability to exhibit appropriate selective attachment (e.g., excessive familiarity with relative strangers or lack of selectivity in choice of attachment figures).

B)    The disturbance in Criterion A is not accounted for solely by developmental delay (MR) and does not meet criteria for PDD.

C)    Pathogenic care as evidenced by at least one of the following:

  1. Persistent disregard of the child’s basic emotional needs for comfort, stimulation, and affection.
  2. Persistent disregard of the child’s basic physical needs.
  3. Repeated changes of primary caregiver that prevent formation of stable attachments (e.g. frequent changes in foster care).

D)    There is a presumption that the care in Criterion C is responsible for the disturbed behavior in Criterion A.

E)     Specify Type

  1. Inhibited type is predominated by Criterion A1
  2. Disinhibited type is predominated by Criterion A2

Although we can not entirely eliminate the possibility of predispositions due to heredity or biological causes, RAD cases will typically present with a clear etiological path to pathogenic care.  There is also evidence that some familial circumstances may provide predisposition to RAD.  In a generational study of caregivers demonstrating unresolved loss and abuse, Zajac and Kobak (2009) found “a consistent association between caregivers’ unresolved loss and teacher ratings of children’s behavior problems… but solely among caregivers who had insecure (dismissing or preoccupied) states of mind.”  (Zajac & Kobak, 2009, p. 182)

RAD is prevalent in the foster care system.  (Schwartz, 2008)  However, children in foster care are not the only high risk group for developing the socio-emotional issues associated with RAD.  A recent study, concerned with the developmental issues impacting military families during deployments, found that young children with a deployed parent demonstrated increased behavior problems during deployment and increased attachment behaviors at reunion (compared with children whose parents had not experienced a recent deployment.  Children in their “deployment groups” had a deployed parent that was gone, on average, half of their lifetime.  These findings were conclusive despite the fact that some military families and children seem to show fewer detrimental effects in response to parent deployment.  (Barker & Berry, 2009)

“While there is no empirically supported treatment for RAD, evidence suggests that children with attachment problems are best served by therapies that promote environmental stability as well as caregiver patience, sensitivity, and consistency.”  (Wilson, 2009, expression Treatment Considerations)  Interventions suggested by Wilson include group-based interventions to encourage parent sensitivity and responsiveness, labeled “Circle of Security,” or direct instruction to guide parental response to child behavior via a “bug in the ear,” labeled Parent-Child Interaction Therapy (PCIT).

Other therapies use coercion, fear, and emotional dysregulation to address concerns in attachment formation.  Although less common, such controversial interventions remain in practice and claim to “cure” attachment disturbances by invasive techniques, such as restraining or confining a child for extended periods of time.  Sometimes called holding, rebirthing, rage, or past-life therapy, such interventions have little empirical support, are theoretically counterintuitive, ethically problematic, and of questionable utility.  (Wilson, 2009, expression Other Therapies)

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American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Barker, L. H., & Berry, K. D. (2009, Oct). Developmental issues impacting military families with young children during single and multiple deployments. Military Medicine, 174(10), 1033-1041. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1884841381&sid=4&Fmt=3&clientId=4683&RQT=309&VName=PQD

Cline, L. (2008, Jan). Reaching kids with reactive attachment disorder. Journal of Psychosocial Nursing & Mental Health Services, 46(1), 53-59. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1411292941&sid=4&Fmt=3&clientId=4683&RQT=309&VName=PQD

Schwartz, L. L. (2008, Summer). Aspects of adoption and foster care. Journal of Psychiatry & Law, 36(2), 153-171. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1602451041&sid=4&Fmt=3&clientId=4683&RQT=309&VName=PQD

Wilson, S. L. (2009, Aug). Understanding and promoting attachment. Journal of Psychosocial Nursing & Mental Health Services, 47(8), 23-28. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1835014081&sid=4&Fmt=3&clientId=4683&RQT=309&VName=PQD

Zajac, K., & Kobak, R. (2009, Jan). Caregiver unresolved loss and abuse and child behavior problems: Intergenerational effects in a high-risk sample. Development and Psychopathology, 21(1), 173-188. doi: 10.1017/S095457940900011X