Chris Kerno, Field Education Director

So you have your DSM in front of you and are looking at the symptoms of Reactive Attachment Disorder. Could this be the problem? How do you really know? After all, the DSM only lists a set of symptoms, a road map really, but it cannot make the diagnosis for you. Knowing how to get somewhere to some extent has to do with how many times you have been there before. The places along the way become familiar. So it is with diagnosis. After years of practice, you start to just know that you have been here before.

Joe sat in front of me. He was clearly a very disturbed and angry young man. He was 14 and could not stop railing about how many therapists he had had and how they all “sucked.” But I was different. I really understood him. I did not tell him what to do or judge him for his choice of music, hair or dress. I was a great therapist. Wow, this felt pretty good! After all, I went into the business to help people, and here was a young man who not only wanted my help, but also complimented me for it.

But I had been around for a while. I had some great teachers and mentors and had worked with many, many severely disturbed young men. They all taught me the way … not to jump to conclusions and to wait. With more time, more data would emerge. I had learned the hard way to always allow for new data.  Often, especially in crisis, it is practically impossible to make an accurate diagnosis.

So, I waited. Soon, Joe was not so friendly. He became distant in counseling and seemed to almost completely shut down. His school teachers reported erratic mood swings and aggressive behavior. Hmm … bipolar? No, it did not feel right. Wait.

Then, his prospective adoptive family began to report trouble. Instead of their “perfect” future son, their relationship began to feel like a yo-yo. I knew what they were talking about. I was experiencing the same thing with Joe. Pop culture calls it the “come close, go away” syndrome. It became clear that the closer the adoption came, the more Joe deteriorated, until he sabotaged the placement beyond repair.

Then it struck me. A past echo of someone else … I had been here before. The more I thought about it, the closer I got to the answer. It was Sheila, the 18-year-old young woman with whom I had worked 12 years prior. Sheila had done the same thing. Initially, I was the best therapist in the world. She could trust me. In fact, I was “the first man she had ever trusted.”

In those days, I was much more likely to get hooked, and I bought it. She had appealed to my narcissistic need to be a “good therapist,” a trap into which many a young therapist falls. Was it perhaps a right of passage, a need to help, to rescue? Then, when I thought I had developed a “therapeutic alliance,” the basic building block to therapy, she refused to even see me.

When I wrote her a note offering “to be there for her when she was ready,” I found it torn up and thrown in my box at work. I never found out how she did this without the secretaries seeing, but she did. I thought I had failed, but thanks to good supervisors, I knew I was dealing with a borderline personality, unable to attach. Now I knew it was the same with Joe, although we call it reactive attachment disorder when it occurs in children.

To some extent, all our clients attempt to draw us into their process, (i.e., a re-creation of all their old patterns). Some call it “a dance with the client,” with the client always in the lead. That is where good supervision plays an important part, especially early in one’s career. Good supervisors help us untangle from this emotional and psychological fray, “to see the forest from the trees” and understand the client’s process.

“Process, process, process” one of my former supervisors used to say. It is all in the process; the trick is to make increasingly educated guesses at your clients’ processes and then relay the information back to them. Whether it means something to them is all that is important. Your theories are meaningless in the absence of awareness on your clients’ part. Whether they use the information or carefully crafted interventions you devise is up to them. We are powerless to make our clients change. All we can do is create an environment whereby the chances of change occurring are increased.

So, as I learned with Sheila and then with Joe, I had to resist the temptation to try and build a therapeutic alliance. The clients are in control of the level of intimacy at all times, especially true with people like Sheila and Joe. While counterintuitive to our nature (at least for most of us), we must resist the temptation to “chase them,” which is just what their disordered process wants.

When life occurs and disappointment sets in, as it inevitably does with all relationships, it proves to them once again that the world is not safe, with a never-ending cycle of perceived disappointments, rejections, and/or despair. How do you work with a person who cannot form even the most basic of relationships? 

It all comes down to expectations and the limits of treatment. Once understood, it is possible to help them. It all begins with a complete “letting go” of what we think is necessary for treatment, namely the all-important relationship. If you can let this idea go, you are well on your way to understanding how to work with attachment disorders. The key is how you position yourself with them. Believe it or not, done right, it can be very satisfying work … but more on this later.