Children’s Behavior Problems: Not Always What They Seem

Figuring out and helping young children with “bad” behavior

By Julie Maccarin, Ph.D., OT/L

In my work, I am often asked to see young children with behavior problems. I like to think of my work as a bit like the job of a detective. What is underlying the behavior? What is contributing to it? What is provoking it? What is sustaining it?

“Bad” behavior may be anything from being uncooperative; whiny and complaining; having frequent crying jags, outbursts or tantrums; being defiant and oppositional; overly fearful; angry and aggressive; avoidant or withdrawn; mean or bullying.

My skills as both a child psychologist and a pediatric occupational therapist contribute to my reasoning.  My first order of business is to meet with the parents and get a picture of the family situation and the problem as it presents – When does it occur? How often? What is the intensity? What are the antecedents? What are the responses to the behavior from the various family members? How does the child react to those responses? How does the child feel after it’s all over – is she sad, sorry, resentful, still angry, or is she calm and able to move on? How are other family members functioning and how are they contributing to or helping alleviate the problem?

Joey* would have a melt down every day in the car when his mother picked him up from school. He would cry, yell and hit his sister. Simply bringing a snack for Joey in the car quickly eliminated the problem. Being “hangry” (hungry and angry) often leads to meltdowns in young children, as does being over tired and over stimulated.

Eli * would also have a meltdown every day in the car when his mother picked him up from school. He would also cry, yell and hit his sister. Eli’s problems were much more pervasive.  Eli was a fussy, highly sensitive, “high needs” child who had never adjusted to the birth of his sister when he was two and a half.  Now at six, he frequently hits his sister, criticizes her and calls her names. His parents are at their wits end after repeatedly trying to teach him to be a “good big brother”, and running through numerous strategies to change his behavior, from rewarding and punishing to ignoring.

Eli was on the “high needs” end of the spectrum. This is also known as having a “difficult” temperament, which may include such characteristics as being highly sensitive to environmental input, such as sound, movement, light, smells; being slow to adjust to new situations; being moody or intense; etc.  Children with this type of temperament are often highly emotionally sensitive as well – quicker to react to emotional slights, easily getting their feelings hurt, and generally having poor self regulation. These children are the opposite of the easy going child, who seems much more likely to let things roll off his back and not get upset in the first place. Children with a “difficult temperament” need a different type of parenting then “typical” children.

When Eli learned to express his feelings and needs about some of the things that “bother” him, he was able to find ways to help himself feel more comfortable and to ask for help when he needed it. Eli’s parents were assisted in learning ways to acknowledge and validate Eli’s feelings, provide him with one-on-one time, and support him in finding solutions. As Eli was able to feel more at ease and more competent, his self esteem improved, he was less resentful of his sister and he was able to develop a healthy relationship with her.

Elizabeth* was a child who had difficulty socially. In second grade, she was rarely invited to birthday parties and although she invited other children for play dates, they often declined. Worried that she was not liked, Elizabeth often asked children if they liked her. Elizabeth’s single mother suffered from significant untreated anxiety and frequently shared with Elizabeth her own experience of feeling unlikeable and suffering because of being unpopular with schoolmates when she was a child. She repeatedly asked her daughter about her friendships at school, transmitting her anxiety onto Elizabeth who, for reassurance, often asked others if they liked her, making them uncomfortable.

While Elizabeth’s social difficulties could have resulted from an autism spectrum disorder, a developmental lag, a language disorder, ADHD, low self esteem or other issues, in this case, parenting was creating the problem. Parents who are overly stressed, anxious, depressed or have other emotional baggage may transmit their emotional state to their child, both verbally and non-verbally. Parents who lack attunement and are unable to give their child unconditional love and focused attention, or otherwise are unable to meet their child’s emotional needs, may be preoccupied with other matters such as their job or their need to attend to younger children, or they may be reacting to their own painful experience in childhood of neglect, abuse, indifference, etc.  Some parents, even those who aren’t terribly wounded themselves, just lack parenting skills or have expectations that are mismatched with the child’s developmental level, abilities, or personality. Sometimes parents are misaligned with each other, giving mixed messages to their child.

In Elizabeth’s case, once her mother worked on her anxiety in her own therapy, she was able to stop transmitting it to Elizabeth. At the same time, Elizabeth developed better social skills through play therapy and was able to be more successful in her social relationships.

Five year old Milo* had a great fear of bad weather. He didn’t like to leave the house if there was even one dark cloud in the sky. It appeared that Milo was suffering with an anxiety disorder, however, as it turned out, his older brother had informed him that he could get hit by lightening if he went out on a cloudy day. His literal interpretation of this information turned out to be a function of his belatedly recognized high functioning autism. Once the misunderstanding was cleared up, using multiple sources and modalities of information, Milo was fine going outside, even when there were clouds in the sky.

Many difficult behaviors that children exhibit can be the result of any number of different underlying etiologies. For example, aggressive behavior can be a manifestation of a mood disorder, attachment issues, sibling rivalry, ADHD, inconsistent or harsh parenting, an Autism spectrum disorder, or even psychosis.  Sometimes, aggression is the only way a child knows how to communicate what they are feeling.  The impulsivity, distractibility, and high activity level that looks like ADHD may actually be coming from underlying anxiety. For each child who is avoidant, controlling, distracted, socially inept, perfectionistic, anxious, withdrawn, or otherwise exhibiting problematic behavior, the job of the child psychologist is to determine what is going on for that particular child. With a good understanding of what is underlying the behavior it is possible to provide the intervention that is needed to help the child feel and behave better and improve family relationships.

* Client’s names and identities have been disguised in this article.

Julie Maccarin, Ph.D., OT/L is a California licensed psychologist and occupational therapist with over 30 years specializing in serving young children and their families. She has also served as a consultant and expert witness in over 40 forensic cases involving young children across the country. She is a mother, a stepmother and a grandmother. She recently relocated to Marin. Her practice, Child Psychology Marin is located in Corte Madera, California.

For more about Julie Maccarin, visit:

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Please visit for more information about our association and membership benefits or to locate a licensed clinical psychologist in Marin County.

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Blog Disclaimer:

The opinions expressed by the authors are their own and do not reflect the opinions of the Marin County Psychological Association. The information posted on this blog is not intended as, and is not, a substitute for professional mental health services.

Nonverbal Cues in Psychotherapy Related to Culture

by Diane A. Suffridge, Ph.D.

“I recently had a first session with a client who immigrated from India last year. I’m Caucasian and haven’t lived outside the United States. My client didn’t seem as receptive to therapy as most of my other clients, and I assume this has to do with our cultural differences. What can I do to make it easier for her to benefit from therapy? “

It is good for you to begin this therapeutic relationship with an awareness that you will need to make some adjustments in your usual therapeutic practices in order for this client to benefit from therapy. When we have significant cultural differences from our clients, it is our clinical responsibility to learn about the implications of these differences for establishing a therapeutic relationship.

The first step I would suggest is to get some education and consultation on your own, with supervisors, professors, and colleagues and by accessing professional publications in print or online. Since there are many cultural groups within India, it will be important to know your client’s geographic, religious, and class identifications. The easiest aspects of this education will be general information about views of health and mental health, symptoms, and treatment. Your client will also be able to tell you about her understanding of these aspects of her culture. Issues and struggles for first generation Indian clients are reflected in movies and books. The movie “Bend It Like Beckham” and the book “Life’s Not All Ha Ha Hee Hee” by Meera Syal are examples.

In general, boundaries within the Indian culture are very different from those in the West. Many generations live together, elders are expected to be cared for, and daughters in law are expected to bear the brunt of the work in traditional homes. Explore your client’s family structure and expectations, including the family members and living arrangement she left in India and whether she lives with family members or has acquaintances in the U.S. Approach these discussions with openness and keep in mind that individuation may not be the goal of therapy for your client. The structure of a family system that fosters both a sense of connection and a sense of individual wellbeing for this client may look different than for your clients who come from traditional Western culture.

The more difficult aspects of your need for education will be learning about the relational expectations of your client’s culture including nonverbal cues (i.e., eye contact and other gestures) and boundaries. It may be helpful to supplement your education about your client’s specific culture by consulting with colleagues and acquaintances who have immigrated from other cultures. They may be able to share their observations about the unspoken practices and expectations of U.S. culture which are outside of your awareness.

Regarding Indian culture specifically, clients are likely to present as cautious, anxious, or even timid with limited eye contact. These nonverbal cues are not a reflection of avoidance or resistance to therapy, but are signs of deference. The client will expect guidance and direct instruction and will feel comfortable knowing that the clinician is the expert. Therapy initially should be somewhat structured and have clear goals.

If your client immigrated in midlife or later, be aware that many older generation Indians are not psychologically educated and as a result present with somatic problems. They may be referred by a physician rather than self-referred. Consider spending time understanding how the somatic issue affects to the client’s life and overall sense of wellbeing including how it affects their spiritual practice, diet, and family life.

In addition to education and consultation, your attentiveness to your client in session will give you valuable information. You mention that she didn’t seem as receptive to therapy as other clients, so I recommend giving some thought to what you observed or inferred in her behavior. Notice the nonverbal aspects of her interactions with you, and see if you can match her level of engagement in terms of expressiveness and eye contact. This may increase her comfort by reducing the interactional discrepancies between you. Be attentive to times in the session when she seems more or less comfortable and think about what may have been different in your relational style at those times. Emotions are often communicated through nonverbal gestures as much as or more than our words, so be careful about making interpretations about her emotional state based on your cultural assumptions. Note that the meaning of nonverbal cues is different across cultures; for example, a nod of the head that indicates saying “no” in western culture means “yes” for Indians.

It may also be useful to have some direct discussion with your client about some of the structural aspects of therapy that are unfamiliar to her. Interpersonal boundaries are experienced very differently in different cultures, so the meaning of professional behavior may be different for your client than you intend. Consider telling your client about the meaning of your professional boundaries and the therapeutic frame, acknowledging that these practices may be unfamiliar to her and may even seem odd. Invite your client’s comments and be open to shifting some aspects of your boundaries in minor ways if that will facilitate the development of the therapeutic relationship. For Indian clients, examples of appropriate differences in boundaries are accepting a small gift or a hug offered out of gratitude from the client, joining in the use of humor to bring warmth to the session, and using a double-handed hand shake.

My colleague, Fenella das Gupta, LMFT, Ph.D. Neuroscience, provided consultation in developing the content of this blog post. See Fenella’s website at for more information about her practice.

For more about Diane Suffridge, visit:

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Please visit for more information about our association and membership benefits or to locate a licensed clinical psychologist in Marin County.

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Blog Disclaimer:

The opinions expressed by the authors are their own and do not reflect the opinions of the Marin County Psychological Association. The information posted on this blog is not intended as, and is not, a substitute for professional mental health services.

Having Difficult Conversations

by Diane A. Suffridge, Ph.D.

“I have a client who has been 10-15 minutes late to every session since we started meeting three months ago.  My supervisor says I need to talk with her about this, but I’m afraid she might stop therapy if I confront her.  Is it possible to continue seeing her in therapy without talking about why she’s late?”

I sometimes say to my supervisees and people I am training that as mental health practitioners we are in the business of having difficult conversations.  Growing into the role of clinician means developing skills to talk about issues and areas of conflict in a way that is different than usual social conversations.  I’ll discuss first some of the steps that can help us in having these conversations, then address the specific situation you describe.

Each of us comes into the clinical role with interpersonal skills that are familiar and comfortable, and these familiar strategies involve avoiding some type of discomfort.  As we work with different kinds of clients, we find that these interpersonal skills are helpful in some of the situations we face but not in others.  We also face situations with supervisors, peers, and colleagues that may challenge our familiar strategies for coping with conflict or distress.  When we can expand our repertoire of skills in managing these difficult conversations, we are capable of being effective in a broader range of clinical challenges.

In working toward greater interpersonal flexibility, it will be helpful to take some time to reflect on the situation and your emotional responses to it.  Supervision and personal therapy are good resources to use in developing greater self-awareness.  Some steps to consider are to identify 1) the specific nature of the conflict or discomfort you feel, 2) the benefits and limitations of your familiar strategy for managing this type of conflict or discomfort, 3) the fears or worries that arise when you consider handling the situation in a different way, and 4) a small step you could take to expand your skills.  Remember that change usually happens in small steps, so think about developing your interpersonal skills incrementally rather than pressuring yourself to do something dramatically different.

Applying these steps to the specific situation you mention, we start with the nature of the conflict.  It seems your supervisor is suggesting something that you perceive as confrontational, but it isn’t clear whether you perceive the client’s lateness to be a problem and why discussing it would become adversarial.  A starting point would be to explore more of your own response to the client being late and the potential meaning it might have.  This would be something to discuss in supervision as well.  It seems that your familiar strategy with managing this type of conflict is to avoid discussing it directly, so the next step would be to consider the positive and negative results of this type of avoidance in other situations in your life.  It may be that this was the most effective way to respond in your personal relationships, but remember that your job as a clinician is to help your client face and resolve the issues that are interfering with her life.  A limitation of relying solely on avoidance of potential conflict is that your client will not have an opportunity to gain insight into a pattern that may contribute to her difficulties outside of therapy.

A third step to consider is the nature of fears and worries you have about responding differently to this situation.  You express a fear that your client will stop therapy if you discuss her lateness.  This seems to reflect an assumption that she will feel judged or criticized by you and that your therapeutic alliance isn’t strong enough for a conversation about something that affects your work together.  Consider approaching the conversation with curiosity rather than judgment.  You can talk about the issue without requiring that she begin coming on time.  A small step you could take toward handling this situation differently would be to say something like “I notice that you usually come a bit later than our scheduled time and I wonder if there is anything about that you’d like to discuss.”  The client may simply say “no” and move on to another topic, but taking this step moves you into an area that has previously been fearful for you.  You can then look at the meaning of your client’s pattern and additional ways you might discuss it with her.

For more about Diane Suffridge, visit:

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Please visit for more information about our association and membership benefits or to locate a licensed clinical psychologist in Marin County.

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Blog Disclaimer:

The opinions expressed by the authors are their own and do not reflect the opinions of the Marin County Psychological Association. The information posted on this blog is not intended as, and is not, a substitute for professional mental health services.

Changes from DSM-IV to DSM-5

by Diane Suffridge, Ph.D.

The DSM-5 (it is “5” rather than “V”) was published in May 2013 but many agencies are not yet using it or are just beginning to transition to the new version.  There are a number of structural changes in the organization of the DSM-5 and a number of revised or new diagnoses as well.  The DSM-5 itself contains a summary of the changes in an appendix, which you may find helpful to review.  In addition, I recommend that you look up the criteria for each diagnosis as you begin to use the DSM-5 to make sure you are applying it correctly.  I have summarized the structural and diagnostic changes below.

Structural Changes

The DSM-5 no longer uses a five axis diagnostic system as has been true in DSM-III and DSM-IV.  Instead of five axes, you list the mental health and substance use disorders that apply in the order of their clinical relevance to your treatment, followed by listing the client’s medical conditions.  Many of the psychosocial stressors that were previously listed on Axis IV are contained in an expanded section of “other conditions” called V codes or Z codes so they are included in your diagnostic list.  The GAF is no longer used, but several assessment measures are included in the DSM-5 as alternatives to the GAF for assessing the client’s level of functioning.

Some diagnoses are combined on a continuum with codes for severity rather than having different diagnoses corresponding to different levels of severity.  Autism spectrum disorder and substance use disorders are two commonly used diagnoses that have been changed in this way.  The DSM-5 calls this a dimensional approach to diagnosis rather than a categorical or binary approach. Instead of “alcohol abuse” and “alcohol dependence” disorders, DSM-5 uses “alcohol use disorder” with a code for severity based on the number of criteria met by the client’s use.

The organization of diagnostic categories has been revised so that the categories are more clearly differentiated from each other.  For example, all disorders formerly in the category of “disorders usually first diagnosed in infancy, childhood or adolescence” have been moved to the category of the diagnosis itself (e.g., attention deficit hyperactivity disorder moved to neurodevelopmental disorders).  In addition, some categories have been divided into two smaller categories (e.g., bipolar and depressive disorders, anxiety and obsessive-compulsive & related disorders) or have been combined differently (e.g., trauma & stressor related disorders).

The category of “Other Conditions” has been greatly expanded to cover some of the conditions previously listed on Axis IV as well as other historical and current situational circumstances that may be relevant to the current treatment.

Diagnostic Changes

There are a number of new diagnoses in the DSM-5 as well as revised criteria for other diagnoses.  Below is a partial list of new diagnoses:

  • Disruptive mood dysregulation disorder (age of onset between 6 and 10 years of age)
  • Persistent depressive disorder (combines dysthymia and major depressive disorder, chronic)
  • Premenstrual dysphoric disorder (previously listed as a condition for further study)
  • Hoarding disorder
  • Excoriation disorder
  • Disinhibited social engagement disorder (differentiated from reactive attachment disorder)
  • Gambling disorder (previously listed as a condition for further study)
  • All disorders in the category of “somatic symptom and related disorders” (renamed from “somatoform disorders” in DSM-IV)

This is a very brief summary of the changes between DSM-5 and DSM-IV.  As mentioned above, you should look closely at the diagnostic criteria for each client’s diagnosis when you begin using the DSM-5 and also look at the listing of categories and diagnoses to see if there is a new diagnosis that fits your client’s symptoms more closely than a diagnosis which is familiar to you from the DSM-IV.

I hope you found this blog to be a helpful introduction to DSM-5.  Please email me with comments, questions or suggestions for future blog topics.

For more information about Dr. Suffridge, visit her website:


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Please visit for more information about our association and membership benefits or to locate a licensed clinical psychologist in Marin County.

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Blog Disclaimer:

The opinions expressed by the authors are their own and do not reflect the opinions of the Marin County Psychological Association. The information posted on this blog is not intended as, and is not, a substitute for professional mental health services.

Your text message made me feel 🙂

Using technology to enhance attachment security 

by Daniel Sonkin, Ph.D.

“I received a text message from my wife, and before I even read it, I smiled!”

John Bowlby’s attachment theory (1969, 1973, 1980) revolutionized developmental and social psychology (Cassidy and Shaver, 2008), and infant mental health research (Beatrice and Lachmann, 2013). More recently both researchers and clinicians have begun to explore its clinical application as well (Wallin, 2007; Fonagy, 2010; Obegi and Berant, 2010).  Attachment theory has become a widely accepted concept, whose clinical appeal has grown over the past decade.  Social and personality psychologists have also been interested in attachment theory, primarily in its application to adult relationships (Mikulincer and Shaver, 2010) and group dynamics (Simpson and Rholes, 1998).  Two particular social psychologists, Mario Mikulincer  and Philip Shaver (2010) through their collaboration, have greatly expanded our understanding of attachment in adult relationships, and in particular, the underlying cognitive and emotional processes that lead to particular attachment behaviors (Mikulincer, Shaver, Sapir-Lavid & Avihou-Kanza, 2009).  What is most fascinating is their research on secure base priming which they have been conducting for the past 13 years (Mikulincer and Shaver, 2001).  The implications of their findings, as well as the methodology they employed, are very applicable to our work as psychotherapists.

Secure Base Priming: In their original study, Mikulincer and Shaver were able to create a research methodology that asks the following question.  Can we alter adult insecure attachment emotional, cognitive and behavioral patterns temporarily, so as to reflect secure attachment?  In other words, can people with insecure attachment temporarily act like they have secure attachment?  The answer turned out to be yes. And this methodology has been repeated many, many times over the past 13 years.   This was done through a process called secure base priming.  Secure base priming has been found to be correlated to a wide range of positive outcomes.  It has been associated with increased compassion, altruism, and openness to different ethnic groups.  It has been found to temporarily increase self-esteem (Carnelley and Rowe, 2010), reduceanger (Dutton, unpublished manuscript) and possibly even protect people from post-traumatic stress disorder (Mikulincer, Shaver & Horesh, 2006). Most of the studies have involved single priming exposure and the changes are generally short-lived (minutes or hours).  There are only a few studies on the long-term effects of multiple priming experiences, which to date look promising (Gillath, Selcuk and Shaver, 2008).

Priming is a form of implicit memory.  It is the mechanism through which we learn things through indirect observation, rather than a focused attempt to develop a skill – though it can also occur via a more deliberate process of attention. Mikulincer and Shaver used both subliminal and supraliminal priming techniques to activate “secure base” mental representations of individuals assessed as having insecure attachment as measured by an empirically validated assessment questionnaire (Fraley, Heffernan, Vicary, & Brumbaugh, 2011).

Typical priming techniques include the subliminal presentation of words (eg, love, hug, etc.) and images (parents and children, couples, etc) on a computer screen.  It may also include visual imagery, such as recalling actual secure base experiences.  In their original priming studies Mikulincer and Shaver also asked subjects to create (make up) a secure base story, which had the same effects as actual secure base memories.  Subsequent studies have included subliminal presentation of the names and images of the subject’sattachment figures.

More recent imaging studies have determined that secure priming does affect particular brain structures, which suggests that secure attachment can be neurologically differentiated from insecure attachment (Canterberry & Gillath, 2012; Gillath, Adams, & Kunkel, 2012).   These studies point to a number of physiological processes in the brain that may give rise to attachment security.  Secure base priming appears to, in part, activate memories (ostensibly of positive attachment experiences) (Quirin, Gillath, Pruessner & Eggert,  2010) in conjunction with the simultaneous activation of structures related to the release of attachment-enhancing  hormones, such as vasopressin, oxytocin and dopamine (Gillath, Shaver, Baek & Chun, 2008).  It is theorized that when the brain is primed to activate positive memories (mental images), feelings and thoughts of attachment, these representations are more readily available when experiencing stress, distress or when there is an opportunity for dyadic soothing or problem-solving (Mikulincer, Shaver, Sapir-Lavid, & Avihou-Kanza, 2009).

Priming and Psychotherapy: Secure base priming techniques are very similar to what naturally occurs in psychotherapy.  Therapists utilize words and their non-verbal expressions to express affection, caring, support and concern for their clients.  They also suggest solutions to specific as well as general problems the client is experiencing.  Often therapists will encourage clients to remember positive outcomes from the past, or imagine positive outcomes in the future (both of which result in the creation of mental images and expectations in the brain).  All of these aspects of therapy both directly and indirectly experientially give clients secure base experiences.  It is the hope of therapists, that these repeated positive experiences will result in change.  One can say that clinicians are exposing their clients to repeated secure base priming.

However, there is a huge difference between temporarily changing attachment representations and/or affect in the laboratory via computer, and doing so in psychotherapy with a real live person.  However, change in psychotherapy can be a long, arduous process that could take years to generalize in outside relationships.  So a critical question is can therapists use the secure base priming research to enhance the security-boosting effects of psychotherapy?

Therapists often recommend adjunctive activities that clients can participate in that support change, such as medication, changes in lifestyle, and mindfulness or meditation training.   Mindfulness meditation, in particular, has been shown to improve mood (reduce depression and anxiety) and promote positivity (states of well-being).  Davidson (2004) found that individuals who meditated for 30 minutes a day, six days a week for two months changed the their activation ratio of their prefrontal cortex  – from favoring withdraw emotions on the right to favoring approach emotions on the left.  This change resulted in reduced anxiety and increased states of wellbeing.  Secure base priming may also be a valuable adjunct to traditional psychotherapy.

Texting Can Make You Happy: In a recent study researchers explored whether texting secure base guided imagery exercises can increase self-reported feelings of “felt security” (Otway, Carnelley and Rowe, 2013).  These researchers expanded the traditional view of felt security – feeling care, love and safety.  They have included an energy component that can best be described as a “subjective vitality as feelings of aliveness and vivacity.”  They differentiate this state as discretely different from an overall sense of positivity (Luke, Sedikides and Carnelley, 2012).  Their rational for this particular experiment was their that it was logistically impractical to prime individuals only in the laboratory.  Due to the wide spread use of smart phones, the researchers decided to explore whether or not texting could substitute for in-lab priming.

Subjects were assigned to either a secure or neutral priming condition before starting the priming process.  During the first exposure (which was conducted in the laboratory), subjects were asked to either write a story about a security-inducing attachment figure or a neutral assignment (eg. a supermarket shopping trip).  Twenty-four hours later, subjects were texted a 3-minute visualization task (either secure or neutral).  Twenty-four hours later, subjects received another text with another 3-minute visualization task (secure or neutral).  And again twenty-four hours later they received another text.  They received a total of five primes over the course of a week every twenty-four hours.  Felt security was measured with a 16-item scale (that was developed by the researchers) which assesses feeling secure and safe (eg, loved), as well as this sense of energy.

The findings were in line with other secure base priming studies.  Secure base priming increased feelings of “felt security” as compared to the neutral primes.  Most importantly, they found that the feelings of felt security stayed active for a number of days.  This is important because it suggests that repeated priming may act as security boosters over time.  The results suggest that texting can be used as an intervention with clients.  CBT therapists have been using texting to facilitate treatment for a number of years now (Aguilera and Monoz, 2011).  Why can’t attachment-oriented therapists do the same?

Secure Base Priming Program: Another way of delivering secure base primes to a client is through the Internet.  The smart phones that are able to receive text messages also have access to online information via a web browser.  I have developed a web site ( that is able to deliver three different types of primes to a user, which can be accessed by the client at any time.  The three priming exercises are words (secure, support, care, etc.), images (mother/fathers and children, opposite and same-sex couples – all of different ethnicities) and guided imagery exercises.  The three guided imagery exercises based on the concept of a Secure Base Script (Waters & Waters, 2006).

“If I encounter an obstacle and/or become distressed, I can approach a significant other for help; he or she is likely to be available and supportive; I will experience relief and comfort as a result of proximity to this person; I can then return to other activities.” 

The first guided imagery exercise is simply an affirmation (saying the secure base script aloud).  The second guided imagery exercise is the creation of a story that reflects the secure base script.  And the third guided imagery exercise is the recalling of an actual secure base experience with a real-life attachment figure.

The web site is the basis of an online research study that will examine the effects of repeated secure base priming on attachment style, mood and relationship behaviors (as measure by the partner of subjects).  Therapists, who are interested in referring subjects, are welcomed to try out the primes themselves and see what effects they may have on their mood and attachment style.

Conclusion: Utilizing technology for enhancing attachment security has potential, but more questions need to be answered before making any claims of beneficial effect to the public.  First, we need to know whether or not repeated priming can have a lasting effect on enhancing attachment security.  We know that the studies date have found short term effects, but it’s not clear whether or not those changes can be sustained over time.  Like most brain-training programs, it is likely that the client will need to prime over a longer period of time in order to experience lasting effects.  Plus, we don’t know if after a specified period, whether or not the effects will begin to plateau or wane altogether.  We don’t know if clients need one type of prime or different types of primes over time.  We also don’t know what types of clients would most benefit from priming.  Most importantly, we don’t know if there are any adverse effects of repeated priming.  All of these questions and more need to be answered through research.  However, in the meantime, there is no question that real relationships can enhance attachment security – this is already been demonstrated though longitudinal studies on attachment (Roisman, Padrón, Sroufe & Egeland, 2002).  Whether or not these effects can be gained electronicly is yet to be determined.

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Aguilera, A., & Muñoz, R. F. (2011). Text messaging as an adjunct to CBT in low-income populations: A usability and feasibility pilot study. Professional Psychology: Research and Practice, 42(6), 472.

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Bowlby, J. (1973).  Attachment and loss: Vol. 2. Separation. New York: Basic.

Bowlby, J. (1980).  Attachment and loss: Vol. 3. Loss, sadness, and depression. New York: Basic Books.

Canterberry, M., & Gillath, O. (2012). Neural Evidence for a Multifaceted Model of Attachment Security. International Journal of Psychophysiology.

Cassidy, J., & Shaver, P. R. (Eds.). (2008). Handbook of attachment: Theory, research, and clinical applications. Guilford Press.

Davidson, R. J. (2004). Making a life worth living neural correlates of well-being. Psychological Science, 15(6), 367-372.

Fonagy, P. (2010). Attachment theory and psychoanalysis. Other Press, LLC.

Fraley, R. C., Heffernan, M. E., Vicary, A. M., & Brumbaugh, C. C. (2011). The experiences in close relationships—Relationship Structures Questionnaire: A method for assessing attachment orientations across relationships.Psychological assessment23(3), 615.

Gillath, O. E., Adams, G. E., & Kunkel, A. E. (2012). Relationship Science: Integrating Evolutionary, Neuroscience, and Sociocultural Approaches. American Psychological Association.

Gillath, O., Selcuk, E., & Shaver, P. R. (2008). Moving toward a secure attachment style: Can repeated security priming help?  Social and Personality Psychology Compass, 2(4), 1651-1666.

Gillath, O., Shaver, P. R., Baek, J. M., & Chun, D. S. (2008). Genetic correlates of adult attachment style. Personality and Social Psychology Bulletin, 34(10), 1396-1405.

Luke, M. A., Sedikides, C., & Carnelley, K. (2012). Your love lifts me higher! The energizing quality of secure relationships. Personality and Social Psychology Bulletin, 38(6), 721-733.

Mikulincer, M., & Shaver, P. R. (2010). Attachment in adulthood: Structure, dynamics, and change. Guilford Press.

Mikulincer, M., Shaver, P. R., Sapir-Lavid, Y., & Avihou-Kanza, N. (2009). What’s inside the minds of securely and insecurely attached people? The secure-base script and its associations with attachment-style dimensions.Journal of personality and social psychology97(4), 615.

Mikulincer, M., Shaver, P. R., & Horesh, N. (2006). Attachment bases of emotion regulation and posttraumatic adjustment. In D. K. Snyder, J. A. Simpson, & J. N. Hughes (Eds.), Emotion regulation in couples and families: Pathways to dysfunction and health (pp. 77-99).Washington, DC: American Psychological Association.

Mikulincer, M., & Shaver, P. R. (2001). Attachment theory and intergroup bias: evidence that priming the secure base schema attenuates negative reactions to out-groups. Journal of personality and social psychology81(1), 97.

Obegi, J. H., & Berant, E. (Eds.). (2010). Attachment theory and research in clinical work with adults. Guilford Press.

Otway, Lorna J., Carnelley, Katherine B., & Rowe, Angela C. (2013). Texting “boosts” felt security. Attachment & Human Development, (ahead of print).

Quirin, M., Gillath, O., Pruessner, J. C., & Eggert, L. D. (2010). Adult attachment insecurity and hippocampal cell density. Social cognitive and affective neuroscience, 5(1), 39-47.

Roisman, G. I., Padrón, E., Sroufe, L. A., & Egeland, B. (2002). Earned–Secure Attachment Status in Retrospect and Prospect. Child Development73(4), 1204-1219.

Simpson, J. A., & Rholes, W. S. (Eds.). (1998). Attachment theory and close relationships. Guilford Press.

Urry, H. L., Nitschke, J. B., Dolski, I., Jackson, D. C., Dalton, K. M., Mueller, C. J., … & Davidson, R. J. (2004). Making a life worth living neural correlates of well-being. Psychological Science, 15(6), 367-372.

Waters, H. S., & Waters, E. (2006). The attachment working models concept: Among other things, we build script-like representations of secure base experiences. Attachment & Human Development, 8(3), 185-197.

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Daniel Jay Sonkin, Ph.D. is a Licensed Marriage and Family Therapist in an independent practice in Sausalito, California. Since 1981, his work has focused on the treatment of individuals and couples facing a variety interpersonal problems. In addition to his clinical experience, he has testified as an expert witness since 1977 in criminal cases where domestic violence is an issue. He has also evaluates defendants facing the death penalty conducting social histories with a focus on their childhood abuse and its impact on adult criminal behavior. He has also testifies as an expert witness in malpractice cases and licensing actions. Learn more about Daniel or contact him through his website:

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Please visit for more information about our association and membership benefits or to locate a licensed clinical psychologist in Marin County.

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Blog Disclaimer:

The opinions expressed by the authors are their own and do not reflect the opinions of the Marin County Psychological Association. The information posted on this blog is not intended as, and is not, a substitute for professional mental health services.

Working with depression 

By Diane Suffridge

“I’m worried about one of my clients who was very depressed and overwhelmed in our last session.  How should I decide whether to call her before our next session?”

This is a common and distressing situation for students in psychotherapy training.  You may find yourself preoccupied with worry and uncertainty about your client’s wellbeing, especially if you are personally vulnerable to anxiety.  Part of the developmental process in clinical psychology training is expanding your focus from alleviating your own distress to evaluating the impact on your client of different interventions.  As behavioral health professionals, our primary responsibility is client welfare so all of our clinical interactions should be centered on that consideration.

Regarding a depressed, overwhelmed client, your first step should be consulting with your supervisor.  This is especially important if you are in your first practicum or field placement setting and you should continue to consult with your supervisor throughout your training whenever you are concerned about a client’s safety.  These situations bring up intense feelings for clinicians and it is hard to be objective in evaluating the most appropriate response when you are caught in the emotional intensity.  Some of us respond to intense emotions by shutting down and minimizing the client’s risk and others of us become agitated and overestimate the risk.

Some of the factors to consider in evaluating your client’s risk, in consultation with your supervisor, are the length of your relationship with the client, whether the client’s emotional state is a change in response to a recent stressor or is more longstanding, how the client has coped or reacted to similar feelings in the past, and what internal strengths and external supports are available to the client.  Clients who are new to you, who are reacting to a recent precipitating event, who use self-destructive or impulsive coping strategies, and have few strengths and supports are at greater risk.  If you are concerned about suicidality, use a risk assessment tool such as the Suicide Assessment Five-step Evaluation and Triage (

If you and your supervisor agree that the client’s risk is high, you should contact the client to make a further assessment.  If the client’s risk is low, you can wait until your next session to do further assessment.  If there is a moderate level of risk, your decision will be based on your understanding of the meaning your intervention will have to your client.  You may contact the client as a way to communicate your care and concern, but the client may experience your call as intrusive and undermining.  You can develop an understanding of your client’s likely interpretation of your interventions based on your knowledge of her/his early experiences with parents and other caregivers and your observations of her/his relational patterns.  A client who experienced neglect and has an expectation that others will be absent and uncaring will respond more positively to an unexpected call from you than a client who experienced abuse and intrusion.  However, because psychotherapy always has the overriding goal of supporting client autonomy and self-determination, it is safer to refrain from initiating contact with a client unless there is a clear reason to do so.

After consultation and consideration of your client’s welfare, you may determine that contact with the client isn’t appropriate but still feel worried.  This is the time to refocus your attention on your own coping strategies and self-care.  Learning psychotherapy involves strengthening your ability to manage intense emotions and placing the client’s welfare above your personal needs.  It also involves differentiating between your relationships with family and friends and your professional relationships with clients.


Diane Suffridge is a licensed psychologist with over 25 years experience training clinicians who are entering the field of psychotherapy, mental health or behavioral health. Her training philosophy is grounded in the belief that becoming a skilled clinician requires integrating what we know and learn in academics with what we feel and intuit when we sit with a client. Learn more about Diane or contact her through her website:

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Please visit for more information about our association and membership benefits or to locate a licensed clinical psychologist in Marin County.

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Blog Disclaimer:

The opinions expressed by the authors are their own and do not reflect the opinions of the Marin County Psychological Association. The information posted on this blog is not intended as, and is not, a substitute for professional mental health services.

(Originally published:

Marin Voice: Challenges of parents of adolescents

By Roberta Seifert, Ph.D. and Mark Phillips

IN THE BOOK, “The Good Marriage,” by the late Marin psychologist, Judith Wallerstein, the section on adolescence was called “Adolescence: A Wolf in Denim Clothing.” She treated adolescence as an almost universal family crisis.

It is a time most parents find challenging that can confront us with problems that are difficult to solve. Even the best parents can find themselves frustrated and self-critical, partly due to unrealistic expectations they’ve set for themselves.

In another book, “Compassion and Self-Hate,” the psychologist Theodore Rubin focused on the illusions we have about who we are supposed to be and what we can accomplish. He included as an example the illusion that if you have enough money you’ll be happy.

Each illusion he describes results in unrealistic expectations that make us self-critical and unhappy.

1. You can and should be able to connect with your adolescent.

Of course you should aspire to this, but you will set yourself up for frustration if you expect it to happen with the same constancy as it may have earlier in your child’s life. Adolescence is filled with complex challenges. No matter how caring and open you are as a parent, your son or daughter may be caught up in relational problems or struggling with internal issues that they’re not ready to share.

They’re also busy developing independence from you and that may create barriers that you just can’t get through until they feel more secure in their newly independent identity.

2. You can (should) always be able to protect your child.

While you do your best to keep your adolescent safe through setting fair and effective rules, there is a limit to what any of us can control. Your teen may usually heed your rules and your advice, but you can’t possibly know all of what is going on internally with your child. And, you have little or no control over what they do with peers or in school.

Parenting is always finding that balance between safety and letting a child grow and learn, even from making mistakes. Finding it is even more difficult in adolescence when kids are making choices with serious risks and consequences.

3. If you are good and caring your children will always feel love for you.

Adolescence is a time of tumultuous emotions coupled with increased idealism and thoughts about how much better they would do things if they only were in charge. Kids at this time seemed programmed to see your quirks and mannerisms as flaws, your sense of humor as boring, your advice as intrusive and insulting.

This can be a normal part of their process of separation and individuation and, while necessary, can be trying for parents.

If you harbor the illusion that there are better families in which children mature without rough patches, you’re doing yourself a big disservice.

4. You can (should) always make the right decisions as a parent.

Even the best parents have bad moments. You may lose your temper, make some unreasonable demand, be insensitive to something that’s delicate for your child.

If you feel you have too many of these moments and are not able to parent as you’d like, it may be helpful to seek counseling about your parenting. Sometimes just getting an objective perspective from someone outside the family can be a big help.

But even if you’re one of the great majority of caring, intelligent, loving parents, you will sometimes screw up!

The bottom line is that while we should always be working to improve within each of these categories, we will never attain anything approaching perfection. Believing that we can insures continual dissatisfaction and unhappiness as parents.

Roberta Seifert, Ph.D. is a psychologist in private practice in San Rafael (visit her website). Mark Phillips of Woodacre is a professor emeritus of education at San Francisco State University. He is a regular contributor to Marin Voice.

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Please visit for more information about our association and membership benefits or to locate a licensed clinical psychologist in Marin County.

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Blog Disclaimer: The opinions expressed by the authors are their own and do not reflect the opinions of the Marin County Psychological Association. The information posted on this blog is not intended as, and is not, a substitute for professional mental health services.


By Annette Holloway, PsyD

Many families are faced with questions about how to best raise children when the adults don’t live together any more. This is particularly difficult when you are feeling angry, hurt or betrayed by the other parent.

You might know in your mind that it’s best for the children if the parents can cooperate about parenting issues, but how do you actually do that when the littlest thing the other person says sets your teeth on edge? And what do you do if you feel that the other parent isn’t treating your child well?

Here are some general guidelines and helpful resources to get you started, if you feel this applies to you.

What you can do

Keep the children out of the middle.

This basic principle covers many situations and can also be a touchstone to consider whenever you are about to do something that involves the kids and the other parent. Keeping kids out of the middle means not using them to carry messages of any kind to the other parent, not bad mouthing the other parent in front of the kids and not using them to find out what the other parent is up to in his or her private life. It’s important to remember that a person can be a good parent even if he or she wasn’t so great at being a spouse. By keeping the kids out of the middle, you avoid asking them to choose between two parents whom they love. Children want to be loyal to each parent; they are in a very painful position if being loyal to one means being disloyal to the other.

Take care of your needs with the help of people other than your children.

You do need to vent about what the other parent said or did, to de-stress after juggling your complicated schedule and to take care of your finances. You need to learn (or add to your) good self-care techniques, and develop a support network or strengthen the one you already have.

But you need to do these activities and learn these skills without leaning on your children for help. They need you to help them manage the changes that are happening in their lives, and over which they have no control.

Children of divorce whose parents can be neutral with each other and who maintain households with totally separate routines and rules usually do just as well as children whose divorced parents cooperate well and interact easily. You don’t need to co-parent by meeting frequently face to face, creating similar schedules and meal routines, and doing things together; some couples can manage to do this but many can’t.

The good news is that co-parenting separately, with different styles and conventions in a “parallel play” style can create just as good outcomes for the children as being more coordinated.

How you can do it

Talk with people who can empathize with you – understanding, nonjudgmental friends, a therapist, a spiritual or religious leader – or write in a journal. Find ways to lower your stress level: exercise, seek beauty, look at interesting things, be in nature, pet an animal, or do something nice for someone else.

Inform yourself about co-parenting by reading a book (“Mom’s House, Dad’s House” by Isolina Ricci or “Parenting after Divorce” by Philip M. Stahl) or taking a class. Two local groups that offer classes specifically about co-parenting are Family Service Agency of Marin (FSA) and APPLE Family Works (492-0720), both in San Rafael.

At FSA, Parenting Apart is a 6-class series that helps parents better understand their children’s experience of divorce, learn skills that promote the healthy development of their children and help manage conflict with the other parent. The class focuses on positive actions parents can take for the benefit of their children (for more information call 491-5723).

Talk to your children about what is happening and ask how they feel about it. Children need to be told explicitly that the separation or divorce did not occur because of anything that they said or did. They also need an age-appropriate explanation about why their parents don’t live together (“We tried to make things work but we couldn’t be happy together, so we separated, but we both still love you” might be appropriate for a preschooler.) These kind of discussions need to occur on an ongoing basis, as their understanding of the world and of people grows.

As a parent, you know your child better than anyone. If you feel like they need extra support to help them adjust to belonging to two households, find appropriate help. Clinics like FSA and APPLE Family Works offer a variety of services at a sliding scale if your insurance doesn’t cover what you need.

Whether you and your child are going through a high-conflict or low-conflict divorce, there are steps you can take to help them do well in the long-term. Your sense of confidence about being a “good enough” parent and your intent to help them negotiate the new status quo will help both of you get through a difficult time more easily.

To contact Dr. Annette Holloway (PSY 25056) call 415/843-1453, or email


Lamb, M. E., & Kelly, J. B. (2009). Improving the quality of parent-child contact in separating families with infants and young children: Empirical research foundations. In R. M. Galazter-Levy, J. Kraus, & J. Galatzer-Levy (Eds.), The scientific basis of child custody decisions (2nd ed.). Hoboken, NJ: Wiley.

Pruett, M., & Barker, R. (2010). Effectively intervening with divorcing parents and their children: What works and how it works. In M. S. Schulz, M. Pruett, P. K. Kerig, R. D. Parke (Eds.), Strengthening couple relationships for optimal child development: Lessons from research and intervention. Washington, DC: American Psychological Association.

Ricci, I. (1997).  Mom’s house, Dad’s house: A complete guide for parents who are separated, divorced, or remarried (rev. ed.). New York: Fireside for Simon & Schuster.

Stahl, P. M. (2007). Parenting after divorce: Resolving conflicts and meeting your children’s needs (2nd ed.). Atascadero, CA: Impact.

Whiteside, M. F. (1998), The parental alliance following divorce: An overview. Journal of Marital and Family Therapy, 24, 3–24.

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Please visit for more information about our association and membership benefits or to locate a licensed clinical psychologist in Marin County.

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Blog Disclaimer:

The opinions expressed by the authors are their own and do not reflect the opinions of the Marin County Psychological Association. The information posted on this blog is not intended as, and is not, a substitute for professional mental health services.

The MCPA Birding Adventure

by Jeffrey Martin, Ph.D.

Snowy Egret

Our day was very successful with curious eyes magically transforming duck ponds into diverse wildlife habitats. The sun was shining bright as were the bright colors and designs on species such as the Green-winged Teal and the Ruby-crowned Kinglet that provided a rare flash of a widely spread ruby crest.  We spotted, in less than 2 hours together at the marsh, at least 35 different species of North American birds. A special surprise was several dozen Cackling Geese.  These look like “miniature” Canada Geese.”  They often hang out with Canada Geese, but are much smaller (perhaps one third the size) and are a separate species (keep your eyes out in the winter for them).  They are only here in the winter, and only a few.

 Northern Pintail

Birds of prey were plentiful, as two Northern Harriers demonstrated their low flying agility in territorial combat with White-tailed Kite and Red-shouldered Hawk. A couple dozen Black-crowned Night Herons spent their daytime dotting the trees nearby. It was also a stress-free day and fun to hang out with colleagues, just for fun, and it was great to meet families.  And the two fruit salads were a great complement to lox and bagels we shared afterwards.  Special thanks to Dan, a birding friend of Jeff’s who brought a 60 power spotting scope, and a crate for the kids to stand on for a good look! 

Cackling Goose (several dozen)

Canada Goose


American Wigeon


Northern Shoveler

Northern Pintail

Green-winged Teal


Ring-necked Duck


Ruddy Duck

Horned Grebe

Eared Grebe

Western Grebe

Great Egret

Snowy Egret

Black-crowned Night Heron

White-tailed Kite

Northern Harrier

Red-shouldered Hawk

American Coot

Black-necked Stilt

Mew Gull

Anna’s Hummingbird

Black Phoebe

Say’s Phoebe

American Crow

Marsh Wren (heard)

Ruby-crowned Kinglet — rare display of fanned out ruby crown

Yellow-rumped Warbler

Song Sparrow

Red-winged Blackbird

Western Meadowlark

House Finch

Get Involved, we need you in MCPA and CPA

Thoughts from Beth Cooper Tabakin, Ph.D.

Have you ever wondered how to increase your professional wellness? One of the answers may be as simple as joining and participating in one of the many offerings of professional activities available to you. Please join me and attend this year’s Leadership and Advocacy Day in Sacramento. Meet other psychologist leaders and learn to advocate and educate legislators about issues of our concern.

A secret to success may be as simple as joining your colleagues in MCPA or CPA.

What is the difference between illness and wellness? ‘LLNESS’ is the same in each word, the difference is illness starts with an ‘I’ and wellness starts with a ‘WE’. Hmmmmm I and we……….

I encourage people who have not participated in their local professional associations to do so. The California Psychological Association acts as the voice of psychology in California.

We need you and you need us. Join your colleagues in one of the many MCPA activities such at a social meet and greet, a CEU activity, hike, committee or list serve to name just a few.

This year, I am nominating Dr. Frederick Luskin to receive  the DISTINGUISHED CONTRIBUTION TO PSYCHOLOGY award from CPA which, if he is chosen, will be awarded at this year’s convention in Newport Beach. The Distinguished Contribution to Psychology award honors a psychologist or non-psychologist who has improved the image of psychology by increasing the public’s understanding of the discipline and/or the profession of psychology. This award is open to all Californians and is intended to promote good will and broader understanding of the field. The person nominated might be a writer (both print and electronic), teacher, manager/administrator, health professional, mental health advocate or the like. The important factor is that the public’s understanding and awareness of psychology is increased in some significant way by the nominee’s contribution. If anyone would like to help me write the proposal, please email me at or call (415)2258683.  The proposal is due by December 10th and I would love to have collaborative input (I to WE).

May you be healthy and happy and enjoy this life we are given.

All my best,

Beth Cooper Tabakin, Ph.D.


Individual, Couple, and Family Psychologist

412 Red Hill Avenue Suite #6

San Anselmo, California 94960

(415) 459-7707

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Please visit for more information about our association and membership benefits or to locate a licensed clinical psychologist in Marin County.

# # #

Blog Disclaimer:

The opinions expressed by the authors are their own and do not reflect the opinions of the Marin County Psychological Association. The information posted on this blog is not intended as, and is not, a substitute for professional mental health services.