My practice, Southeastern Counseling Center, is dedicated to the health of families in the community. The focus of treatment is on disrupting unhealthy inherited family patterns and helping clients design a new future. I take a family systems approach in all my cases, based a thorough assessment, family genogram and gathering of historical information. Attending to the issues of attachment is an important part of that process, as well as identifying the family story/narrative that keeps the history of trauma and unhealthy family patterns in place. With regard to individuals with attachment problems, their stories or narratives are either missing or have gaps (like Swiss cheese), yet they are living at the full affect of their personal histories. It's not so much what happened, but their memory or age-old interpretation of it that sustains the trauma. Whether they remember the incidents that shaped their lives or not, their story of victimization precedes everything they do. I help clients face their past in such a way that heals them from the trauma of abuse, neglect, or break in attachment, thus enabling them to make new choices in the future, as well as alter their sense of the past.

In addition to the above, I ascribe to the entire mission, vision, and philosophy of ATTACh, as listed on its website. I share its commitment to "educating the public about attachment issues in order to improve both prevention and treatment efforts," as well as "recognizing and promoting healthy attachment and its critical importance in human development." In fact, the sum total of my professional experience reinforces and sensitizes me to the importance of attachment in human development. In September of 2004, I traveled to Ecuador for 10 days and worked with 25 mothers and their children from a poor barrio in Manta. In partnership with a psychologist from Rio Bamba, Ximena Valverde, we taught these mothers how to nurture their children and taught them the basics of attachment. Our work has just begun.

The importance of attachment in human development is cross cultural. Fostering attachment among children strengthens communities and helps children connect with their families and the outside world in an authentic manner. As a Spanish speaking attachment therapist, my practice is dedicated to bringing this work not only to citizens of the US, but also to the Spanish-speaking community, both here and abroad. This is my way of promoting world peace.

Target Population:

More than half of my caseload involves treating children, adolescents, and their families. My present focus has been on serving the 0-10 age group, which has been my primary focus for the past twelve years, largely because of my own children: twin girls who are now fourteen years old. However, I continue to work with older adolescents as well, which has been my specialty for the past 25 years. In addition, I do extensive work with adults with attachment problems.

Level of Practice:

A therapist with broad training and experience, much of which is in attachment, who sees clients with mild to severe symptoms, and uses a variety of techniques and modalities, some advanced, for treatment. While I treat a wide assortment of problems in my practice, the greatest focus is working with both children and adults with problems in attachment.

Program/Practice Overview:

The bulk of my services are office-based, although I do provide some therapy in the home, especially in more intensive cases.

My areas of specialization are:

1. Adults, with emphasis on anxiety, depression, and stress management issues.
2. Adolescents and their families, with emphasis on family therapy. Have run adolescent therapy groups in numerous clinical settings.
3. Children, 12 and under, with particular emphasis on attachment and bonding work. Also, help children express anger and other feelings through play therapy, role-play, drawings, and story telling. Perform Child Custody Evaluations. Write court reports and serve as expert witness in child custody situations.
4. Substance Abuse Counseling. Southeastern Counseling Center is licensed by the NC Dept. of Facility Services to provide outpatient counseling to CD Clients.
5. Premarital and Marital Counseling
6. Eating Disorders (a family approach).
7. Family Violence Cases
8. Sexuality and Sexual Identity Issues-Gay and Lesbian Issues
9. Also have a wide range of experience dealing with clients with other Axis I Mental Disorders, such as Bipolar, Borderline Personality Disorder, and Schizophrenia.

Intake/Admission:

I use a standard intake data sheet for completing an intake on all of my clients. It includes demographic data, addresses, phone numbers, presenting problem, family composition, income, previous treatment, insurance information, and any other information necessary in judging the appropriateness of a referral. In the case of certain managed care companies, specific paperwork is required or utilized for both the intake and assessment process, but I always think in terms of my own intake and assessment and try to cover all the bases no matter what format I'm using. I receive referrals from managed cares, insurance companies, The Guilford Center, church organizations, EAP's, mental health centers, schools, and other clients. On rare occasions, clients call in because of seeing my listing in the phone book. In some cases, it is the client himself/herself who calls in and, in other cases; it is someone representing a referral agency. In most cases, no matter what the referral source, I take intake information from clients themselves over the phone before meeting with them the first time. Sometimes, questionnaires are sent out ahead of time, especially when attachment problems are indicated, so that I have the maximum information possible before opening the case. If I feel I am not qualified or experienced enough in dealing with a particular issue, I would refer the client to another therapist or agency. For instance, I don't do intensive work with sex offenders. Therefore, I would refer those cases to someone specializing in that area. Also, I am not equipped to deal with actively suicidal people. Lastly, in the case of a woman, the client may want a female therapist, thus I would refer the case to another clinician.

Assessment:

The last 3 pages of my standard intake data form are used to complete the assessment. This includes initial goals for treatment, mental status, family history, drug and alcohol history, medical history, suicide and homicide risk assessment, physical and sexual abuse history and other relevant factors. I supplement the drug and alcohol history, when substance abuse is the primary problem or when doing a D.O.T. evaluation, with the TAAD (Triage Assessment for Addictive Disorders). In the case of attachment, other tools are used to supplement the basic assessment, such as the attachment symptom rating scale, developmental history, child's biography and parent's biography, or the Life Script by the Evergreen Psychotherapy Center. Furthermore, I sometimes use the subtests in the CHAFCA Manual (Cline/Helding Adopted & Foster Child Assessment), especially the subtest related to sexual abuse.

However, my most effective method of assessing an individual or family is the taking of a family genogram, which is generally completed by the end of the second session. Whatever may have been missed during the completion of the initial assessment is elicited and uncovered during the genogram process, including information about a person's attachment history. I try to ask questions that will fill in gaps in a person's biographic data, as illustrated in my questionnaires. I'm interested in uncovering the unhealthy inherited family patterns in the family and gleaning the family story; that is: the interpretation or meaning that the person or family puts on past events, keeping the cycle of trauma or break in attachment in place. The mere taking of the genogram in this context, often shifts the narrative in a healing way. This is a fairly non-threatening process that allows family members to make connections they haven't seen before and it is common for details to surface that were originally missed in the initial interview, even with regard to issues or problems the client identified as not being relevant at the beginning of the assessment.

Treatment Planning:

My first step in contracting for treatment is having the client or guardian sign a consent for treatment. It addresses what to expect in treatment and has a section on the limitations of confidentiality. It also allows this therapist to communicate with a particular managed care, insurance company, or mental health authority involved in the referral. In addition, I have each client and/or guardian read and sign a statement of understanding, which gives further information on services provided, the assessment and treatment planning process, confidentiality, and mutual expectations for treatment. Since I serve Hispanic clients as well, I have translated both documents into Spanish so that there are no misunderstandings with my Spanish-speaking clients.

The next step is to establish a treatment plan based on identified problems during the intake and assessment phase. In addition to forms sometimes required by respective insurance companies and managed cares, I have a treatment plan form that I consistently use in most of my cases. The first page is a diagnostic face sheet that includes identifying information, family stories that were uncovered during the assessment and genogram process, DSM-IV Diagnoses, long term goals, client strengths, and estimated length of treatment. The second page is broken up into 3 main sections: problem description, goals, and objectives. The goals are stated in specific and measurable terms. Progress toward these goals is reviewed on a periodic basis. The treatment plan is the foundation for treatment. It clarifies what needs to happen for change to occur, as well as who is involved and what their role is in the treatment process is. Both this therapist and the client(s) sign the treatment plan, making it a contract for how treatment will occur and what our direction will be. If I am dealing with a minor, the parent or guardian signs the treatment plan, as well as the minor himself. I feel strongly that the child needs to buy into the contract in some way and thus his/her input is always included. At times, case managers, guardian ad litems, probation officers, and other adults or professionals significant to the child are included in the treatment planning process and also sign and approve the treatment plan.

My basis for soliciting the child's cooperation in treatment, especially in attachment cases is asking him the five questions by Foster Cline (1991) which serve as the basic contract.

1. Are you happy?
2. Are you partly unhappy with yourself?
3. Do you want to work on it?
4. Do you want to work hard?
5. Do you want to work hard my way?

I periodically ask these five questions again when I see the child's investment in the treatment process waning. I will sometimes fire the child from treatment (on a temporary basis) until he/she can recommit to the treatment process. [I will continue to work with the parents while the child stews about the situation]. I find that this has a disruptive and paradoxical effect on most children, as they do not want to be excluded from what's going on.

Other contracts are necessary when holding therapy is involved, such as the Hold-Harmless agreement that I have parents sign when there is a possibility that I might have to touch their child, and the family intensive contract used when doing intensives.

Treatment techniques used:

The work I do is more than just "talk therapy." After gleaning the family story, identifying the historical events that impact the child, and pin pointing the narrative keeping the trauma in place, I can then do the work of treating the trauma and dealing with the impact. I call this treating the family story or the "story of attachment." This involves reframing, debriefing, revisiting and at times reliving traumatic events, but within the context of the safe-container created by the therapeutic team (therapist, parents, caregivers). This is an intimately interactive and experiential process that can be a painful, even for the caretakers, but when completed, helps the individual heal from the past and create a new life. This is not "retraumatization," but a working through of past hurts. It is done in a rational, safe, and compassionate manner that leaves the person whole and complete and able to go on with his/her life. The goal is a close, intimate connection with the caretaker (mother/father/foster parent, etc.), who is able to absorb, accept, and help modulate the child's feelings from the past. It is a process of attunement that binds the child and the caretaker together in a lasting and reciprocal way. Much of my work in healing the family story resonates with the work of Denise B. Lacher, Tood Nichols and Joanne C. May, which is described in the publications Parenting With Stories and Connecting With Kids Through Stories. The parents/caretakers are used to redefine the child's life, past and present, and create a new context for the future. Story telling and retelling is an important part of my work.

Healing the story is effective because all traumas and past hurts occur within the context of language and it is difficult for the individual to remember things before language. Altering the story or narrative alters history, as most hurts live in memory. Yet attachment work is not simply a cognitive process. We are triggered by sensory memories as well. These can be accessed and healed through the interactive and experiential process of attachment work, even for children with low cognitive skills.

Simultaneously, the parents are taught the basics of attachment, e.g. the common sense things that parents do to connect with their child, in "utero" and during the first three years of life. They are taught the language of attachment and attunement that healthy mothers develop early on in a child's development. Nancy Thomas, in her book Love Is Not Enough, reminds us that "by the time the child is seven days old the attachment between the primary care-taker (mother) should be such that the baby's cries and nonverbal communication are clearly understood. (Verny, 1981) Parents are taught the importance of touch, motion, eye contact, warmth nurturing, good diet, humor, play, curiosity and providing a safe environment, where the child feels safe, secure and accepted. They are taught the importance of compassionate and strong limit-setting and consistency. Behavior issues are addressed and pitfalls of the parents' present responses to the child examined. However, the parents are never treated in a judgmental fashion, but rather as key members of the team. The message from the mom or primary caregiver is that "I am big enough, strong enough, smart enough, and willing enough to care for you no matter what!"

Recently, I have been using the "parts work" as presented by Holly van Gulden and Kenny Miller as a useful tool in dealing with trauma. It allows the stronger and better parts of oneself to intervene when more negative feelings arise. I am beginning to use this with both adults and children dealing with posttraumatic stress. I also make use of life books and autobiographies, especially with filling in gaps in the narrative.

Treatment always includes a review of the parents' attachment issues, especially in relation to how they parent their child. We tend to parent the way we were raised and not in some new and transformed way. Thus parents need compassionate help in disrupting the negative patterns they have inherited from their parents, as well as breaking the cycle of hurt and pain. Addressing the parents' attachment issues makes children get better, even if they are not in the room. I spend as much time dealing with parents alone as I do in sessions with the child.

Parental and caretaker holding is often key and necessary to my work with attachment disordered children. I agree with Gregory C. Keck that holding the child or adolescent results in an intensity that cannot be duplicated in any other therapeutic format. He has stated that "therapeutic holdings - not restraint- mobilize development." It produces emotional responses that are unlikely to occur in any other kind of therapeutic intervention.

In most cases, however, I do not do the holding myself as the therapist, except to help the parents secure control of their children, or to demonstrate a safe or appropriate way of holding a child. This reflects a philosophical shift on my part since 1994. My focus is generally on strengthening the child's attachment with the parent(s), or with other appropriate caretakers for the child, such as foster parents, adoptive parents, or nurturing and healthy parental figures from the child's extended family-not the therapist. This is not to say that I don't spend time building my therapeutic relationship with the child. I do. But I consider helping the child develop a healthy attachment with their parent(s) or caretaker(s), or repairing that bond, of the most primary importance, which is why in most cases parents are always present during my sessions. Some attachment therapists do the holding themselves, based on being able to transfer the attachment back to the parents or responsible others. While I consider this valid, it is a circuitous route and I don't see the point of delaying the child's connection to their own parent or primary caretaker. Also, I am concerned that it puts the parents/caretakers in an auxiliary role for that moment in time and unwittingly undermines their power at a time when they should be sharing in a profound attachment experience with their child. Of course, the therapist must make important clinical judgments regarding the suitability of a parent or other adult figure for such an attachment, and then provide education and guidance in the attachment process. It is not my practice to do therapeutic holding when a stable parent or caretaker is not available for the child to attach to. I feel strongly that such stable figures of attachment should be sought and found for every child that is capable of such attachment. Holding must never be done in a punitive or abusive manner. All persons present are responsible for insuring the safety of the child.

The child is often confronted appropriately both in holding and non-holding situations and eye contact is encouraged and often insisted upon. Avoiding eye contact is a way that children "blow their parents off" and resist the attachment process, and, in severe cases, it is necessary to be intrusive in order to make progress and stimulate attachment. Some therapists feel that eye contact is not as necessary as they once thought. I can think of very few exceptions in which eye contact is not important and in my mind they do not justify diminishing its importance. The eyes are the window to the soul and the soul is what gets healed in attachment work.

Especially with young children, I use Martha's Welch's technique for holding therapy. (She is a lifetime member of ATTACh.) It is important that the therapist assess the strength of the child's psychological core before using this method. However, even with kids with a partially formed core, touch and holding can be of benefit to them. Thus, this must be assessed on an individualized, case by case basis. The greatest safeguard is the therapist's and parent's strong attunement with the child.

I accept the definition of holding as defined by Martha Welch, 1988. It is "an intense physical and emotional interaction between mother and child, during which the whole range of feelings are shared and processed until barriers to closeness are dissolved." This is not just holding for the sake of holding. Rather, this is direct synchronous bonding, which both creates and enhances attachment. Neither is this catharsis or simple anger reduction. Direct synchronous bonding allows the mother to connect with the child in such an attuned way that she is able to help the child express and modulate his/her strong feelings in a safe container of love and support. Holding, in and of itself, doesn't necessarily do this. Direct synchronous bonding helps the child form an authentic and profound relationship with the mother which enables him to develop reciprocal and mutual satisfying relationships with others.

Safety/risk management plan:

I go by and accept ATTACh's guidelines and principles for "monitoring and safeguarding the psychological, emotional, and physical well-being of everyone involved in the intervention process." This is also reflected in my written contract when holding therapy is used. I had been operating under similar principles before ATTACh's guidelines were released. Consequently, in all the years that I have been doing attachment work, I have never harmed a child during one of my holding sessions and no child's life has ever been threatened under my care.

I accept the touchstone that underlies all of ATTACh's safety principle, which is "to do no harm." I accept all of ATTACh's principles for safety and agree that "everyone involved in the intervention process with a child and family is expected to use good clinical judgment coupled with common sense" and I find the accompanying questions suggested by ATTACh helpful in dealing with all safety sensitive situations, both anticipated and non-anticipated.

My best insurance in reducing safety risk is to make sure I don't operate in an isolated manner and that I am never too arrogant about what I do. I'm open with all significant others, professionals, foster or group home parents, and agencies-anyone connected with the case-regarding my approach, the risks involved, and why a particular intervention is being used and what I hope to accomplish. I don't proceed unless all parties are in agreement and releases are signed. I make it a practice to get ongoing supervision for what I do, especially with regard to my attachment cases. At present, I get monthly or bimonthly supervision from Diane Feinberg, M. Ed, attachment and bonding specialist, related to my attachment therapy cases. In addition, I am in absolute partnership with my families in attending to safety issues and making sure the child is "never restrained and has pressure put on them in such a manner that would interfere with their basic life functions, such as breathing, circulation, temperature, etc." This is a principle I have always adhered to and which I consider to be in the realm of "common sense." I never cover the head of a child or allow them to be held in any way that would impede breathing. During a hold, I frequently check the hold to make sure the child is not being hurt. Often a child will complain even if he isn't being hurt, but I still check out their position and sometimes exercise the limb with alleged pain.

Evaluation/outcomes/follow-up:

I have already explained in detail the initial evaluation process. Outcomes are measured in terms of the treatment plan. Treatment ends when both the therapist and clients agree that goals have been achieved. This is measured and assessed in clear and concise behavioral terms. I ask clients to fill out satisfaction questionnaires on a periodic basic basis during and after treatment to get an overall sample of client satisfaction in general. It allows for further comments, which are useful and helping me be attuned to the concerns of my clientele. In addition, several of the managed care companies who refer me clients have their own versions of satisfaction surveys and these are used to rate me as a therapist with the managed care.

Qualifications of staff:

The only staff person of my agency/private practice is myself, Louis M. Di Eugenio, LCSW. However, at times, I do co-therapy with outside therapists, including family intensives with attachment disordered children.

I have a Masters Degree in Social Work from the University of Denver, Graduate School of Social Work (1979).

My attachment work related training is as follows:

1. From 1981 to 1982, while I was on the Family Treatment Team at Jefferson Country Social Services in Lakewood, CO, Ray Curtis from Forest Heights Lodge was a consultant to our team. He is the one who initially introduced me to attachment theory, gave us handouts and trainings, and helped us apply those principles to our cases. The focus of the family treatment team was to prevent adolescents from having to be placed out of the home. We worked with high-risk cases in which there were at least two treatment failures prior to coming to us. 75% of our time was spent keeping kids out of out-of-home placements, 25% was in getting them home earlier than expected.

When I worked in a residential treatment center for adolescents in California, I began to apply the principles Ray Curtis taught me in that setting. We had many children whose behavior became out of control (sometimes physically aggressive) and who ultimately had to be restrained in order to bring them back into control. While I was down on the floor with them, holding them with other team members, I took them through the attachment cycle. This allowed me to see how the attachment cycle worked first hand and I have used attachment theory ever since to help me understand the children I work with.

In terms of formalized course work, I will start with the most recent and work back.

1. "Parenting The Hurt Child"-presented by Gregory Keck, Henderson Co. Library in Hendersonville, NC on May 20, 2005
2. "Pathways to Healing: The Role of Attachment in Families"-presented by numerous leaders in the Attachment field at the ATTACh Conference in Richmond, VA, on Oct. 3-6, 2004
3. "Rebuilding the Broken Bond" presented by Nancy Thomas and "The Neurology of RAD" presented by Dr. James Lee, at the Covenant Presbyterian Church in Charlotte, NC on March 19 & 20, 2004
4. "Reactive Attachment Disorder: Assessment and Diagnosis in the Treatment Planning Process-presented by Bill Goble, Ph.D. & sponsored by WNC ATTACh in Asheboro, NC on Nov. 10, 2003
5. "Attachment Therapy: Current Trends in the Diagnosis and Treatment of children with Trauma-Attachment Problems," presented by Arthur Becker-Weidman, Ph.D., at Holiday Inn, Research Triangle Park, February 7, 2003.
6. Parenting Children with Trauma-Attachment Problems," presented by Arthur Becker-Weidman, Ph.D., at Holiday Inn, Research Triangle Park, February 8, 2003.
7. "Understanding and Treating Reactive Attachment Disorder (RAD)," presented by Kenneth Miller, ACSW, CISW, at the Holiday Inn Brownstone Hotel, Raleigh, NC, Nov. 12, 2002.
8. "20-hr. study group on attachment" with Jaclyn Claes, Ph.D., full professor at UNCG School of Social Work and Chair of the NC Social Work Certification and Licensure Board, from Fall 2001 to Fall 2002.
9. "Understanding The Complexity of Attachment & Bonding Therapy," sponsored by the NC Attachment consortium and North Carolina ATTACh, 4-day workshop with Daniel A. Hughes at the Drury Inn, Greensboro, North Carolina, November 28, 2002 to December 1, 2001.
10. 13th Annual International Conference on Attachment and Bonding in Greenville, SC, October 3-6, 2001.
11. "Attachment Disturbed Youth: A Developmental Approach To Understanding Emotional and Behavioral Difficulties," presented by Jim Fitzgerald, Director of Operations, Intermountain Children's Home in Helena, Montana, all day workshop, sponsored by the Children's Home Society of North Carolina, Greensboro, NC, September 25, 2000.
12. "Treatment For Children Who Cannot Love," by Diane Feinberg M., Ed., Psychotherapist and Attachment & Bonding Specialist, all day workshop, Thursday, Sept. 21, 2000 at the Courtyard Marriott Hotel in Winston-Salem, NC.
13. "Troubled Transplants," presented by Richard J. Delaney, Ph.D., sponsored by the Children's Home Society of North Carolina, Greensboro, NC, all day workshop, April 6, 1995.
14. "Clinical Issues and Adoption," presented by Francie Rieser, MA, and sponsored by The Children's Home Society of NC at Oak Tree Family Enrichment Center, August 1994.

Supervision hours (specific to attachment):

1. Monthly and bi-monthly supervision by Ray Curtis, Forest Heights Lodge, from 1981 through 1982 (18 mos. total) which included daily peer supervision by the family treatment team, Jefferson Co. Social Services, Lakewood, CO with observation behind the one-way mirror (Greek Chorus Method).
2. Weekly peer supervision by the family treatment team, including observation behind the one-way mirror, Oak Tree Family Enrichment Center, April 1991-Sept. 1994.
3. I have been receiving ongoing monthly/bimonthly supervision as needed (depending on the size of my attachment caseload) from Diane Feinberg M.,Ed. since April 2001.

Supervision and Consultation Plan:

I will continue to seek ongoing supervision from Diane Feinberg M., Ed. for my attachment related cases.

I use the following individuals for consultation and supervision on other therapy related issues:

1. Dr. John Edwards, Ph.D. and Dr. Barry Bricklin, Ph.D. for consultation regarding forensic cases.
2. Dr. Susan Stewart, Ph.D., for general client related issues.
3. Deb Young, CCAS, for substance abuse related issues.

Awards:

1. Social Worker of The Year, March 1995-presented by Guilford County Programmatic Unit of NASW-NC
2. Clinical Social Worker of The Year, March 2003-Presented by the Piedmont District Programmatic Unit of NASW-NC

Professional Membership:

1. National Association of Social Workers (NASW)
2. Registered Clinician, Member of ATTACh