Permanent Change: Oxymoron or Possible?

A major advantage of being members of the Society for Research on Adolescence is that we have access to a vast amount of evidence about the social, emotional, and cognitive development of children and adolescents. In addition, we have learned a great deal about the risk factors for dysfunctional development in those areas. Using this information, many educational programs and clinical treatments have been developed that have shown significant pre- to post-treatment decreases in adolescents’ drinking, smoking, and risky sexual behaviors. Unfortunately, many studies that have followed participants over longer periods (6 months to several years) have found that the small to moderate effect sizes tend to dissipate. Perhaps we are missing a piece of the puzzle. Why do these effects often disappear in the longer run? I would suggest that what might be missing is something physiological that interferes with the retrieval of information learned in these programs. Recent research shows that at high levels of emotional arousal, cognitive functioning is disrupted, often inaccessible, resulting in a panic-ridden reversion to over-learned, habitual, and sometimes maladaptive behaviors. In addition, previous attachment research has helped us to understand how these over-learned, habitual, and sometimes maladaptive behaviors develop. I suggest here that we attend to coupling these two lines of research – attachment and physiological arousal – in order to improve the efficacy of our educational and clinical interventions.

Attachment to caregivers in infancy greatly influences the development of individuals’ habitual ways of responding to difficult and arousing situations.  At any age, the attachment behavioral system is activated by stress with the goal of reducing arousal, reinstating a sense of security, and allowing a return to active engagement with the environment. And, early experiences with caregivers have enduring effects on the development of these behavioral patterns and their continuation from infancy through adolescence to adulthood.  Secure individuals in difficult situations are able to regulate high arousal using strategies that involve seeking comfort or self-soothing. The reduction of arousal allows them, in turn, to re-engage with the environment and use their cognitive skills to deal with the difficulty. Secure individuals display prosocial behaviors when interacting with others, even during stressful situations, and are able to continue toward their goals. On the other hand, insecure (avoidant, anxious) individuals in similar situations have difficulty regulating arousal, managing stressful situations, and maintaining exploration and self-confidence in new situations. In stressful and high arousal situations, individuals who are avoidant tend to restrict the communication of anger and distress then withdraw or flee from the interpersonal interactions in which this arousal arose. Anxious individuals become hypervigilant to their own symptoms of arousal and also to the situations in which they experience this high arousal. They heighten their distress and show increased fear, anger, or aggression, thus alienating the very people they hope will comfort them. These response patterns, related to attachment quality (secure-flexibility, avoidant-flight, anxious-fight) from infancy, often become habitual over time and are difficult to alter. The result is that in some situations, particularly highly arousing situations, whether in childhood, adolescence, or later in life, those with insecure attachment revert to their habitual defensive position – fight, flight.  

Many educational programs and clinical treatments have been developed to help individuals learn to alter these habitual responses (aggression, anxiety, fear, withdrawal) and behaviors (drinking, smoking, sexual behaviors, drug use) that individuals may begin in adolescence to manage high levels of arousal. But, as  mentioned above, long-term or permanent changes in these behaviors are rare or difficult to achieve. One reason may be the lack of attention in these programs to the ways that the autonomic nervous system works when individuals are in difficult or highly stressful situations. What follows is a very brief and somewhat simplistic explanation of how this system responds in highly stressful situations. The first response to environmental stress is from the parasympathetic nervous system. Physiological arousal alerts individuals to environmental stressors. If individuals (usually secure individuals) are able to keep their arousal at a manageable level, they can then re-engage with the environment, and use their cognitive abilities to manage the situation. If the parasympathetic system is overwhelmed by the arousal, the sympathetic system kicks in and individuals enact, unthinkingly, their habitual patterns—fight, flight–-which have developed as a result of their attachment (anxious, avoidant) in infancy. The key point here is that individuals in these very stressful situations no longer have access to their cognitive abilities; therefore, they do not remember what they learned in an educational program or from clinical treatment.  But, we also know that for interventions to be effective in permanently changing behaviors, participants must experience high enough levels of arousal within the intervention that their habitual response is triggered. Once triggered in the intervention, individuals can learn how to inhibit these habitual responses (fight or flight), allowing them to access their cognitive processes in times of stress and engage in less habitual, reactive, and destructive behaviors.  Being able to experience and tolerate high arousal in an intervention  once is rarely sufficient, however, to ensure permanent change in these habitual patterns. Intervention that focuses on helping individuals change their habitual ways of tolerating and responding to physiological arousal usually depends on repeated practice. 

What then can be done to help adolescents make decisions in highly stressful situations that might protect them from harm, allow them to have healthy and fulfilling relationships, and continue exploring as they move toward their goals?  One of the most effective interventions developed is the in situ treatment for phobic behavior.  In this type of intervention, individuals are first helped to learn ways to soothe themselves while envisioning what terrifies them; then they are actually taken into these terrifying places (e.g., elevators, planes, outside). The mechanism of change in therapy for phobic behavior is three-fold: 1. Learning techniques for calming arousal, 2. Being in the terrifying place with another person (e.g., therapist, group member), and 3. Tolerating the high arousal by using the calming techniques and remaining in the fearful situation.  Why not a similar intervention for changing habitual patterns of responding (fight, flight) for adolescents facing what might terrify them such as dating, thinking about the future, dealing with angry parents?

The Multiple Family Group Intervention (MFGI; Keiley, 2000-2012) was developed over 12 years ago to help individuals and family members change their habitual responses and access their cognitive functioning. Although our first intervention was with incarcerated adolescents and their families, we have since expanded our focus to couples and non-incarcerated adolescents and families. We focus on several facets of the escalation of physiological arousal and the ensuing interactional cycles that emerge when all family members engage in their own habitual responses – some fighting, some fleeing – as well as how to interrupt these cycles. The process that we use for this MFGI intervention is two-fold:  1) presentation and practice of micro-skills (noting physiological changes, stopping and doing nothing, accessing fear, having empathy, and risking vulnerability) within a group discussion; and 2) role playing.

Within our curriculum, we first focus on managing arousal using the micro-skills mentioned above to decrease the cycles of escalating negative affect. We ask participants about specific physiological experiences that occur when they are feeling aroused. In our group discussion we focus on what the participants fear the most and how the micro-skills might help with managing that fear. The interventionists ask both adolescents and family members, “What has happened recently that really upset you, when you felt a bit out of control or angry?”  Then we talk through the micro skills for managing arousal. For example, do they feel their heartbeat accelerate? Do they feel faint? We explore participants’ abilities to tolerate high arousal. Are they able to stop and find a way to endure intense feelings, rather than either shutting them down or acting them out? Whether they are able to do that or not, we help them find some way to calm themselves long enough to think about the fear that is fueling this powerfully negative reaction. The calming procedures they use may be taking a deep breath, closing their eyes, sitting down, keeping still, or closing their mouths.  The major focus here is how to stop immediately and do nothing for a moment. Participants (and interventionists) often find this process of lowering their arousal during the ‘heat’ of the moment the hardest to implement, given how quickly the neural pathway to the amygdala is activated by arousal. When highly aroused, individuals tend to engage in their habitual responses. For example, secure participants can calm themselves and respond appropriately.  By contrast, insecure participants are more likely to move into a highly aroused panic mode that is not cognitively controlled and that leaves them vulnerable to shutting down, leaving (avoidant), or escalating the coercive interaction (anxious).  Once calm, participants are asked to explore more vulnerable feelings that are related to their arousal. For example, when an adolescent is taunted by a friend about whom he is dating, the adolescent may either confront the friend or storm out of the room. But, it is important for the adolescent to stop and confront the fear that is really fueling his panic-ridden and habitual behavior – fighting or fleeing. Quite possibly, this young man fears that his reputation or social standing is in jeopardy. Once he can calm himself and acknowledge this fear, it is possible to stay in the moment with his friend and talk about his feelings. Feelings of anger and rage help to create disconnection in effect protecting individuals from being vulnerable, while feelings of sadness and fear invite re-connection. Once participants are feeling less aroused and calmed and are thereby able to engage their cognitive skills, we ask them to take another’s perspective by acknowledging the other individuals’ overt affect, which is often anger, and thinking about what the others’ vulnerable feelings might be.  This process allows participants to experience more empathy and respect for the other individuals and their viewpoints.  With this new information, they are better able to risk expressing their own vulnerable feelings, such as sadness, fear, or shame.  The expression of these vulnerable feelings invites others to respond similarly, leading to a re-connection.  When participants are communicating about their more vulnerable feelings and are more connected, they may be able to discuss the problems that have arisen between them, either current or historical and come to some mutual solution. This intervention is geared to helping individuals change the process by which they manage high arousal in order to keep their cognitive skills available, allowing them to use what they may have learned in other programs to make good decisions. In one of our studies (Zaremba & Keiley, 2011), six months after the group, secure participants showed higher adaptive and lower maladaptive affect regulation, fewer externalizing or ‘fight’ behaviors as well as fewer internalizing or ‘flight’ behaviors; insecure particpants also showed similar changes.

After the presentation, discussion, and practice of the micro-skills we move to engaging in role play. Again, we ask participants if a situation occurred recently which they felt they had poorly managed. Recently a father talked about his daughter, who had not attended the group that week, refusing to go to bed when asked. He said that she does this all the time; instead of doing what he asks her to do, she argues with him. And, of course, the father reports that he continues the argument until the cycle escalates to father and daughter yelling at each other. The father reported that this interaction happens a lot and never ends well.

After this discussion, we asked other individuals in the group to role play this situation the ‘bad’ way.  We enact role plays twice. First, we do the role play the ‘bad’ way, meaning that both actors move immediately into habitual ways of responding (fight, flight) that escalate the interaction to very high arousal levels. Second, after discussing the ‘bad’ role play and suggesting ways that the micro-skills could be used in this situation, we have one of the role-players use those skills, allowing the other one to continue in the habitual manner. In this ‘good’ role play, inevitably, the role-player who is not using micro-skills does not escalate in response to the new way the micro-skill role- player is responding. We often have adults play the adolescents and the adolescents play the adults to increase empathy for the other. As facilitators, we have to be unafraid to push the limits in role plays to the point that most participants – role-players and the other group members – feel quite aroused by the escalation.  

Two participants role played the situation between the father and his daughter just as he had described it; all participants in the group agreed that it was very upsetting. These role plays can become quite loud and heart-pounding. When the role play ended, the facilitators and group members talked about what would be the best thing the father in the role play could do. We decided that he should just stop, say or do nothing, and put his hand gently on her arm. When the role-players enacted this scenario, no escalation ensued as the daughter role-player found that she had nothing to fight against resulting in both role-players calming down. After watching this role play, the actual father said, “That won’t work.” Both the other participants and the interventionists, however, encouraged him to try it.  The next week when we asked how the new idea had worked, he said, “I was amazed. When I did that, my daughter couldn’t escalate at all. I gave her nothing to fight against. And she went to bed!”

We conduct the MFGI with about 7-8 families at a time for 1½ hours for 8 weeks. In our 6 month follow-up, we conduct interviews with the participants in our groups. They describe that the end results from the group are that they realize they can survive being very aroused and not get totally out of control. They also learned the skills to calm themselves and use them. They understand more about their own and other people’s responses to arousal and how to keep themselves calm enough to be able to continue thinking, address their fears, experience empathy, and risk moving toward the other in a de-escalated manner.  The interventionists learn a lot as well as they are also invited to suggest problematic situations that they feel they didn’t manage very well to be discussed and role played. Participants and interventionists risk vulnerability together.

I wrote this article to encourage interventionists who work with adolescent populations to consider how using this habitual response to physiological arousal perspective I have presented might be useful in the future. Here are two suggestions. First, consider how individuals from infancy to adulthood manage their arousal when fashioning educational programs or clinical interventions to prevent/treat drinking, drug use, smoking or risky sexual behaviors of adolescents or adults. These behaviors are often the ones that are used to manage arousal that feels unbearable. To allow individuals to ‘keep thinking’ when they are highly aroused, not to move into a habitual response (fighting, fleeing), they must learn how to tolerate and mange the physiological arousal to calm themselves and focus on cognition. Thus, they will be able to access any information they have learned in an intervention and make better decisions about how to deal with the situation. Second, to affect a permanent change in habitual ways of responding, the intervention or educational program must include a way of arousing participants in situ to allow participants to experience high arousal and learn ways to tolerate and manage it in order to make good decisions. Highly arousing role playing works very well in accomplishing just that. By using this habitual response to physiological arousal perspective perhaps more permanent change in interactional patterns and resulting problem behaviors will ensue.

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