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Counseling Adolescents Diagnosed With Conduct Disorder: Application of Emotion-Focused Therapy for Individuals.

According to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013), conduct disorder (CD) is characterized by a cluster of symptoms including destruction of property, violation of the rights of others, and hurting people or animals. The most effective approach to support clients diagnosed with CD involves multifaceted assessment and interventions (Barry, Golmaryami, Rivera-Hudson, & Frick, 2013; Cone et al., 1995; Frick, 2001). Counselors can utilize an emotion-focused therapeutic model as part of the treatment plan to target the emotions causing the maladaptive behaviors and negatively impacting relationships. Emotion-focused therapy for individuals (EFT-I) is one emotion-focused therapeutic model utilized by professional counselors that combines the core principles of person-centered therapy, experiential interventions, and attachment-based corrective experience processing to support clients in exploring emotions and their impact on behavior and relationships (Brubacher, 2017; Diamond, Shahar, Sabo, & Tsvieli, 2016; Greenberg, 2004, 2010; Johnson, 2009). From this perspective, clients process their emotional experience as the modality of change in the counseling relationship (Pascual-Leone, Yervomenko, Sawashima, & Warwar, 2017). This form of individual therapy in combination with other services integrated into a versatile treatment plan can create a blend of services that are particularly helpful for adolescents with CD.

The problem behaviors stemming from CD often cause significant ruptures in relationships, which is the rationale for using a therapeutic modality that relies heavily on person-centered counseling tenets (Diamond et al., 2016; Greenberg, 2002, 2004; Johnson, 2009, 2013). Research demonstrates the efficacy of emotion-focused therapy with a variety of issues, including depression (Greenberg, 2017), social anxiety (Shahar, 2014), and children with emerging conduct issues (Havighurst et al., 2015), suggesting it is a viable approach to addressing challenging emotion-based problems. This manuscript will describe the utility of EFT-I with adolescents diagnosed with CD receiving treatment in a residential facility. The combination of relational and emotional focus in this therapeutic model targets the primary distresses associated with individuals diagnosed with CD.

ADOLESCENTS DIAGNOSED WITH CONDUCT DISORDER

The DSM-5 defines CD as "a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated" (APA, 2013, p. 469). It is important to distinguish between CD as a general pattern of behavior and CD as a clinical diagnosis; careful consideration must be given to the functionality of the behavior in the environmental context (Von Sydow, Retzlaff, Beher, Haun, & Schweitzer, 2013). In a population-based nationally representative cross-sectional survey conducted by A. Moore, Silberg, Roberson-Nay, and Mezuk (2017), the prevalence of youth with "life-course persistent" symptoms of conduct disorder was 1.9% for female and 5.1% for male respondents (p. 439). Youth with life-course persistent symptoms of conduct disorder were also found to have greater odds of developing substance use disorders compared to youth with adolescence-limited conduct disorder (A. Moore et al., 2017).

Outpatient clinics, residential treatment centers, schools, and inpatient facilities are some of the mental health settings where youth diagnosed with CD receive counseling services (Von Sydow et al., 2013; Lynch, Teich, & Smith, 2017). In broad terms, CD is a pattern of behavior exhibited by an individual who harms property, persons, or animals; this pattern is habitual and displayed in many domains of the youth's life (Von Sydow et al., 2013). Due to these severe behavioral disturbances, the systematic effects of CD are evident in the far-reaching damage that can be caused, characterized bv violation of the rights of others. One of the most common methods of assessing CD is a multi-informant approach that seeks to include input from settings across the youth's life (Barry et al., 2013). The most effective forms of treatment for CD currently involve multifaceted interventions that include supporters in multiple settings of the youth's life working in a consistent manner (Barry et al., 2013; Borduin et al., 1995; Cone et al., 1995; Frick, 2001; Scherer, Brondino, Henggeler, & Melton, 1994; Von Sydow et al., 2013).

RESIDENTIAL TREATMENT FACILITIES FOR ADOLESCENTS WITH CONDUCT DISORDER

Due to the pervasive and extreme impact that the symptomatology associated with CD can have on the community and the family unit, many adolescents with CD require treatment outside of the home and are referred to residential treatment facilities for more intensive services (Sternberg et al., 2013). Although there is no consensus definition of residential treatment facilities in the United States (Lynch et al., 2017), these facilities do share common characteristics including 24-hour monitoring, individual treatment plans, trained staff, and services to populations that tend to have severe emotional and behavioral disturbances. The shared characteristics create a treatment setting that serves youth at a higher level of need than outpatient or in-home services, but a lower level of need than psychiatric hospitals (Lynch et al., 2017). In general, residential treatment facilities distinguish themselves from inpatient hospitals because they do not have 24-hour on-site medical care from nurses and primary care providers (Lynch et al., 2017).

For a facility to qualify as a residential treatment center, the primary criteria for admittance for more than half of the youth served must be mental illness or emotional disturbance classified by a clinical diagnostic manual such as the DSM-5 or the International Classification of Diseases, 10th edition, excluding the diagnosis of intellectual disability, substance abuse, or developmental disorders (Substance Abuse and Mental Health Services Administration [SAMHSA], 2016). The type of intervention provided through residential treatment is the most restrictive and expensive psychiatric intervention available due to the intensity of services and the length of stay (Boel-Studt, 2014; Pecora et al., 2010). Aggressive behavior, mental health, and safety concerns are the most frequent reason for admission into a residential treatment facility (Holtberg, Olson, & Brown-Rice, 2016; Sternberg et al., 2013), mirroring the symptoms associated with CD, which include harm to others, animals, and property that cause a significant threat to the safety of others (APA, 2013). Residential treatment facilities are one of the primary treatment settings for youth diagnosed with CD to maintain the safety of the family and community throughout the treatment process.

CHALLENGES OF YOUTH WITH CONDUCT DISORDER IN RESIDENTIAL TREATMENT

In traditional models of residential care, youth diagnosed with CD are placed in facilities to help manage or control the disruptive behavior in a safe environment (Lynch et al., 2017; K. Moore, Moretti, & Holland, 1997). These programs rely heavily on behavioral modification strategies such as token economies and point systems to decrease undesirable behavior and increase desirable behavior (Leichtman, 2008; K. Moore et al., 1997). For youth diagnosed with CD, this increased restriction of autonomy, coupled with authoritarian figures with whom the youth have no prior relationship, can exacerbate feelings of helplessness and negative behavior (Lynch et al., 2017; K. Moore et al., 1997). Even when youth learn to adapt successfully in the residential treatment facility, many of the behaviors do not translate back into the community when they are discharged, because the behaviors were learned in a restrictive environment that does not mirror the home environment (Lynch et al., 2017; K. Moore et al., 1997). Instead, utilizing a treatment modality that uses a "bottom-up" approach instead of a "top-down" approach to support youth in regulating their emotions would increase their self-efficacy (Greenberg, 2004) in adapting the strategies learned in the residential treatment facility back into their home community.

EMOTION-FOCUSED THERAPY

Emotion-focused therapy for couples (EFT-C) is one of the most empirically validated and effective forms of intervention in couples counseling (Johnson, 2004; Johnson, Hunsley, Greenberg, & Schindler, 1999). The work of Johnson and Greenberg (1985) created the foundation for a couples therapy that focused on reciprocal emotional experience and emphasized the use of experiential interventions in session to repair relationship (attachment) ruptures (Johnson & Greenberg, 1985). This couples therapy eventually led the way for additional scholar-practitioners to utilize the same type of emotion-focused and experiential intervention-based treatment in individual therapy (Elliott, Watson, Goldman, & Greenberg, 2004).

Emotion-Focused Therapy for Individuals

EFT-I (Greenberg, 2002, 2010) uses person-centered principles such as unconditional positive regard, empathy, and genuineness combined with experiential techniques drawn from Gestalt therapy and other experiential treatment modalities (Diamond et al., 2016). Researchers have empirically validated EFT-I with individuals experiencing anxiety, trauma-related distress, and depression (Greenberg, 2004). Brubacher (2017) is one of the more recent scholar-practitioners to integrate the work of Johnson (2009, 2013) with neurobiological-based emotional regulation research (Shaver & Mikulincer, 2014) to demonstrate the applicability of emotion-focused therapy in an individualized format. Brubacher (2017) draws heavily from attachment theory (Bowlby, 1969/1982) and postulates that humans are wired to co-regulate emotional experience. By focusing on emotions, thus increasing capacity' to effectively regulate emotions (Shaver and Mikulincer, 2014) and engagement with others (Brubacher, 2017), this type of emotion- and relationship-focused intervention could impact some of the most prominent symptoms in CD (Diamond et al., 2016; Mikulincer & Shaver, 2016). Integrating this type of intervention into the multifaceted treatment plan as an individual form of therapy is one way of supporting clients in creating more adaptive relational patterns before they become entrenched and more difficult to change.

From the perspective of Johnson (2009, 2013) and other counselors practicing emotion-focused therapy (Brubacher, 2017; Greenberg, 2004), how we regulate our emotional experience is the core of what brings individuals into counseling. Through therapy, the counselor works to support the client in trusting the emotional experience and the feelings that accompany it (Greenberg, Rice, & Elliot, 1993), and by trusting feelings, the client is able to be in relationships with others. In session, this may look like using reflection, summary, and exploration of relationship patterns (Greenberg & Paivio, 1997; Von Hockauf, 2011). Counselors may also support the client to find an antidote to their distress (Greenberg, 2004), assess for trauma, and bring awareness to the client's core attachment strategies (Greenberg & Paivio, 1997; Von Hockauf, 2011). After attachment patterns are explored and refrained as adaptive strategies for handling distress, the client and counselor transition the focus of counseling to restructuring the attachment style (Johnson, 2004).

Addressing Conduct Disorder's Relational/Emotional Impacts

Blair, Leibenluft, and Pine (2014) noted that youth with CD may have an increased sensitivity to perceived threats, may demonstrate difficulties in decision-making and decision flexibility, and may have experienced inconsistent or limited caregiver supervision. These traits and early childhood experiences all make interpersonal relationships difficult for people interacting with youth with CD and are an additional justification for a therapeutic modality that focuses on relationships and emotions.

Relational impacts. Emotion-focused therapy describes wellness as the ability to listen and engage with emotions and to trust inner experiences (Johnson, 2009, 2013). The behavioral and emotional strategies utilized by individuals to deal with emotions can either facilitate engagement with others or push others away. The symptoms of CD can be seen as behaviors rooted in maladaptive ways of relating to others, behavioral and emotional strategies that push others away. Parents of youth with CD report their children have difficulties getting along with others and have few friendships (Green, Gilchrist, Burton, & Cox, 2000). Individuals with CD have the potential of creating deeplv embedded emotional and relational problems, such as those seen in individuals diagnosed with antisocial personality disorder (APA, 2013; Borduin et al., 1995; McKenzie & Lee, 2015; Scherer et ah, 1994). These maladaptive ways of relating to others are among the primary foci when utilizing EFT-I as the individual treatment modality (Brubacher, 2017; Greenberg, 2004). This focus is important due to the severity of the symptoms, since youth who do not receive proper treatment are at an increased risk of incarceration (Borduin et al., 1995; Henggeler, Melton, & Smith, 1992). Understanding the social impact that youth diagnosed with CD have on their family, community, and school settings is imperative for proper diagnosis and treatment interventions (McKenzie & Lee, 2015).

For an adolescent diagnosed with CD, counselors can utilize the therapeutic relationship to explore relational patterns. For example, a client may steal from the counselor or break something in the office during a session. This would give the counselor the opportunity to react intentionally to attend to the needs of the client and create a dialogue that avoids shaming or creating distance in the relationship, instead supporting emotional engagement and relationship building (Brubacher, 2017; Mikulincer & Shaver, 2016). The counselor can also facilitate corrective experiences through the enactment of speaking with an "imaged other" and "addressing images of their primary caregiver" (Brubacher, 2017, p. 63). These dialogues allow the client to express emotions, become aware of the underlying attachment needs associated with the expression of those emotions, and work to transform their emotional cycles into positive experiences that promote emotional regulation (Brubacher, 2017).

Emotional impacts. The focused use of experiential techniques in EFT-I is designed to elicit emotions that are being expressed in a maladaptive way and support the client in transforming them into an adaptive emotional response (Diamond et al., 2016; Taylor & Lewis, 2018). For adolescents diagnosed with CD, externalizing behaviors such as violating the rights of others, destroying property, and harming animals can all be conceptualized as hyperactivation of emotions (Mikulincer & Shaver, 2016). Adolescents with CD often display a lack of empathy and poor treatment of others for the purpose of personal gain (Rowe et al., 2010). The role of the EFT-I counselor is to facilitate a corrective experience that supports clients as they practice alternative ways of being through the expression of emotions (Johnson, 2009, 2013). In therapy, the counselor uses empathic reflection, validation, and evocative questions to facilitate the client's awareness of their automatic coping patterns and create a space where the entire spectrum of the client's emotional experience is safe to express in therapy (Brubacher, 2017).

Brubacher (2017) echoed the work of early individual EFT scholars reiterating that the process of change in counseling is to identify patterns associated with emotion regulation and create corrective experiences that can shift the emotions in the identified patterns (Brubacher, 2017; Greenberg, 2004). Brubacher's (2017) work differentiates itself from early individual EFT theorists by emphasizing the work of the counselor in co-regulating with the client in session. Brubacher noted the importance of having the counselor embody the role of an attachment figure in counseling sessions; this focus is supported by the work of Shaver and Mikulincer's (2014) neurobiological-based research on emotional regulation. Since individuals in residential treatment facilities do not have consistent access to primary caregivers, the treatment team could utilize this type of emotion-focused therapy to support wellness and address the emotion regulation challenges associated with CD. By creating a healthy attachment relationship with the counselor, youth in residential treatment facilities could learn to trust themselves and others in a safe and supportive environment. Much as in EFT-C, this newfound trust is then used to engage in healthy relationships outside of the counseling relationship (Brubacher, 2017; Johnson, 2009).

Outcomes for Youth With Conduct Disorder

Youths are referred to mental health professionals for CD and oppositional defiant disorder more frequently than other mental health issues (McKenzie & Lee, 2015). Often, youths diagnosed with CD come into contact with many social service agencies, including special education, mental health, and juvenile justice, and due to the multitude of services associated with this diagnosis, it is one of the costliest in the United States (Von Sydow et al., 2013). Youths are referred for behavior including, but not limited to, aggression, property destruction, and defiance; these can have serious impacts on their home, school, and community (McKenzie & Lee, 2015).

Without effective treatment, youth with CD have poor outcomes. Frick (2012) noted that CD can predict future issues related to poor mental health, legal concerns, school dropout, and employment problems. In their metaanalysis of 40 studies on CD outcomes, Erskine et al. (2016) found that those with the diagnosis were connected with substance abuse, early pregnancy, poverty, and incarceration, all of which not only affect the individual but also their family and social network. They recommended long-term and comprehensive treatment to combat these outcomes.

By utilizing an emotion-focused therapy ("bottom-up") instead of a "top-down" therapy like solution-focused or cognitive-based therapy for youth diagnosed with CD, the counselor can dive deeper into the multiple aspects of the presenting patterns instead of attending to the presenting behavior or cognition. K. Moore et al. (1997) expressed a concern that youth receiving treatment in residential treatment facilities tend to learn to live in an institutional setting fairly well, but the behavioral techniques and rigid structure of those facilities often do not translate to improvement in the community. By utilizing a therapy that does not focus primarily on behavioral change that is stimulus (environment) driven, but instead on emotional awareness and increasing adaptability' in multiple situations, counselors can support clients in learning more adaptive ways to thrive in and outside the walls of the treatment facility. EFT-I addresses the presenting issue by focusing on the connection to attachment needs, emotions, perceptions, and behaviors as the client and counselor bring awareness to the cyclical nature of attachment strategies (Brubacher, 2017; Elliott et al., 2004; Johnson, 2009). The case illustration below demonstrates how EFT-I might be employed with an adolescent with CD.

CASE ILLUSTRATION

Terrance is a 14-year-old African American youth who was recently admitted into the residential treatment center where Monica works; he has a diagnosis of CD, unknown onset. Terrance has three younger sisters and an older brother who live in the home with him. His mother works full time and spends the evenings focused on completing an online degree in teaching. She has little energy to attend to Terrance or his siblings in the evening because her schoolwork is demanding. Terrance's father works nights; when he is not working, he is sleeping during the day and is strict about the home being quiet while he tries to sleep.

Terrance only receives attention from his mother or father when he is in trouble. He has started to hang out with a group of teenagers down the street and has little adult supervision outside of school hours. Terrance does not earn good grades in school and is often distracting to other students. Most recently, he was caught stealing from other students and broke a computer at school when he was asked to turn it off. Terrance was transferred to the local alternative school where he was having trouble adjusting to the stricter rules.

Assessment for Conduct Disorder

Terrance's mother describes his behavior for the past year and a half as "out of control." Terrance got in trouble for stealing from a local convenience store, and the judge required him to attend six therapy sessions. The community mental health counselor decided to assess Terrance for CD by asking Terrance's teachers and mother to report on trends in his behavior over the past year. It was confirmed from the multi-informant assessment that Terrance met the criteria for CD. Approximately a month after starting outpatient treatment, he chased one of his sisters around the house with a knife. Police became involved, and a mobile crisis team also was brought in to evaluate Terrance's mental state. They determined he was an imminent danger to himself and others, and so he was admitted to a short-term inpatient psychiatric hospital. After stabilization, his treatment team determined that residential treatment was the safest treatment option for Terrance and his family. Terrance meets Monica after his arrival at the residential center.

Early Stages of Therapy

When Terrance arrives in Monica's office, he is angry that he needs to be at the residential center. He walks in loudly and proclaims that "this place is shit" and "I do not belong here with all the crazy people." Monica validates his feelings of anger and frustration: "I can tell by your voice and your words that you are angry about being here, and you feel like you don't belong." Terrance responds by crossing his arms and nodding his head. The first part of EFT-I is establishing a working alliance with the client and building trust to explore emotions (Brubacher, 2017; Greenberg, 2004; Johnson, 2009). Monica asks Terrance if he would like to play a game and spends the therapy hour playing Uno and talking about what he enjoys doing. The next two sessions follow a similar pattern, with Terrance given autonomy to choose what is talked about in the session and Monica starting to learn about his patterns of relating to others. The focus of the reflections and summarizations is on Terrance's emotions to begin to bring awareness to his attachment patterns and increase secondary emotion awareness (Brubacher, 2017; Greenberg, 2004; Johnson, 2009). During these initial sessions, Monica pays careful attention to her nonverbal communication, ensuring she is facing Terrance, displaying open body language, and utilizing minimal encouragers like head nodding when he speaks. These behaviors help demonstrate to Terrance that Monica is listening without judgment. Prior to the fourth session, residential staff tell Monica that Terrance got into trouble for punching a wall and throwing a chair when a staff member told him to get off the phone. Monica begins the next session by discussing this event.

Working Stages of Therapy

Monica opens the session by saying, "So I was wondering if we could begin by talking about what happened earlier today on the unit." Terrance responds by recounting the factual information: "I was on the phone, a staff member told me to get off, I got mad, so I hit the wall." Monica responds empathetically by summarizing what he says and ends with an evocative question (Brubacher, 2017), "I'm wondering what you were feeling when the staff member told you to get off the phone." Terrance pauses and has a very difficult time recalling an emotion besides anger. Monica asks him to close his eyes and imagine the interaction happening again. She sees his fists ball up and his body become rigid. "Terrance, can you tell me what you feel in your body right now?" He responds that his heart is racing, and he feels like he is going to explode. In a soft tone, she asks him to open his eves, and Terrance sees Monica is sitting in an open posture, slightly leaning forward to indicate she is attuned to his experience. Terrance remembers that he is in a safe space with a person who cares for him. Monica facilitates emotional awareness while she and Terrance sit together with his feelings. After a moment, he looks away and asks to talk about something else. Monica uses empathic interpretation and states that he feels uncomfortable sitting in his anger. Terrance softly sighs, and she sees shame flash across his face. She states that when he gets that angry and has trouble controlling it, he is ashamed of his behavior. Terrance slowly nods his head. Monica gently explains that emotions serve a purpose and that the work that he is doing in therapy will help him understand his emotions better. She smiles slightly and encourages him to stick with it, reassuring him that she is there to support him.

Over the next 10 sessions, Monica works with Terrance to explore his emotions in session by using visualization and empty chair and by utilizing a time in session when he was angry at her for "promising" to take him outside but ended up being unable to because the weather was too cold. She supports Terrance as he explores the patterns of his emotions and those of his caregivers. They spend time talking about how those around him express or suppress their emotions, and the impact that has had on Terrance's emotional experience. Terrance incrementally begins to see that he feels more than the singular emotion of anger. The more he can reflect on his experience and relive it in the counseling session with a supportive attachment figure present, the more he is able to express primary emotions like shame, fear, hurt, and joy. Monica creates a space to have corrective emotional experiences where Terrance can attend to his unmet needs (Brubacher, 2017).

Final Stages of Therapy

During the final months of therapy, Monica works with Terrance to connect the emotional experiences he has processed in therapy to feelings of self-worth and trust in others to attend to his needs. In a telephone family session, Terrance practices asking his mother and father to spend one-on-one time with him to address his need to feel loved and cared for. He explores how to reframe negative expectations of his social interactions with teachers and peers so that he can better understand how his behavior was eliciting the response from those around him that he feared most, isolation. Together, Monica and Terrance work to create a plan for him to begin to show vulnerability in his relationships with others and express the need for connection in a more adaptive way. Monica ensures throughout the counseling relationship that her nonverbal behaviors such as eve contact, body posture, tone and volume of voice, and facial expressions indicate to Terrance that he is welcome and that she is attuned to his experience without judgment. Terrance ends therapy with a deeper understanding of how his anger was pushing others away from him, an increased ability to regulate and tolerate a range of emotions, a deeper awareness of the origin of his anger, and a trust in his own emotional experience, which is the first step in beginning to trust others again.

DISCUSSION AND IMPLICATIONS

The above case illustration highlights many of the key aspects of EFT-1 (Brubacher, 2017; Greenberg, 2004). Monica used the early sessions to validate Terrance's feelings and build a working alliance. Given the lack of emotionally expressive relationships in the lives of many clients with CD, therapeutic-relationships can take time. Monica used genuineness, empathy, and unconditional positive regard to start building a safe space for Terrance to explore his emotions. She also attempted to provide opportunities for autonomy in a space where Terrance had little control over his daily experience. Giving him simple choices such as what games to play or what to discuss further helped build trust in the therapeutic alliance.

Next, Monica began to use reflections to help Terrance become aware of his attachment patterns and increase emotional awareness. Using her connection to the residential center staff, she was able to discuss a recent violent outburst from Terrance as a way to explore feelings within the counseling session. Monica used this experience to help him visualize the interaction in the "here and now" process of how he managed his emotions. At this point, Monica had taken on the role of a supportive attachment figure and was able to show Terrance through her calm and empathetic responses that his distancing behaviors would not change their relationship. This role as the supportive attachment figure is different from the typical role of a professional counselor in at least two ways. First, counselors acting as an attachment figure believe that their role is to attend to the client in the same way a primary caregiver would. This includes being acutely attuned to signs of distress in session. Second, the counselor acting as an attachment figure utilizes their counseling skills to facilitate connection as the primary modality for change in the counseling relationship. With Monica functioning as a supportive attachment figure, Terrance could truly "feel his feelings" through this experiential technique, leading to a broadening of emotional awareness and expression.

Monica continued to serve as a supportive attachment figure as she and Terrance explored ways of being through the expression of the full spectrum of emotions. They also discussed how to regulate his emotions and practiced how to bring his emotional awareness into his interactions with important others in his life. Ultimately, Terrance learned to embrace a range of feelings, to trust in his emotional awareness, and to better control his emotions to create more positive interactions with others.

Youth diagnosed with CD show a destructive pattern of symptoms that ruptures relationships and often creates feelings of fear for individuals in the youth's family, community, and educational setting (Frick, 2001). As a result, many receive treatment in out-of-home placements such as residential treatment facilities (Sternberg et al., 2013). Residential treatment facilities offer a restrictive setting that requires youth to be placed away from their primary caregiver(s) and family for treatment (K. Moore et al., 1997; SAMHSA, 2016). For this reason, EFT-I with the counselor acting as an attachment figure is an ideal modality for this setting. Rather than using reward and punishment to incentivize pro-social behavior (Leichtman, 2008), counselors utilizing an emotion-focused therapeutic modality such as EFT-1 provide a stable and consistent attachment figure to stimulate reflexivity in a therapeutic space focused on processing emotions and their impact on others (Brubacher, 2017; Greenberg et al., 1993). This treatment modality allows the youth to examine patterns of emotional reaction and work with the counselor to learn to trust their own emotional experience and others (Brubacher, 2017).

LIMITATIONS TO APPROACH

As with all counseling theories, limitations exist with this approach. The main challenge of all therapeutic treatment modalities in a residential setting, including EFT-I, is the generalization of skills learned in treatment back to the home environment (Lynch et al., 2017; K. Moore et al., 1997). If the client goes back into a home environment where pushing others away is necessary for emotional or physical safety, then they will have a difficult time translating the relational skills outside of the counseling relationship. This limitation can be addressed by including the primary caregivers in the treatment process and encouraging family or systems treatment modalities when the youth is discharged from the residential facility. As mentioned earlier, EFT-I should be one component of a multifaceted treatment approach for youth diagnosed with CD (Barry et al., 2013; Borduin et al., 1995; Cone et al., 1995; Frick, 2001; Henggeler et al., 1992; Von Sydow et al., 2013). Counselors also must keep in mind the effect that gender, age, and culture may have on the way that clients express and process their emotions (Seligman & Reichenberg, 2014). The counselor should be culturally sensitive to the challenge some clients may have with discussing their emotions and rely on the relational aspects of this therapy to inform the speed of therapy to ensure they are "joining with" the client and pacing the treatment process effectively.

CONCLUSION

This conceptual article provided an overview of the use of EFT-I with adolescents with CD who reside in residential facilities. Empirical research on this topic needs expansion, and future studies could explore which specific EFT-I interventions are most effective with this population or how EFT-I best addresses the symptom of conduct disorder. Research could also explore differences in treatment efficacy by gender, age, or ethnicity'. Nevertheless, EFT-I appears to be a valuable approach to effectively addressing the underlying emotional regulation issues inherent in teens with CD.

Counselors in residential treatment settings have a unique opportunity to work with youth in a controlled setting for a prolonged period of time (SAMHSA, 2016). This provides the opportunity for long-term change through working with the youth as they encounter a variety of challenges that are beyond their scope of coping. The case illustration demonstrated how a professional counselor in a residential setting could utilize EFT-I to support a male adolescent client in developing more clearly an awareness of his emotional experience and how it was impacting his relationships. This type of treatment supports a more flexible way of expressing emotions that does not just teach skills but changes the embedded attachment strategies that lead to more adaptive ways of relating to parts of self and others across settings (Brubacher, 2017; Greenberg, 2004; Johnson, 2009). Ultimately, trusting oneself to express a range of emotions and being able to regulate these emotions can lead to healthier behavior choices for adolescents with conduct disorder.

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Charmayne R. Adams, Educational Psychology and Counseling Department, University of Tennessee at Knoxille; Melinda M. Gibbons, Educational Psychology and Counseling Department, University of Tennessee at Knoxville.

Charmayne R. Adams is now at College of Education, University of Nebraska Omaha.

Correspondence concerning this article should be addressed to Charmayne R. Adams, College of Education, University of Nebraska Omaha, Roskens Hall, 6001 Dodge Street, Omaha, NE 68182.

E-mail: charmayneadams@unomaha. edu

https://doi.org/10.17744/mehc.41.4.01
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Title Annotation:PRACTICE
Author:Adams, Charmayne R.; Gibbons, Melinda M.
Publication:Journal of Mental Health Counseling
Geographic Code:1U2NY
Date:Oct 1, 2019
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