A simple e-mail makes all the hard work worthwhile for Susan Branco Alvarado. “I may not show it all the time,” an adopted teenage client wrote to Alvarado, “but I really appreciate everything you have done for me. Thanks to you, my relationship with my mom has gotten a thousand times better and my life has also changed for the better. So thank you!”

Alvarado, who runs a private practice in Falls Church, Va., that specializes in adoption issues, had begun working with the client and her mother after individual therapy for the daughter failed to yield improvements in her mood or her connection with her adoptive mother. “Initially, the sessions were not smooth with the family because years of disconnectedness and resentment had built a wall between them,” says Alvarado, a member of the American Counseling Association. “This wall was especially evident in session when the teen would pile several pillows between her and her frustrated mom.”

The teen displayed a high level of anxiety, anxious attachment to her mom and an increasing level of withdrawal and irritability, while the mother felt rejected by her daughter and helpless. After Alvarado tried a combination of narrative and expressive therapies in addition to Theraplay, a form of directive parent-child play therapy, the mother-daughter duo reported progress. “Both excitedly shared that they had a successful disagreement with a healthy repair to reconnect them,” Alvarado says. Helping adopted children and their families has personal meaning for Alvarado, who was adopted herself from Bogotá, Colombia.

The work is equally personal for Suzanne Clark, who runs a private practice specializing in adoption issues in Roswell, Ga. Born in Kentucky and raised by adoptive parents in Florida, Clark says she didn’t have much interest in or understanding of adoption until she went to college and began working as a Big Sister to pregnant teenagers.

“At the time, I didn’t realize why I was so fascinated with this population. I just thought it was a fun community service activity,” says Clark, a member of ACA. “After I graduated from college, I began working within the foster care system, then transitioned to a job at a maternity home. I completely immersed myself in my work with these girls, some of whom were parenting, some of whom were making adoption plans for their children. It was around this time I began to realize that this was the one way I was able to connect with my own birth mother and give back to her. The only thing I had ever known about her was that she was 15 when she had me. I never thought much about it past that.”

Both Alvarado and Clark offer counseling to individuals who have been adopted, birth parents who have chosen to make a plan of adoption for their children and families who have adopted a child. Clark also offers consultations to adoptive families and birth parents who are considering adoptions, as well as group counseling and lectures on adoption issues throughout the Atlanta area. Alvarado, whose clients range from infancy to middle adulthood, also provides workshops to local adoption and child welfare agencies, as well as presentations at adoption conferences.

According to Alvarado, counseling on adoption-related issues relies heavily on family work. It includes normalizing typical adoption-related developmental milestones, such as when children begin wondering why they were adopted or express a desire to meet their birth parents, and involves helping family members learn to trust one another.

“Additionally,” she says, “adoption therapists should be knowledgeable in identifying and treating trauma-related disorders. This can be a factor in situations where a child has been removed from his or her first family because of abuse or neglect or has experienced trauma in institutionalized settings. This type of counseling also includes birth family searching and preparation for birth family reunions and post-reunion relationships.”

Counseling that’s focused around adoption issues requires practitioners to pick up on subtle nuances in complex situations, Alvarado adds. “Therapists must be skilled in identifying the layers of adjustment issues that can stem from prenatal conditions, heredity, parental bonding and child attachment concerns, identity issues, trauma, and grief and loss experienced by both children and adoptive parents within adoptive families.”

Handling loss

Clark points to research showing that even if a child has been adopted at a very early age, grief can still emerge as a by-product later in life. “That grief, even though it’s preverbal, is still imprinted in them and definitely affects how they interact with people and form relationships,” Clark says. Grief can also weigh on adoptive parents, she adds, who might still mourn the biological child they couldn’t have on their own.

Clark often starts by telling these families that she understands their desire to be considered a “normal” family, while also encouraging them not to overlook the fact that their family was created on the basis of some type of loss. The parents might have struggled with infertility and not dealt with the grief, she explains, while the adopted child must deal with the loss of his or her original family. “When those two things are overlooked and the family tries to come together and pretend like everything’s OK, everyone’s feelings of loss and grief are still there,” Clark says. “And it comes out in the relationships.”

An important first step, Clark says, is acknowledging that everyone might be experiencing grief. She often recommends allowing parents to admit and deal with their grief alone with the counselor rather than in front of the adopted child. Clark then helps the parents or child pay tribute to the lost relationships.

With parents, she says, the process can begin by having them describe the initial hopes they had for their family or what they think their biological child would have been like. “Depending on what the parents identify as their choice of expression, I have them draw a picture, write a poem, tell a story [or] act out a scenario that depicts these feelings,” Clark says. “Based on this, we decide how they would like to pay tribute to this child. Some people make a memory box, some plant a tree. It’s really about giving them permission and then a voice to express these things.”

The process is similar with the children, although geared toward their age and how they feel most comfortable expressing themselves, Clark says. “Based on this, we decide how they would like to pay tribute to their birth family. If the adopted child is younger or adolescent and still living with the adoptive family, the adoptive family is included in what the child wants to do. We also discuss that the grieving process is a continuum of feelings that will change as the child reaches certain milestones throughout life.”

Clark says building a bridge between the adoptive family and the birth family — even if the adoptive family doesn’t know anything about the birth family — is important so the child will feel connected to everyone. There are ways for adoptive parents to acknowledge the child’s grief and honor his or her relationship to the birth family through talking, Clark says. For example, an adoptive parent might tell the child his ability to play soccer so well must come from his birth parents. Talking openly takes away some of the unspoken shame the child might feel, Clark says.

In session, the counselor can also help children understand why they were “given away,” which is how Clark says many children phrase their adoption. Even if children have a wonderful adoptive family and are functioning well, they still long to know where they came from and why they didn’t remain there, Clark says. She suggests that counselors offer these children space to acknowledge those feelings. Journaling, writing “letters” (not to be mailed) to the birth family and drawing pictures are among the useful techniques that can help adopted children heal and gain insight, she says.

In addition to grief, Alvarado says common issues that adopted children face include feelings of being “different” from their peers, potential discrimination, particularly with transracial or transcultural adoptions, and curiosity about their heritage and birth families. “Counselors can be very helpful to children experiencing these typical concerns by normalizing them, facilitating exploration of their identities within a safe environment and facilitating discussions of these topics within the context of the family system,” she says.

Telling the story

Alvarado points to family therapy as the most effective tool in working with adoptive families. “Regardless of the age of the child, it is very important that the counselor is facilitating increased connections between the child and the parent or parents,” she says, adding that Theraplay is one method that enhances the quality of the attachment. In addition, she says, narrative and expressive therapies such as drawing, sand tray and bibliotherapy are helpful in creating and retelling the story of a child’s adoption journey within the family context. Alvarado also uses cognitive behavioral techniques, relaxation and mindfulness training to reduce anxiety and some trauma symptoms among clients.

Andrea Miller, a registered play therapist in Charlotte, N.C., who has worked with a number of adopted kids during her three years in private practice, says communication between adoptive parents and the children is often a challenge. She sometimes asks the parents and child to take part in an activity, such as drawing individual pictures of the day the child was born. Even though the child can’t remember the event and the adoptive parents most likely were not present, Miller says discussing how each person views that day can serve as a good jumping-off point.

Miller, a member of ACA, also points to “adoptive stories” as a helpful tool, with the child drawing a time line from when he or she was born up through the present. The child can use the time line as a way to identify, verbalize and open up about feelings related to his or her biological parents. “Showing [adoptive] parents that time line and having them involved helps them understand some of the questions that the child might have but may not have asked or didn’t know how to ask,” she says.

Among adoptive parents, a feeling of competition with the birth parents can sometimes surface, Clark says. It’s important for counselors to let the adoptive parents admit that and then give them a comfortable place to talk about it or cry about it. “Not all adoptive parents feel competitive, and there may be varying degrees of these feelings,” Clark says. “It’s offering a space to voice these feelings, acknowledge them, discuss them and maybe even use the topic as a discussion point with their adopted child, depending on the age and maturity of that child.” Group counseling can be helpful, she says, because it allows adoptive parents to see others at different stages of the process who have made it through difficult times.

Adoptive parents can also bear the burden of feeling that they’re expected to meet a higher standard of parenting, both before and after an adoption. “For lack of a better term, adoptive parents have many hoops to jump through before they are able to adopt,” Clark says. “In addition, they typically have to endure long periods of time while they are approved and matched with a child. These experiences alone set them apart from families who are able to conceive biologically. You add to this having to navigate an open or semi-open adoption gracefully without any signs that they maybe feel tired and frustrated by the process, and you have a family who is already having to meet a higher standard than non-adoptive families. Simply acknowledging or suggesting that this might be the case and offering a place for the family to voice their frustration, or just exhaustion, can be very healing.”

In extreme cases, Alvarado says, some parents can experience post-adoption depression (PAD), which can be similar to postpartum depression. “In these situations, parents can experience extreme levels of depression and anxiety, may report a desire to disrupt or dissolve the adoption and even harm their child,” says Alvarado, who recommends screening clients for symptoms of PAD. She believes counselors can be most helpful to parents by educating them about normative adoptive family milestones, normalizing grief and helping them find coping mechanisms and community resources.

In recent years, Clark says, the trend has been toward doing more open adoptions, in which the adoptive and birth families stay in contact. This can present a host of challenges, such as determining when to include the birth family in events and how much freedom to give the child when it comes to contacting the birth family. Talk is often the answer, Clark says, and counselors can help adoptive parents and children (if they are old enough to be part of the conversation) identify the issues by encouraging them to share their fears, wants and expectations with one another. In many instances, this serves to decrease each family member’s anxiety level.

Even when counselors help adoptive families open the lines of communication, the prospect of search and reunion can present a major hurdle. The issue is more prevalent now that e-mail, the Internet and social networking sites are making it easier for birth families and those who have been adopted to find each other, Clark says.

“Adoptive families have varying degrees of comfort with the topic,” Clark says. “Some are totally open to it and are just waiting for the day that their child decides to make contact or to offer the information to their child without hesitation. Others feel that their child should have all of [his or her] needs met by the adoptive family, and there is no need to discuss it. Regardless of where the family is on the continuum, it’s really key to open up the topic for discussion and acknowledge that it is something to consider when everyone feels comfortable.”