Concerned About Unconventional Mental Health Interventions?

Concerned About Unconventional Mental Health Interventions?
Alternative Psychotherapies: Evaluating Unconventional Mental Health Treatments

Friday, January 2, 2015

Conversion Therapy and the Petition

Several days ago I received a message from about a petition whose goals I certainly share, but I hesitated to sign it because of some of the language used and its implications, As far as I can tell, these messages only allow you to join or stay out of the petition, rather than to comment or suggest statements. Yesterday I received a comment on this blog from reader Marianne M., and I responded to her, but I’m going to go into this further today. (If you read my response to Marianne’s message, at, please excuse some repetition here.)

The petition was triggered by the suicide of a girl who had been subjected to Conversion Therapy, the “alternative psychotherapy” claimed to alter sexual orientations, now illegal in several states for mental health professionals to use with minors (but legal everywhere when practiced by members of the clergy). Marianne commented on the text of the petition as follows: “Children in distress should have access to *RESEARCH”-based therapies to help them with their depression and/or other mental health issues. Conversion Therapy is quackery at best. Torture under the name of  ”therapy” at worst. It should be banned, as should all other therapies applied to under-age children, until supported by research. We control substances that treat mental health through the FDA. Why shouldn’t other treatments be effectively regulated?” [1/4/14  PLEASE NOTE that in writing this I originally confused a statement that Marianne M. had made with the actual text of the petition, so read this para as a more general comment on whether it's possible to prohibit all but evidence-based therapies.--JM] 

Let me begin my comments by saying that Conversion Therapy is very much an “alternative psychotherapy”. It has no basis in outcome research; it is implausible in the sense that it is incongruent with well-established principles of emotional development; and it has been associated with harm and distress to clients. Because commercial speech is so well protected in the United States, I doubt that we can ever prove that the treatment is fraudulent when used with adult patients or prohibit it by law for adults, but legal protection for minors is much easier to establish, and this fact has permitted legislation to prevent mental health professionals from using the method to treat minors. I applaud that legislation and hope that more states will pass similar laws. 

But why am I hesitating about the rest of the language about research bases, when I’ve put so much energy into fighting Attachment Therapy and other alternative child psychotherapies? Although I agree strongly with the petition’s aspirations and Marianne M.'s comments, I have two problems with the suggestion that an evidentiary foundation for a psychotherapy shows that it is a desirable practice. One is that I am not at all sure what everyone means by research-based therapies. There are several levels of research evidence that can be adduced to support the effectiveness of a treatment. The use of the terms “research-based” or “evidence-based” has become exceedingly vague outside disciplines like psychology that use these terms technically. Proponents of some treatments call their methods “evidence-based” when the research is at a much lower level than what that term technically means. Others call a program “evidence-based” when only one of many components meets this standard. This is not how it should be, but is how it is.

To establish the highest level of evidence for a child psychotherapy is difficult, time-consuming work, and most treatments now in use fall short of having that level of evidence. Some have never been subjected to systematic investigation. Legislation prohibiting the use of treatments with weak or no evidence bases would potentially make criminals of therapists who used Dance and Movement Therapy or Sensory Integration Therapy with minors. Although in a perfect world this might be a desirable outcome, I don’t see such legislation as being supported by professional groups in the foreseeable future.

So, I am worried about defining what is “research-based” and about the logical outcome of legislation banning child psychotherapies that are not well-supported by research evidence. But I have another worry too, about a concern that I would place at a higher level even than the need for evidence-based treatment. This concern has to do with adverse events associated with a child psychotherapy. It’s well-known that medical treatments, even those that are effective cures for a problem, may have side effects that can range from dandruff to death. It’s less well-understood that psychological treatments can also have side effects. Awareness of this fact advanced with news about child deaths associated with Attachment Therapy/HoldingTherapy. A 2013 paper by Michael Linden, “How to define, find,and classify side effects in psychotherapy: From unwanted events to adverse treatment reactions” (Clinical Psychology and Psychotherapy,4, 286-296)  did an admirable job of spelling out the adverse events that can accompany psychotherapy. Linden proposed an event he referred to as the “emotional burden” of psychotherapy--  distress and unhappiness caused by the treatment, but not necessarily needed as an instrument of change. Linden pointed out that if there are treatments that do not involve making people cry and feel unhappy, those treatments that are emotionally painful should never be chosen.

I believe that , wonderful though the goals are, it's a mistake to focus on the research basis of child psychotherapies before considering the problem of adverse events from suicide to unnecessary emotional pain. In my opinion, regulation of psychotherapies should begin with examination of their actual or potential adverse effects—of which Conversion Therapy has many. Prohibiting the use of treatments associated with adverse effects is a most important first step in controlling the use of therapies whose evidence basis may not be well established. Legislation or regulatory guidelines based on the potential harmfulness of a child psychotherapy would be far easier to put into place than regulation on the basis of outcome research evidence. I would be very happy to sign a petition that took that approach rather than using the language as presently written.  

In closing, though, let me note once again that prohibition of Conversion Therapy by legislation has affected only mental health professionals. To prevent members of the clergy from doing this “treatment” would require a major First Amendment battle and would probably work only if there were more suicides to function as poster children for this issue. For myself, I do not know that I would want to win the victory on those grounds. 

Sunday, December 14, 2014

SIDS, Outcome Research, and Proxy Measures

I mentioned a few days ago that Ed Clint of Skeptic Ink had objected to my comments on the research evidence behind the Back to Sleep/Safe to Sleep campaign to have parents put young babies in the supine position for sleep. Without concluding that a particular position was safest for infant sleep, I had queried whether the epidemiological research available actually provided evidence that supine sleeping reduces the rate of Sudden Infant Death Syndrome, as has been claimed. Now Ed has posted his own take on the situation, at

In his post, Ed included a familiar graph that shows 1.4 SIDS deaths for every 1000 live births in 1988, a gradual decline to 1.2 SIDS deaths per 1000 in 1992, the first year of the American Academy of Pediatrics recommendation for supine sleeping position, a reduction to 1.03 per 1000 in 1994, the first year of the Back to Sleep campaign, and then a continuing gradual reduction to a rate of 0.55 per 1000 in 2006. The graph also indicates changes in proportions of parents using prone or supine sleeping positions for their infants. From 13 % sleeping supine in 1992, this figure gradually rises to 75% in 2006.

This graph looks pretty significant, doesn’t it? Ignoring the fact that the rate of SIDS deaths was already decreasing before any recommendations for supine sleeping occurred, we see that the increase in the proportion of babies sleeping supine is accompanied by a decrease in SIDS deaths. It’s easy to assume that one caused the other… but of course the graph doesn’t show everything that could be affecting the SIDS rate. What other factors should we be looking at?

There are quite a few factors other than sleeping position that are associated with a lower or higher SIDS rate. Let’s just look at one of them—a variable about which much research has been done : tobacco smoking. Maternal smoking during and after pregnancy is known to be associated with a higher risk of SIDS. So, what has been happening about smoking during this period when the SIDS rate has been dropping? You can see this on slide 7 at For those readers who hate trying to read graphs, I’ll describe what it shows: Between 1990 and 2010, a period roughly equivalent to the time shown on the SIDS and sleeping position graph, there was a reduction in cigarette smoking in the United States, from 3000 cigarettes per capita per year in 1990, to about 1000 in 2010. If we were to draw a new graph showing the relationship between SIDS and smoking, it would look very much like the association between supine sleeping and SIDS (only reversed, so that less smoking goes with less SIDS, whereas less SIDS goes with more supine sleeping, less prone sleeping).

Assuming for the sake of argument that SIDS is caused primarily by one of these two factors (which might not be the case), we apparently need to ask which one it is. The graphic representation of the relationships between SIDS and each of the factors look just alike. If we are going to have a campaign to reduce the SIDS rate, and we are going to tell people to do just one thing, which will it be--  don’t smoke, or don’t have the baby sleep prone? The figures don’t, and indeed can’t, answer this question, and can’t even tell us whether our two candidate factors are the only important ones. The choice is made for other reasons, and this is why I said that this kind of policy is in fact not strictly speaking science-based.

But let’s look a bit at the issue of whether either smoking or sleeping position is actually at work in affecting the SIDS rate. The problem with epidemiological research is that the factors looked at may be only proxy measures that are markers for the existence of some other factor that is more difficult to measure. Take, for example, a study that looked at (among other things) the effect of socioeconomic status on SIDS rates (Gelb, Aerts, & Nunes (2006). Sleep practices and sudden infant death syndrome: A new proposal for scoring risk factors. Sleep, 29, 1288-1294). Rather than do an elaborate and intrusive investigation into a family’s income and property to decide SES, these authors used maternal education as a proxy measure for SES, assuming that high maternal education is more likely among affluent families. Low maternal education was associated with the use of a set of high-risk sleeping practices, including not only prone position but soft bedding and allowing the child’s head to be covered during sleep. Young mothers and smoking mothers were more likely to use high-risk sleep practices, as were mothers who had fewer prenatal doctor visits. The mothers’ practices and their other characteristics were confounded in such a way that it was difficult to know what factor caused any outcome.

Proxy measures can be useful shortcuts to measurements that are hard to do. However, it’s important to remember that any factor chosen may in fact be a proxy measure that is determined by some background factor that is unnamed.  When parents choose to comply with advice about supine sleeping, is the factor that influences SIDS sleeping position itself, or is this just a proxy marker for parental characteristics such as carefulness, compliance with rules, middle-class status, education, and affluence? As developmental psychologists have proposed with respect to other topics, it may be that “good things go together” and that we don’t know which “good thing" is at work.

Choosing one “good thing” to work on may allow a simple campaign to be developed, but, once again, that choice is not based on clear scientific evidence about SIDS.

N.B. The point here is not to advise about infant sleeping positions, but to discuss the complexities of extracting helpful advice out of the available information.

Friday, December 12, 2014

Mistaken Attachment Beliefs, Persuasion, and "Trojan Horses"

I’ve been trying to figure out a name for a persuasive technique. Here’s an example: at, the authors Arshad and FitzGerald provide a good deal of well-substantiated information about children’s emotional attachment to their parents. They describe different qualities of attachment and refer to stages of attachment as they occur in the course of early development.

But now the trouble begins. Forgetting or ignoring the fact that insecure attachment is perhaps not ideal, but is within the normal range rather than pathological, these authors make the following statements: “Reactive attachment disorder is a severe form of insecure attachment, with symptoms of emotional dysregulation, anger, guilt, impulsive [sic], disinhibition, aggression, hostility, reactive [sic], proactive [sic], impulsiveness, stealing, hypervigilance, aggressive, withdrawn, destructive, temper outbursts, demanding, clinging, sleep problems, enuresis, overfamiliarity with strangers, oppositional, fidgety, poor hygiene, learned helplessness, abnormal eating habits, lack of eye contact, can’t keep friends, blames others for mistakes, mistrustful, manipulative, lack of remorse, irritable, fussy, swears, diffuse boundaries, and jealousy.” Rather than being supported by systematic research evidence, or drawn from any of the DSM discussions of Reactive Attachment Disorder, this symptom list is characteristic of websites like

The same technique is evident at and at The latter has separate pages, one with material from DSM-IV and the other with a list of “symptoms” that are certainly concerning (like “fascination with blood and gore”--  by the way, is gore different from blood?) but that are not associated with disorders of attachment. These notional symptoms seem to have been drawn from the non-evidence-based 1996 article by Keith Reber which I discussed recently on this blog.

In the pages and documents I just mentioned, we have several examples of a persuasive technique. Trying to persuade people is not in itself a problem--  that’s something I am doing here, and even a simple presentation of well-founded statements is an effort at persuasion. However, persuasive devices are problematic when the goal is to convince readers that claims are correct, when they are not. It does not really matter whether the persuader is a true believer, has financial goals that depend on persuasion, or sees persuasion as a path to glory. Getting people to think that something is true when it is not is never really the right thing to do. In “wars of propaganda”, like World War II there may be short-term goals of persuasion that can lead to improved long-term outcomes, but even that use of persuasive devices may be based only on a guess as to what a good outcome may be. (Jane Austen’s novel Persuasion gives a good example of the difficulties here).

But what is the particular persuasive device seen in the examples above? It mingles true and false statements, apparently setting up an appeal to the authority of the true statements in order to “spread” that authority to cover the false statements as well. As I have tried to find a name for this device, I’ve found nothing among lists of fallacies or errors of critical thinking that might lead to persuasion in this way. There is such a thing as the fallacy of composition, which is the mistake of assuming that something true of a part of a whole must also be true of the whole, but that doesn’t seem to be exactly what’s going on here. I have found references to the method under the rubric of “disinformation” or intentional spreading of confusion about facts and logic, but no specific label to describe this technique as opposed to other disinformative methods.

Can any reader provide me with a name for a method that mixes true and false claims with the purpose of gaining belief for the false ones? In the absence of any other name known to me, I’m going to call this a “Trojan horse” technique. Presenting the reader with some well-established information, the “Trojan horse” user suggests the verity of ill-founded statements that have the potential to harm those who accept them. That’s certainly what appears to be happening in the examples given earlier, where accepting mistaken beliefs about attachment can lead to mistaken--  in fact, dangerous--  choices about treatment of children.

Tuesday, December 2, 2014

More About "Back to Sleep": The Neglected "Tummy Time" Part

Yesterday I posted some comments on the complex causes of Sudden Infant Death Syndrome (SIDS) ( I pointed out that there are many factors that increase the risk of SIDS--  that supine sleeping is not the only one, even though it has received the greatest emphasis by far. I ended that post by referring to adverse events associated with supine sleeping.

One of these unwanted side effects, deformational plagiocephaly, I have written about at Lying in the same position for long periods can flatten an infant’s still-soft skull, which gradually hardens into an asymmetrical shape. Once flattening has begun, the baby’s head naturally turns to place the flattened area down, increasing the extent of flattening. But although the resulting asymmetry can have an effect on ear positions, it does not damage the brain or otherwise cause problems. (As anthropologists have pointed out, there have been many cultures that intentionally bound or flattened baby’s heads to get an appearance that they considered highly attractive.) Still, most parents today would rather their babies did not have flattened or asymmetrical heads, so paying attention to babies’ head positions and varying them is probably a good idea when babies sleep supine.

A more complicated side effect of supine sleeping as currently practiced by many parents is that some early events in motor development are delayed (see Pin, T., Eldridge, B., & Galea,M.P. (2007). “A review of the effects of sleep position, play position, and  equipment use on motor development in infants.” Developmental Medicine & Child Neurology, 11, 856-867.) The review by Pin et al indicated that motor delays are due not simply to supine sleeping in itself, but result from the lack of experience of the prone position during waking time. Here are the conclusions of this review paper: “In healthy infants born at term, those who spent time in prone when awake achieved developmental milestones significantly earlier than those who did not or who spent limited time in prone when awake in the first 6 months of life… Those infants who slept in supine attained developmental milestones significantly slower than the norm… before 6months of age…. most of these healthy infants born at term walked independently or developed within normal age limits. … Low-risk preterm infants who slept in supine attained head control… and rolling between supine and side and bringing hands to midline significantly slower than infants sleeping in prone or non-supine positions. All these preterm born infants walked independently within normal age limits”  (p.865).

Why would experiences with supine or prone positions make a difference to motor development? It’s easy to think that motor development just “automatically” progresses from the top to the bottom of the body, just as we see physical growth proceed in the cephalocaudal direction. But motor development involves both maturation of the nervous system and practice which leads to muscle development. Full-term newborn babies lie in a flexed “fetal” position and need both maturation and appropriate exercise to be able to extend the body. When babies are in the prone position, they can be seen working on this from the first days of life, lifting the head awkwardly and turning it from one side to the other. With arms under them, they soon become able to lift the head briefly to look around. Within a few months they can extend the arms enough to get the shoulders up, then chest up with fully-extended arms. These achievements depend on strengthening the muscles of the neck and shoulders by exercise. Babies who spend most of their time in the supine position will eventually develop muscles and motor skills, but the supine does not provide the same opportunities and challenges for mastery of arm extension as prone does, and it forces the baby to work against the pull of gravity.

Is this phenomenon of motor delays a problem? In one sense, no, it is not. The evidence is that these babies walk and show other motor abilities within a normal age range. This is not very surprising, given evidence about other cultures that limit babies’ movement capacities. Margaret Mead reported in the 1930s that Balinese babies were never permitted to crawl, this being considered “animal-like” and incongruent with the babies’ recent arrival from the divine realms. Yet, the babies walked independently within a normal age range. Similarly, Geoffrey Gorer described the use of swaddling for babies up to a year of age in Russia, but found that the babies walked independently within a normal age range even though they had had very limited experiences of independent movement.

In another sense, though, motor delays may be a problem. A common and effective way of assessing early development involves comparing an infant’s motor skills to norms developed by observing large numbers of babies. But the norms we have now were developed at a time when almost all babies slept prone, so they do not necessarily give a good comparison for babies who sleep supine. These “outmoded” norms make it difficult to know whether a young baby’s development is progressing in a typical way. This may be especially important now that there are reports of slow motor development as a predictor of later communication problems in infants at risk for autism (see Bhat, A.N., Galloway, J.C., & Landa,R.J. [2012]. “Relation between early motor delay and later communication delay in infants at risk for autism.” Infant Behavior & Development, 35, 838-846). The diagnosis of genuine motor delays may be important in more ways than one.

Is there anything that parents can do to encourage good motor development in their supine-sleeping  babies? The first step would be to use “tummy time” regularly and to work with reluctant babies to tolerate and later enjoy the prone position. “Tummy time” may be awkward at first, but the baby’s motivation for mastery of the environment will soon help move the process forward, especially if parents have been given good information about what to do.
Is there evidence that “tummy time” or other techniques do any good for motor development? There has been an experimental study showing the effects of a program to encourage motor development (Lobo,M.A., & Galloway, J.C. [2012]. “Enhanced handling and positioning in early infancy advances development throughout the first year.” Child Development, 83, 1290-1302). These authors noted that the prone position is challenging to young infants and that most caregivers tend to avoid it. They taught caregivers in the experimental group to do the following for 15 minutes each day, beginning when the infants were two months old: “placing them on the floor or [on the] caregiver while encouraging them to push up to lift their head.. pulling them up [by the arms] and lowering them down while assisting them to keep the head in line with their body…supporting them in sitting and standing while encouraging them to weight bear and to reorient their body upright with respect to gravity, and… moving their hands to midline for play to encourage a shift from lateral to more midline arm placement” (p. 1292). Caregivers in the control group put their babies in the supine position and played face-to-face with them for 15 minutes a day. The caregivers in both groups continued their activities for three weeks.

The  babies in the experimental group were earlier than the control babies in their achievement of reaching for an object at the midline, transferring objects from one hand to the other, creeping on hands and knees, walking with support, and walking independently. This intervention apparently counteracted the motor delays associated with supine sleeping.

I think an important point about the success of the handling and positioning intervention is that caregivers were carefully taught what to do with the babies. They were provided with an illustrated manual and a diary to record their activities with the babies. In addition, activities were suggested other than simple prone positioning--  the prone position being especially feared by parents who know that SIDS risk is much higher when babies who are accustomed to supine sleep are placed in prone. The usual casual admonition to ”do tummy time” does not convey much information to caregivers, and new parents who delay prone positioning until their baby is three or four months old will probably find that the baby objects strongly to an unaccustomed position, a situation that further discourages anything but supine positioning.

Perhaps an appropriate change in the “back-to-sleep” mantra would be “Back to Sleep; Tummy to Be Played With”.  Young babies don’t exactly play by themselves, but as the song says they can remind us how to play, and our mutual enjoyment can encourage good motor development.

Monday, December 1, 2014

SIDS, Sleeping Position, and Single-factor Theories

I had a disagreement last week with I had submitted, and a moderator had  posted, a piece discussing whether the research evidence actually supports the idea that the use of supine sleeping positions for young babies is the cause of a reduction in Sudden Infant Death Syndrome (SIDS) over the last 20 years. People at skepticink apparently thought it was dangerous to babies even to talk about this possibility, took down my post, and have been unwilling to discuss the issue with me. As for me, my opinion is that it is dangerous to refuse to discuss controversial questions. If I had proposed that parents switch babies used to supine sleep over to a prone sleep position, that would have been dangerous, as it increases the risk of SIDS dramatically (see “The changing concept of sudden infant death syndrome: Diagnostic coding shifts, controversies regarding the sleeping environment, and new variables to consider in reducing risk” (2005), Pediatrics, 116, 1245-1255), but I did not do that, nor give any other recommendations about sleeping conditions.

My attention was  called back to this issue by an article in the New York Times (Saint Louis, C.,
“Federal study finds 55 percent of infants sleep with soft bedding, raising risk of death “, Dec. 1, 2014, p. A21 , reporting on a recent article in Pediatrics. The study used data from the 1993-2010 National Infants Sleep Position Study, which interviewed about 19,000 parents by telephone and examined changes in sleep practices year by year. The study reported that the use of soft bedding, blankets, and pillows, decreased by 23% between 1993 and 2000, but has not decreased much further, with 55% of infants in the United States still experiencing this known SIDS risk factor.

Could the problem here be that most of us, unless we try quite hard, tend to select one factor that we think causes an outcome, and to ignore all the other related factors? Few medical or developmental events have a single cause, so we are likely to be mistaken if we concentrate too hard on one factor. In addition, the great majority of developmental events are not only caused by more than one factor, they are also influenced by the ways those factors interact with each other--  the whole of the causes being rather more than the sum of their parts. Causes thus become too complex to lend themselves to easy solutions or slogans, but we tend to choose easy solutions anyway, even though that choice can make us neglect other important points.

From the earliest research on SIDS, it’s been clear that although prone sleeping position appears to play a role in sudden infant deaths, there is a list of further factors that have important effects. These are discussed in some detail in the 2005 Pediatrics article I mentioned earlier, so I will just list them: the use of soft bedding (an important point in the early New Zealand research on SIDS), exposure to tobacco smoke, failure to immunize, failure to breastfeed, failure to use pacifiers, overheating, premature birth and/or low birth weight.  Yet, as the recent study showed, the use of soft bedding continues; resistance to immunization is still present and even fostered by state laws supporting parental choice in medical care; smoking remains common in some populations, especially among the young mothers whose babies may have additional SIDS risk factors. As for the use of pacifiers, which would be an easy recommendation to make and carry out, there is still a sense of repugnance about them and a feeling that parents who give a pacifier have somehow failed.

Given this list of risk factors for SIDS, why is “Back to Sleep” the great recommendation to the public? The slogan sounds good (the baby will go back to sleep if she awakens in the night, it seems to imply) , and it provides a simple solution that appears to make it unnecessary to worry about stopping smoking or deciding to immunize. It’s hard to conceive a similar catchy slogan for avoiding soft bedding--  “Be Hard on Your Baby” doesn’t really work. Besides, once people have developed a single-factor belief about SIDS, another slogan will probably not catch on.

Please notice: I am not saying that I think babies should sleep in one or the other of the possible positions. I am saying that the claimed success for “Back to Sleep” (and there are reasons to question that success) may have occurred at the expense of forgetting about other SIDS risk factors.

I also want to comment on a nonfatal but problematic outcome of “Back to Sleep”. Parents who use the supine sleep position for their babies most often do not do the second part: “Tummy to Play”.  As a result, there have been considerable increases in the incidence of head shapes made asymmetrical by a baby’s constant lying position, and a tendency to delays in motor development milestones. I will be commenting on those issues in the next few days.

N.B. I now see that on Facebook Ed Clint of Healthy Skeptic has said that my statements about SIDS and sleeping position are comparable to someone without good evidence saying that all the statements of climate scientists are wrong. No, actually, what it's like is a student of the climate saying that more factors than human activity are responsible for global warming, and in order to understand the impact of human actions we must take into account what the other factors are and how they operate.    

Saturday, November 22, 2014

Children, Faith-healing, and Religious Exemptions

Do your state laws protect parents who allow their children to die without medical care because of their religious beliefs? Until recently I was not sure how this question should be answered for my own state--  and just as a reminder for readers  outside the U.S., the 50 states have differing laws on many topics, so knowing one state’s position does not tell you what happens in other states.

Ordinarily, a failure to provide medical care for a child when it is desperately needed would be considered a criminal matter of neglect and abuse. Civil suits against the parents might also be a possibility. But some states provide religious exemptions to parents who cite religious beliefs such as commitment to the power of prayer as justification for a failure to seek medical care for a child. As far as these parents are concerned, prayer or similar activities are the treatment they should give, and in fact to do otherwise indicates the weakness of their faith in God and endangers their souls and those of their children.

I’m indebted for information about this to CHILD, Inc. (, and to a map displaying the legal positions of the states at . (This map is based on data drawn from
You can probably look at the map graphic yourself, but I am going to describe the similar positions taken by groups of states. By the way, as you will see, this does not play out geographically exactly as one might guess.

Let me point out first that six states allow no religious exemptions to either criminal or civil charges involving abuse and neglect. These forward-thinking states are the following: Hawaii, Oregon, Nebraska, North Carolina, Maryland, and Massachusetts. (Boo, New Jersey! I had expected better of you!)

Twelve states allow no criminal exemptions, but they do allow religious exemptions in the case of civil suits resulting from neglect or abuse of children. Exemptions in civil suits may discourage child protective services from pursuing a case at the civil level, which requires a less stringent proof than criminal cases do. The states that allow these religious exemptions to civil suits are these: New Mexico, Arizona, Montana, Wyoming, North Dakota, Michigan, Illinois, Kentucky, Pennsylvania, Connecticut, Vermont, and Florida. Parents who fail to provide medical care to very sick children for religious reasons are liable for criminal prosecution, which has a high standard of proof, but not for civil actions, with their lower standard.

Fourteen states allow religious exemptions only in criminal cases involving misdemeanors like a non-felony level of child endangerment, not in cases of murder or manslaughter. These states are: California, Nevada, Colorado, South Dakota, Kansas, Missouri, Mississippi, Alabama, Georgia, South Carolina, New York, New Hampshire, and Maine.  In those states, there are no religious exemptions for civil suits related to incidents of neglect or abuse.

Nine states allow religious exemptions to prosecution for felony crimes against children, in which sexual assaults are included, as are child endangerment and neglect. These states are: Washington, Utah, Texas, Oklahoma, Minnesota, Wisconsin, Illinois, Tennessee, West Virginia, New Jersey, and Rhode Island.
Finally, almost unbelievably, there are six states that allow religious exemptions to prosecution for negligent homicide, manslaughter, and even capital murder. These are: Idaho, Iowa, Arkansas, Louisiana, Ohio, and Indiana.

The reasons for the broad religious exemptions in this last group of states presumably have to do with the proportion of their populations who want to choose faith-healing over standard medical care, probably for themselves, but most relevantly for their children. The most obvious community for these people to belong to is Christian Science, but there are a wide variety of other faith-healing-oriented groups like Followers of Christ or Church of the First Born. Charismatic churches in general are committed to the principle that once “born again”, Christians can have access to the gifts of the Holy Spirit, including discernment (diagnosis) and exorcism or deliverance (expulsion of the demons responsible for both physical and mental illness). Like other people, these groups of believers are attracted to areas where there are many of their co-religionists, and as they increase in number move into a position where they can influence state laws. In addition, of course, once laws have created religious exemptions for child abuse and neglect, even more such believers will arrive. This process helps to establish the polarization responsible for the current “culture wars” in the U.S.

One more point: this blog usually focuses on issues that have to do with child development from a psychological viewpoint. Do religious exemptions to abuse and neglect charges play a role in those issues? I think they probably do, although child deaths are much less likely even in alternative psychotherapies than they are in cases of medical need. However, injuries short of fatality may still be considered abusive. Religious views seem implicated in the apparent use of Attachment Therapy at the Seventh Day Adventist school, Miracle Meadows, in West Virginia (see above, by the way). There is considerable overlap between the authoritarian views held by some religious groups and those held by practitioners of Attachment Therapy. If practitioners or parents claim that religious beliefs are the justification of child mistreatment as a psychotherapeutic or educational method , there are a number of states in which this reasoning will help them evade prosecution.

There was little discussion of these issues during the successful efforts to ban “conversion therapy” in California and New Jersey. This may have been because only mental health professionals are prohibited from doing this treatment, and then the ban involves minor clients only. Parents and clergypersons can go ahead and use “conversion therapy” if they want to--- but perhaps one day an affected minor will grow up able to prove that he or she was harmed, and we will see whether courts accept the religious exemption then.  


Friday, November 7, 2014

That Reber Paper, Attachment Therapy, and Darkening Counsel

Everybody is busy nowadays, and even mental health professionals who should know better sometimes skimp on careful reading of articles that they later quote or reference. Occasionally they make other hurried mistakes like drawing a bibliography from an article without carefully examining the papers that are included. There are worse things to do, you say? Yes, that is surely true – but unfortunately these careless practices can bring misinformation into the mainstream and encourage beliefs and actions that are indeed worse.

A case in point: an article from the 1990s that conveys dozens of erroneous statements about attachment, attachment disorders, and Attachment Therapy has been cited repeatedly, by authors and editors whose positions give them great influence. The article in question is by Keith Reber (1996), “Children at risk for reactive attachment disorder: Assessment, diagnosis,and treatment.” Progress: Family Systems Research and Therapy, 5, 83-98. (Progress was and perhaps still is a publication of the Phillips Graduate Institute in Encino, CA, one of the freestanding mental health training organizations, unaccredited outside the state,  that appeared in California in the 1970s.) Reber’s paper has been cited many times, and has even formed part of the training of lawyers who will serve as guardians as litem for children; a paper on mental health needs of dependent children references Reber (

Yet, almost everything Keith Reber said in that 1996 paper is wrong, and not just wrong, but wrong in ways that are potentially harmful to children and families. So what did he say? I’m going to quote and comment on a number of points, but I have to say that this paper, once easily found on the Internet, is now not to be found there. I have a copy and will forward it to readers who give me an e-mail address.

To begin at the beginning, Reber believed that the emotional attachment of a child to a parent begins before birth as a “connectedness in utero…Attachment begins before birth on a neurological and emotional level. “ In addition to the effects of neurochemicals and hormones on the child, Reber stated that the mother’s attitudes before birth affect the child’s attachment.( It is difficult to quote only a small part of these remarks without losing the effect of the logical jumps of the original, but Reber in a single sentence linked the claims of Verney that unborn children are conscious and aware with the statement of Fahlberg that attachment influences the sense of self. ) However, these statements by Reber are without empirical support in spite of the numerous unrelated citations he provides, and in fact all the evidence tells us that attachment—as discussed and defined by Bowlby and many others--  does not occur  until some months after birth, and develops as a result of social interactions. To assume that Reber’s statements were correct is to open the door to a host of unjustified fears on the part of adoptive families, and to suggest to them that harmful treatments like Attachment Therapy are necessary for them.

Naming some frequent forms of social interaction between parents and babies, Reber stated that when these are absent, infants “can lose interest in the world, become ‘insecure’ or ‘anxiously attached’, or even die”.  No doubt there is a little truth to this last claim, because social interactions so often occur in the context of daily care routines, and where there are few social interactions, the chances are that daily care activities are missing too. It’s also likely that in the absence of normal social interactions, infants may fail to engage with either people or objects. But how do these serious consequences parallel insecure or anxious attachment? Although these qualities of attachment are not ideal, they are nevertheless well within the normal range and are not related either to a disengaged, autistic style, or to unexplained death. Reber appears to have been determined to attribute all unwanted outcomes to attachment problems.

Now, I need to quote an entire paragraph from Reber’s paper (but I will omit citations to save space): “After birth there are several specific child behaviors and maternal responses that need to take place in order for the child to develop normal attachment… The child behaviors include crying, smiling, clinging, rooting, postural adjustment, and vocalization, and are exhibited by children a few days after birth… They are goal-oriented… and are the child’s way of making contact and encouraging the caregiver to respond to him. When a caregiver meets the expressed needs of a child, the child begins to experience trust. This process is often called the Trust Cycle. There is some disagreement, however, about whether or not these behaviors need to take place immediately after birth…”

Let’s examine the statements in this paragraph. First, Reber seems to have had some uncertainty about whether some necessary child behaviors occur a few days after birth, or whether they need to take place immediately after birth in order for attachment to occur. The basic problem here seems to be that Reber was not sure whether he was talking about bonding, the adult’s intense positive response to the baby (at one time erroneously thought to occur only within a brief sensitive period following birth), or about attachment, the baby’s gradually developing desire to maintain proximity to the familiar caregiver. The child behaviors described are certainly attractive to caregivers, and the caregiver’s responses both demonstrate adult bonding to the child and help to facilitate the gradual development of the child’s attachment to the adult. However, Reber was so concerned with early behavior that he barely mentioned the adult social responses that do indeed support the child’s attachment to a familiar person and which need to continue over many months before attachment is apparent. Instead, he seems to have attributed attachment (or trust--  which he seems to have thought to be the same thing) to gratification of needs, as in the old Freudian “cupboard love” principle. As for the proposed process “often” being called the Trust Cycle, I suggest that readers Google this term and let me know if they can find a single use of either Trust Cycle or Attachment Cycle outside the writings of Attachment Therapy proponents. (In fact, you will see that the great majority of references to this involve the National Trust and cycle paths.)

Reber continued his discussion with the statement that “Attachments run along a continuum between securely attached and unattached, with the normal child falling somewhere in the middle” ( as statement he references to the AT proponents Magid and McKelvey). Now, interestingly enough, there is an ongoing discussion among students  of attachment as to whether attachment behaviors can in fact be ranked on a continuum, and whether we might fruitfully regard secure attachment as “more of something” than insecure attachment of various kinds. However, most writers who discuss attachment assume that there is no continuum, but rather several attachment patterns that are qualitatively different from each other. This was the view taken by Mary Ainsworth in her studies during the 1970s, but she and more recent researchers have not usually considered either an “unattached” pattern or the “disorganized” pattern described by Mary Main and others. The three basic attachment patterns were all considered to be  aspects of typical development. In any case, Reber’s reference to a continuum from secure to unattached  with the normal child in the middle would seem to assign the “normal child” to an anxious or insecure position, which Reber earlier classed as a risk with disengagement and even death.

Are any readers still with me? This is a very trying task, isn’t it? But I’m afraid it’s all too much worth doing because of the role Reber’s paper has played in providing misinformation and obfuscation to people who want a quick read on attachment and Reactive Attachment Disorder. Still, I will just mention two other points about the paper.

Let me take one sentence from a paragraph on the third page of Reber’s paper. He says, “The tie in between abuse and attachment disorder is supported by the work of Cicchetti and Barnett (1991) who classify eighty percent of maltreated infants as having insecure/ambivalent attachment.” But---  one moment, please. How did we get from attachment disorder to insecure/ambivalent attachment? Insecure attachment is not ideal, but is one of the normal patterns of attachment originally described by Mary Ainsworth in her studies of normal populations. It is not an attachment disorder, and certainly not Reactive Attachment Disorder as defined by any version of DSM. Reber has conflated a normal attachment pattern with a psychiatric disorder and has thus provided a source for confused thinking about attachment issues, a source that will continue to function until mental health professionals have learned to dismiss his paper as worse than useless.

Now, a final point about the paper, before I go on to report some facts about its author. In spite of just having provided the then-current DSM description of Reactive Attachment Disorder, Reber gave a table that is supposed to guide diagnosis of RAD on completely different grounds than those referenced in DSM. Anyone who has read the writings of Attachment Therapy advocates will recognize the symptoms that Reber wants to have diagnosed as RAD. These include all the usual: superficially engaging, no eye contact, fights for control over everything, affectionate with strangers but not parents, cruel, hoards food,  fascinated with blood and gore, lacks cause and effect thinking, has abnormal speech patterns, etc.,etc. The actual sources of these items are probably to be found in a psychopathy scale created decades ago by Hare, but Reber attributes them to the files of the Family Attachment Center in Salt Lake City. But this is as far as his attribution goes. He does not deal with the obvious unanswered questions: how many children were seen at this center in total? How were the claimed symptoms assessed? What proportion of children had each symptom? And, rather importantly, what information was used to connect any of the symptoms to any attachment behavior or attachment history? In the absence of answers to these questions, it seems most likely that these claims were created more or less out of the whole cloth--  yet poorly trained mental health professionals and many journalists have happily accepted them, and like Reber have seen them as justification for the use of Holding Therapy..

Does Keith Reber still make the same claims? Who was or is he, anyway? As far as I know, he has never published another paper, but he seems to have kept the same belief system. Trained as a marriage and family therapist, he probably received little instruction on the actual development of attachment, but instead was easily convinced by the AT proponents he quotes in his paper. His continued use of Holding Therapy caused his professional license to be revoked in Oregon  ( In 2003, the Utah Division of Professional Licensing asked a state judge to order Reber to cease practicing at a clinic that had been associated with the death of a child ( He would now seem to be a hearing aid salesman in Provo, UT.

Whether because of carelessness or genuine misunderstanding, Reber’s 1996 paper—which might have been expected never to be read--  has had an extraordinary  and highly negative impact on public understanding of Reactive Attachment Disorder. When I see this paper in any list of references, I immediately question whether the author of the citing material has any real knowledge of the subject. Sometimes people have apologized to me about citing Reber and have confessed that they simply copied someone else’s reference list. Others presumably actually believe Reber’s claims.

Parents, journalists, and mental health professionals, I ask you to recognize the Reber paper for what it is and to stop using it as a source. For the sake of children and families, let that publication die a well-deserved death and proceed to the obscurity that should have been its original fate!