Concerned About Unconventional Mental Health Interventions?

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

Wednesday, August 19, 2015

Craig Childress Tries to Drag Attachment Theory Into the Parental Alienation Swamp


It was only a few weeks ago that I first encountered the name of the California psychologist Craig Childress. The context was a discussion with advocates of the concept of parental alienation (PA to its familiars). If you have not yet encountered PA, you have been lucky so far, but that luck is about to run out if you keep reading. There may be such a thing as PA—no doubt there sometimes is—but it is embedded in a morass.
PA is a designation for the events and results that may occur in a divorce if one parent influences a child to reject the other. The rejection is evidenced by the child’s willingness to remain in the care of one parent but fear of and reluctance to be with the other. If the first of these people is seen to be persuading the child to fear and avoid the other parent, the former is sometimes described as the alienating parent, and the latter as the alienated parent (although this last is rather confusing because it is the child who feels alienated from the rejected parent, not the parent himself or herself). My own preference would be to call the people the accepted parent and the rejected parent, respectively.

 Some students of PA, especially, it seems, those connected with fathers’ rights groups, propose that a child cannot develop in a mentally healthy fashion without relationships with both parents, and that therefore the alienation must be resolved for the child’s own sake. As a result of this assumption, they define situations of PA as child abuse, unless there are rational motives for the child’s rejection, for example that the rejected parent has been frightening or abusive in the past. If PA is abusive, the accepted parent is an abuser, and needs to have his or her behavior corrected; the rejected parent is a victim, and needs the relationship with the child restored in order to facilitate the child’s emotional development. When courts are in the picture, of course, the treatment of the accepted and rejected parents can include the threat or reality of custody or visitation changes as means to stop PA, or court-ordered therapies designed to correct the situation and foster good relations between the child and the parent(s) who cooperate in the process.

Advocates of PA have argued that there is a definable parental alienation syndrome (PAS) that should have been included in DSM-5. The DSM-5 group rejected this proposal on the grounds that there is no evidence that PAS exists in some way that makes it separate from other diagnoses in the manual. Similarly, there is at this time no support for the idea that any treatment used for PA is an evidence-based treatment. (This is why I refer to all this stuff as the parental alienation swamp.)

Now, here’s where we get to Craig Childress. Childress, a licensed clinical psychologist in California with a Psy.D. degree, and a faculty member at California Southern University, a distance-learning, on line outfit, has attacked others’ claims to treat PA and has presented his own claim that he knows 1) what causes PA behavior by accepted parents, and 2) how to treat the child’s rejection of one parent. He has published a book with a “boutique” publisher, Oaksong Press, about how this all works, and maintains an elaborate Facebook page and web site to argue for his views.  There he comments on the “abject ignorance” of his opponents, a statement no doubt entertaining to some of the FB audience, but certainly not professional discourse. (Childress’ on line CV appears to show no activity between 1985 and 1998, raising more than one question about his professional history.)

Let’s have a look at Childress’ claims about the sources of PA behavior by the accepted parent and the impact it has on a child. Childress attributes a parent’s persuasion of a child to reject the other parent to re-enactment of the accepted parent’s own traumatic attachment history.  Where such a history exists, he proposes, the affected parent develops a narcissistic/borderline personality, with a tendency to “split” the world into all-good and all-bad components. Childress chooses two aspects of a problematic development of attachment as critical here: the early existence of disorganized attachment, and relationships that involve role reversals, so that, e.g., child cares for mother. These characteristics, according to Childress, make the accepted parent a “pathogenic parent”.  This is an interesting set of ideas, and eminently testable by empirical means. But… Chandless has not done this testing, and although on his web site he refers to his claims as “well established in the scientific literature” (notably omitting a list of references), this is certainly not the case if we assume as many do that “scientific literature” involves empirical work beyond the level of anecdote or clinical report. Yes, attachment theory is based on careful observational work and on longitudinal studies, but the fact that there is a scientific foundation for some aspects of attachment does not mean that the foundation can properly be generalized to every statement that shares concepts with attachment theory. (There is a good deal of this kind of thing around just now, I’m afraid.) As for pathogenicity of any parenting pattern, this requires longitudinal study to ascertain.

Let’s look at Childress’ claims about treatment of PA effects on children. He rejects the idea that reunification can be facilitated by work with the child and both parents. Instead, he proposes that help can be given only by “protective separation” of the child from the accepted parent. During this period of separation, the child experiences treatment as described by Childress on his web site, with the goal of coming to enjoy and seek to be with the formerly rejected parent. If the child is successful in meeting this goal for 10 weeks, two one-hour Skype or phone sessions per week with the formerly-accepted parent will be allowed. According to Childress, this method empowers the child: “It is in the child’s power to extend or shorten the Treatment period. If the child continues to remain symptomatic [i.e., express rejection of the parent], then the Treatment period can be continued to six months or longer. However, if the child chooses [sic, N.B.] to become non-symptomatic, then the Treatment period can be ended in as little as 8 weeks or less, based on the child’s behavior. “ Childress argues that a study design can be used to demonstrate the effectiveness of this method, but he does not appear to have done this, nor does he take into account the effect of maturational change.  

Is Childress’ approach less supported by empirical work than other PA approaches? No, it is not, although his pugnacity and undue confidence about his statements tend to obscure that fact. Actually, all of the PA discussions of which I am aware, as well as many judicial decisions concerned with parenting relationships, have the same flaw. They completely neglect  to consider the effects of developmental change on the child’s interactions with the social environment and their effect on him or her. The effects of parenting patterns on children involve transactional processes in which each person affects the other in ways that change over time; the changes occur because of learning by both parties and because of maturational changes, rapid in the child and slow but present in the adult. This means that when treatment is appropriate (an enormous issue), the way it is done, especially if it is to involve separation from the accepted parent, must be congruent with the child’s developmental needs for attachment and for exploration. These are vastly different in toddlers and in kindergarteners, and different from both in teenagers. Perhaps Childress does not mean to suggest that a two-year-old who resists going with his father should be separated from the mother for 8 or 10 weeks or longer--  but if he does not mean this, he would do well to say so.

There are many more issues to be considered here. I am still taken aback, I must say, by Childress’ view that a child may “choose” whether or not to show fear and rejection of a parent; there is a flavor of “breaking the spirit” about the whole thing. But the main considerations, I think, are 1) show us the evidence for these claims,  2) tell how developmental age should be taken into account, and 3) describe the treatment goals in transactional terms. This is a challenge that I hope will eventually be addressed not only by Childress but by other PA proponents.


Sunday, August 16, 2015

APA and Torture: A More General "Nocere" Issue


People who are interested in psychology as a subject of study or as a profession can hardly have missed the recent brouhaha in the American Psychological Association, following public attention to the complicity of psychologists and the organization itself with the use of torture in the interrogation of prisoners at Guantanamo. This complicity of the organization included some shuffling of the ethical code to make it acceptable for psychologists to recommend “enhanced” interrogation techniques and thus to make themselves agreeable to the Department of Defense. (The American Psychiatric Association refused to do this, and they are most pleased with themselves--  which I acknowledge that they have every right to be.)

 At the recent APA (that’s the psychologists) annual convention  in Toronto, “town hall” meetings discussed the ethical issues concerned, and a resolution was passed, with only one dissenting vote. Among other things, the resolution stated that APA members should not be involved in national-security-related interrogations in any way, including supervising or advising on how other people do them. Members of APA were invited by e-mail to give feedback on this resolution, and I did so. Here is what I said:

“In my opinion, the resolution, with its focus on national security issues, completely misses the point. Psychologists should not employ or contribute to methods that are potentially harmful, whether the context is national security, domestic prisons, residential treatment centers, or outpatient treatment. In addition, there should be a clearly-stated ethical obligation for psychologists who become aware of such actions by other psychologists to call attention to them by reporting to APA or to licensing authorities. APA, in turn, needs to be responsive to such reports and to make public statements about substantiated reports even when the offending psychologist is not an APA member.”


Psychologists as a group have never adopted the principle of primum non nocere (first, do no harm). There has been a long-standing assumption that what psychologists do must be beneficial—why would we call it “therapy” if it isn’t good for you? Nocere has not been considered to be one of the options; in fact, when patients found treatments distressing, it was assumed that such distress was needed to motivate change or to overcome resistance, and that in the long term such unpleasant experiences were actually beneficial. This attitude was especially prevalent in the ‘70s, when bullying at Esalen was considered a viable intervention, when two practitioners in Flagstaff, AZ caused the death of an adult patient through physical methods, when Robert Zaslow lost his California psychology license after serious injuries to a patient, and John Rosen in Philadelphia apparently pushed a patient down a flight of stairs. Today, painful “psychotherapy” for adults is less common, but distressing methods for children, especially adoptees, are still advocated by some practitioners. These people may argue that just as chemotherapy for childhood cancer is painful but necessary, the treatments they use are similarly distressing but needed; unfortunately for their argument, they forget that there is good evidence for the efficacy of chemotherapy, but no such evidence for distressing psychological interventions.

In recent years, a small groundswell of disapproval for harmful behavior by psychologists has begun to appear. I can point to my own efforts to fight holding therapy by describing its distressing and physically harmful effects, beginning in 2001. Scott Lilienfeld in 2007 suggested the term “potentially harmful treatments” (PHTs) for interventions that have a history of doing harm or that could reasonably be expected to cause harm. The PHT designation provided a category whose existence indicated that nocere was in fact one of the options for psychologists—not all “therapies” were actually therapeutic. More recently, Michael Linden, a German psychiatrist, has put forward the concept of adverse events of various types that can accompany psychological interventions, just as they may occur with physical or pharmaceutical treatment. In a 2013 paper, Linden argued that feeling distress during psychological treatment should be considered an “emotional burden” and an unwanted side effect that should be avoided if at all possible.

These facts about psychological treatment and its potential for harm, in my opinion, need to be added to APA’s discussion of the harm done by psychologists who supervised torture. Simply to refrain from engagement with the Department of Defense provides only a small part of the solution to the problem. It is time for psychologists--  and not only psychologists, but other mental health workers—to recognize that there is a power for ill as well as good effects in our practices. It is time for us to stop passing by “on the other side”, like the priest and the Levite, when harm is caused to any person by the exercise of psychological skills. When APA recognizes this and builds awareness into the code of professional ethics, we may be able to move forward. As long as we point the finger only at the guilty parties at Guantanamo, we cannot.



Follow the Child's Lead to Create Attachment

A recent e-mail from Jessica Pegis called my attention to a set of “rules for bonding” as put out by the magazine Adoption Today (www.adoptiontoday.com/bondingarticle2.html). An on line article on this topic, “Jump-starting attachment with babies and toddlers”, by Mary Ostyn, contains a range of misunderstandings about attachment and young children’s needs, as well as some good advice – e.g., that nurturing does not “spoil” a child.

My first concern about Ostyn’s remarks is that they suggest that attachment (not bonding) is something an adult can do TO a child, and that it is accomplished by ritually re-enacting with toddlers the behaviors that are normal parts of caring for infants. The term attachment refers primarily to attitudes and behaviors of young children toward adults, although some authors have tried to bring all later relationships under the attachment umbrella. As far as we presently know, attachment of a child to a caregiver occurs when the caregiver is sensitive and responsive to the messages the child sends about needs and wishes—that is, when the caregiver pays close attention to the child’s communications about both affectionate interactions and autonomy. (This kind of attention and response is just one detail of what is sometimes called “following the child’s lead”).

Ostyn seems to assume that the caregiving behaviors that typically precede an infant’s attachment to a parent are identical with the behaviors that will encourage attachment in a toddler or preschooler. My guess is that she takes this position because she shares with advocates of attachment therapy the belief that a child who has experienced separation has in some way been blocked from and stopped further development, and therefore experiences characteristic of early life must be recapitulated in order to “jump-start” typical development. However, the fact is that no living child stops developing in any way. Development may be distorted by events, but it continues to occur. This means that a toddler who has undergone separation cannot be considered to be stuck at the stage of development where she was at the time of separation. It’s more accurate by far to consider that aspects of development have been derailed and need to be guided back onto a desirable track.

Re-enacting baby care with an older child is thus not a plausible approach to helping kids who have experienced rough histories. What’s more, this kind of re-enactment of events ignores the important role played in attachment by the caregiver’s responsiveness to the child’s signals. Just doing what a caregiver thinks ought to be done may well involve being unresponsive to child communications, especially if a child is hard to “read”.

As Mary Dozier has pointed out, improving the parent’s ability to understand subtle child cues is the way to improve the child’s attachment to that parent; caregivers who proceed to follow “rules” without considering the child’s signals are working against attachment, not toward it. Ostyn suggests actually ignoring child cues to insist upon physical contact. She also ignores the fact of the typical extreme ambivalence of the toddler toward being held and being let go – the behavior that Margaret Mahler called a “rapprochement crisis”, where a normally-developing child wants to be held and then put down, wants help and then has a tantrum when receiving it, etc.  Rather than recognizing age-appropriate behavior, Ostyn is confused by her assumptions about  “stuck” development into thinking that this is an expression of genuine reluctance to develop a relationship. Instead, it’s an opportunity for a caregiver to show responsiveness to the confused and confusing signals the child is giving. The child’s desire for autonomy needs to be honored as much as the child’s desire for attachment—and I am at a loss as to how hours of carrying a big child can accomplish this, especially when the child resists. Once again, following the child’s lead as much as is practical is the way to go; carrying out a ritual re-enactment of some idea of infant care is not.

This leads me to the whole feeding issue. According to Ostyn, “bottlefeeding is great for bonding”—but there’s certainly no evidence that it makes any difference to attachment, any more than breastfeeding does. Does she mean that bottlefeeding makes a caregiver feel good? That would make sense if she’s really talking about bonding, which is the increased positive feeling of the adult for the child. Not so much if she means attachment, the feeling and behavior of the child toward the adult, however. A toddler or preschool child is likely to resist being given a bottle and will probably want to hold it herself and even take the nipple off to drink better, but caregivers who are convinced by Ostyn will not follow this lead as they should. (Some will even interpret these actions as a refusal to attach to them and a personal dislike.)

 As a further comment on feeding, Ostyn advises that only the mother should feed the child, and all treats should come from the mother. Here we have a clear commitment to the Freudian concept of attachment as “cupboard love” created by associating a caregiver with food or other gratification. This outmoded view has long ago been replaced by the idea of attachment as a robust development that occurs in response to pleasurable social interactions and adult sensitivity to child communications. Certainly mealtime offers many opportunities for happy social engagement and responsiveness to the child’s cues, but these are not based on satisfaction of hunger or experience of “treats”. I might point out also that the idea of monotropy, the attachment of the child to a single individual, as initially argued by John Bowlby in an analogy to the imprinting of ducklings, is long gone from professional discussions of attachment. Most children experience attachment to several caregivers, including fathers and grandparents, and benefit from learning that there are a variety of ways of having pleasurable social play.

Ostyn should be given credit for a couple of good suggestions. One is about responsiveness to children’s night-time concerns, and in her comments about this she does encourage sensitivity and responsiveness to child communications. Her comments about playing on the floor every day are also excellent. “Floortime” (as it was dubbed by Stanley Greenspan) offers many opportunities for pleasurable, sensitive, and responsive communication and for following the child’s lead in play.  

You can’t “jump-start” attachment by making the child go through ritual re-enactments of infancy. But you can gradually encourage a child’s attachment by becoming sensitive to subtle communications and being willing to follow the leads he gives you. If this seems difficult, sometimes it can be helpful to make videos of your interactions with the child and to look at them later to see whether there are cues that you are missing and leads you are not following. Keep in mind, too, that a toddler is developing attachment relationships that include negotiation and compromise, not just dependence, and that autonomy is an essential goal for development. That toddler or preschooler is not literally “stuck” at a baby’s emotional level—he or she needs experiences that resonate with current needs, not to what some adults imagine as past needs.








Saturday, July 4, 2015

Doulas, Shamanism, and Sham

where (by using Google translate) we can read about the June 2015 international midwives conference in St. Peterburg, which drew participants from the U.S., Ukraine, Russia, and other countries. This article uses the term doula in what appears to be a broader way than is usual in the U.S., where a doula is usually a “birth companion” who attends and comforts the laboring mother rather than actively focusing on the baby. We also tend to use “midwife” to describe a person trained to work with the delivery and the baby, but without the medical training of an obstetrician or a neonatologist. The Google translation as I read it seems to mix the vocabulary describing these functions.

As many readers will know, a rebound from the intense medicalization of childbirth as it took place before World War II was underway in the 1950s and increased greatly in the 1970s in the U.S. Resistance to medicalization caused some real changes, including the presence of fathers or other relatives in delivery rooms and the establishment of birthing centers that had medical services but a relaxed atmosphere where a family’s older children would be welcome. This movement, added to insurance coverage changes, led to shorter hospital stays for healthy mothers and babies. The motivation of medical facilities to please birthing families also began  not only to allow fathers or grandmothers to be present with the laboring mother, but to permit a doula who might be a friend or relation (but who might also be hired by the family) to stay with the mother and give her the help that nurses rarely have time for.  

Those of us who gave labored in isolation and gave birth while attendants shouted at us in the “old days” can appreciate the changes that have been made, and appreciate the idea of a nurturing, supportive environment during labor. Because being alone during labor is frightening for most women, having a relative or a hired companion with us seems like a wonderful idea. This swing of the pendulum to an older, less medicalized has many advantages.

BUT!

Regrettably, whatever may be the attitudes of individual doulas or  midwives, organizations of these persons have a strong tendency to pursue the opposite pole from mechanistic, objectively-evaluated medical practices. Rather than simply humanizing some unnecessarily problematic medical approaches to childbirth, and reaching some sensible central position, the organizations have often gone far from center toward New Age beliefs and practices that stress subjectivity and the supernatural. This tendency is seen in the material at the link given above. For example, one recommendation has been to keep a large pyramid over the mother’s head during labor and delivery—an idea that seems directly related to Wilhelm Reich’s “orgone box” which was claimed to keep life energies from dissipating. Similarly, it was suggested that the umbilical cord and placenta should be left attached to the baby for several days after the birth, in order to “drain” back into the child all the beneficial substances that had been taken in during gestation.

The article on the St. Petersburg conference is difficult to follow because of some of the vagaries of Google translate, so I took the opportunity to look at web sites of some U.S.participants. For example, Gail Tully at www.spinningbabies.com mentions a number of ideas that involve rituals of sympathetic magic and shamanistic approaches--  for example, visualizing the unborn baby moving into an ideal position for birth, in order to create this desired outcome. This web site makes clear the connections between organizations of midwives and doulas and the Association for Pre- and Perinatal Psychology and Health (APPPAH).

APPPAH members promulgate a variety of beliefs about embryonic and fetal life that fail to be congruent with what is known about prenatal development or with basic assumptions of developmental studies, such as the connection between consciousness or memory and considerable advancement of nervous system maturation.  APPPAH members have claimed that the unborn human being is aware of external events from the time of conception or even before (some suggesting that each human being has memories of life in sperm form and life in ovum form). These views are quite similar to those stated by L. Ron Hubbard in Dianetics and repeated in other Scientological discussion. APPPAH has also supported and repeated the views of Lloyd DeMause, the “psychohistorian”, about the psychological pain and suffering of the fetus before and during birth, and how this trauma marks each personality and distorts its development.

Not to put too fine a point on it, when I see APPPAH links, I understand that any systematic evaluation of treatment outcomes has been abandoned by the linker. It appears to me that except for the rare individual doula or midwife, these entire professions have been contaminated by an APPPAH-like perspective on reality that abandons all scientific knowledge about prenatal life and development. In addition, the commercialization of these fields has moved them from shamanism right on to sham.

What was gained by past efforts to give families more healthy choices about the conduct of childbirth has unfortunately come to offer a choice between the simply outre’ and the outrageous and dangerous. The New Thought period has been over for many decades. It’s time for reasonable people to stand up and say we want potentially harmful alternative practices to be regulated.
   


Thursday, July 2, 2015

More Nancy Verrier, or, Don't Say "Ain't" When She Says "Is"


Quite some time ago, I posted here some comments about the claims made by the California MFT Nancy Verrier, to the effect that all adopted children, even those adopted on the day of birth, suffer from a “primal wound” caused by the disruption of the prenatal attachment to the mother, and experience life-long misery as a result. This belief is not congruent with anything we know about the responses of young infants to separation from familiar caregivers, nor with established information about the development of attachment. I wrote an open letter asking Nancy Verrier to explain her position and say why it should be considered plausible (http://childmyths.blogspot.com/2011/08/open-letter-to-Nancy-Verrier.html ). Verrier did not reply, unsurprisingly, but periodically I receive vituperative comments from her followers.

I recently received one of these privately rather than as a blog comment. The writer, whose name I will not mention because she did not apparently intend to make her remarks public, started   thus: “As an adopted person, a lawyer person, and a sensible person, I say this:- As long as the law is the way it is the worst case scenario is possible thus accounting for various responses but all under the rubric of the denial of our loss. What’s your investment in denying that unprocessed grief can [emotionally disturb ] a person…? And if you know [person’s name] you should recuse yourself from this discussion. Thank you.”
This relatively mild, though not very coherent, statement was followed by two others in which I was said to be “nasty nasty nasty” and [person’s name] was vilified for having adopted two children of an ethnicity different from her own.

I don’t think it will be useful to address the implied ad feminam attack (“what’s your investment…?”) as this is a common technique among proponents of alternative treatments and belief systems—rather than discussing the evidence for their viewpoint, they propose that the opponent has some pathological, malicious, or greedy reason for taking a contradictory position. The proponents don’t seem to see that this opens the possibility of questioning their own motives, but perhaps they realize that most of us who oppose them would not waste our time in that kind of discussion.

Let me just focus in on the primary point of the message I have quoted, that somehow my remarks involve “denial of our loss”. This is a frequent rejoinder from Verrier supporters, who accuse critics of claiming that they, the supporters are not unhappy.

No one, including me, has ever said that adopted individuals do not experience a sense of loss as they realize their own history. All adoptions begin with a narrative of sadness, as their stories may involve abandonment of mother and child by a biological father, poverty, the fear and shame of a young girl, the death of one or both parents, civil war, etc., etc. Although some adoptive families may experience undiluted joy and satisfaction from bringing a new child into their home, many also have a history of their own sadness because of infertility or even the deaths of children in the past. There is plenty of sadness to go around, some of it like the sadness that may be found in nonadoptive families, some of it characteristic of adoption. Whether this narrative of sadness does or does not have a life-long impact on an individual depends on factors like personality and resilience, a tendency to depression or to bipolar disorders, a culture’s perspective on the adopted individual (for example, native Hawaiian culture does not consider a person to have any connection with the birth family that did not rear her), and of course the family’s handling of the adoption as “secret” or otherwise.  

Verrier’s claim, and the claim of the Association for Pre- and Perinatal Psychology and Health (APPPAH) group that supports her, is that just as older children may suffer emotionally from separation from familiar people, even the youngest infants experience rage and grief at separation from a birth mother to whom they have developed a prenatal emotional attachment. (Such a posited attachment is explained variously as having biological/genetic causes or by prenatal telepathic communication.)

It is true that children between about 8 months and 2 1/2 years are likely to respond with deep depression and social withdrawal when separated from familiar attachment figures. With sensitive, nurturing care, over time they recover from this loss and form new attachments, but without sensitive care, or if subjected to several such losses, they may be handicapped in their emotional and social lives. Infants under perhaps 6 months of age, however, do not show concern about separation or anxiety about the approach of unfamiliar people. Their behavior does not include attachment behavior like watching or trying to stay near familiar caregivers, or like depression, feeding and sleeping difficulties, irritability, or apathy when separated abruptly and  for a long period. For these reasons, it appears implausible that early-adopted children suffer from a “primal wound” (as opposed to sadness and concern about their history) or that any grief they feel can be attributed to the loss of the birth mother. (N.B. the biological father is only rarely mentioned in these discussions, although attachment to a father can be as strong as or even stronger than that to the mother.)

The implication of the Verrier perspective and that of my correspondent quoted earlier is that adoption is never an acceptable solution to the problem of care for a child. This, I think, is a wrong conclusion, given what is known about early emotional development. Certainly it would be repugnant to buy a child from a poverty-stricken mother, when she could be helped to care for her family, and I consider it highly reprehensible for church groups to go to Ethiopia or elsewhere and take children from parents who do not actually have a concept of adoption, but believe the children will return to them. But these concerns are often irrelevant to the choices to be made for infants born to very young or incompetent mothers, to mothers who are very sick, or to mothers who are mentally ill, all of whom may lack social support systems and adequate resources to care for a child. In those cases, the narrative of sadness will be part of the child’s life whether or not he is adopted, and in fact may be worse if he remains with the birth mother.

Incidentally, I have communicated with [person’s name] mentioned earlier. Interestingly, she had no idea that the Verrier position was known outside the pathology of my correspondent—an inadvertent comment on the plausibility of that position.   


Wednesday, June 3, 2015

Why Should Mental Health Practitioners Be Licensed?

Some weeks ago, when I had written a post about the Oregon psychologist Kali Miller and the revocation of her license (http://childmyths.blogspot.com/2015/03/psychology-license-revoked-become.html), one Robert Plamondon commented with severe criticism of psychology licensing boards and advice that unhappy clients of psychologists should sue the practitioners directly instead of going through the licensing board. I pointed out in response that when children were the patients, they did not have the capacity to sue for personal injury, and if their parents had made the decision to seek the treatment, or even carried out some of the treatment themselves, the parents would probably not bring suit on the children’s behalf (behalves?).

I see now that Plamondon has a web site, www.unlicensed-practitioner.com, which purports to provide resources to help alternative and unlicensed practitioners operate “legally and ethically” in Oregon. As far as I can tell, Plamondon objects to decisions made by the Oregon board of psychologist examiners, but in addition he favors mental health treatment by unlicensed persons in a general sort of way. This may be in part because he himself is practicing as a hypnotherapist.

I would be the first to admit that national professional organizations like the American Psychological Association and the National Association of Social Workers have strong “guild” mentalities and are much concerned about their professional hegemony. The current scandal about the involvement of APA with approval of torture is evidence that focusing on putting the profession forward can interfere with everyday ethical decisions, not to speak of professional ethics. But to my mind these are not reasons to abandon regulation through licensure and other methods.

Why do I think this? What are the advantages to the public of licensing mental health professionals? Why, especially, do the educational requirements for licensure benefit the public? There are two primary reasons for requiring practitioners to meet licensing standards  and to do so through formal education--  and neither of them has much to do with whether the practitioner has learned specific techniques of therapy.

The first concern has to do with education about the nature of evidence and the ways we can test the effectiveness of treatments. Plamondon himself states that the major difference between psychologists and counselors is that psychologists are trained to do scientific research. From the point of view of patients, there is probably no advantage to visiting a practitioner who is doing  actual research (i.e., collecting data systematically), but there is an enormous advantage to going to someone who can read research, which few people are able to do well unless they have studied research methods. Practicing psychologists, social workers, and other mental health professionals should be capable of understanding when research evidence supports the use of a treatment method, when there is no such support, and when a treatment is potentially harmful to patients.  No licensure can insure that practitioners do their homework, but licensing standards can  require that professionals have gone through the formal educational process that should provide them with the skills to understand research evidence.

Unlicensed practitioners may be competent and careful about the evidence basis of the treatments they use, but it appears likely that most of them are not. This point is made by Plamondon’s tendency to refer to “unlicensed and alternative” practitioners. Alternative practitioners by definition use methods that lack evidence of effectiveness; if this were not the case, there would be nothing “alternative” about them. Plamondon himself displays his lack of concern with evidence of treatment effectiveness by his references to such methods as Neurolinguistic Programming (NLP) and sensorimotor psychotherapy. These therapies, which Plamondon apparently finds admirable, are without acceptable research support. It is not illegal to use them, but it would be difficult to argue that such use is demonstrably in the best interest of the public. In some cases, methods used by alternative practitioners are not only ineffective, but potentially harmful—as in the case of “conversion” therapy and the related “holding” therapy.

These facts lead us to a second issue about education required by licensing standards. Licensed mental health practitioners have to show that they have been through educational programs that included study of professional ethics. Unlicensed practitioners may be perfectly ethical people in their daily lives, but may be without training in some of the special issues of professional ethics. For example, in daily life, it is “not nice” but not strictly unethical to tell a juicy piece of gossip that has been disclosed to us; in mental health practice, confidentiality is an ethical obligation  that may be handled well only if someone has been trained to think clearly about conflicting motives and benefits. (Does the psychologist tell a patient’s family member that the patient seems to be considering suicide? ) Similarly, in daily life, it does no harm for someone to socialize with a person he employs or works for; in mental health work, the wearing of “two hats” in dual relationships creates a variety of ethical problems, which may be avoided only when earlier training and practice have alerted a practitioner. No one would claim that all licensed mental health professionals are always able to make the right choices in professional ethics (as any state’s list of disciplinary decisions shows), but a requirement of appropriate education excludes from practice persons who have never received formal instruction about ethical choices.

In his earlier comment, Plamondon suggested that patients who have been injured should bring personal suits against mental health practitioners rather than bringing a complaint to a licensing board. Let me point out that personal injury suits are time-limited and in some states cannot be brought more than a year after the event that caused the claimed injury. Although it can happen that the time limit clock starts when the person realizes that an injury was done, in that case the defense for  a practitioner may be a motion to dismiss the case because the individual “should have known” earlier that there had been an injury caused by a treatment. A number of suits by adults who were harmed by inappropriate mental health practices when they were children have failed because the individuals did not manage to understand that they had been harmed and to find counsel for several years after the 18th birthday. Thus personal injury suits are often ineffective ways to obtain redress for people who have been harmed by alternative mental health practices. Similarly, suits for fraudulent deception are likely to fail either on the ground that an injury or loss cannot be clearly demonstrated, or on the ground that the practitioner believed the treatment would be effective and not harmful. Protection of commercial speech in the United States makes fraud even more difficult to prove.

Because of the difficulties of finding justice for people who have been harmed by alternative or unlicensed mental health practitioners, I would argue that in spite of many and various holes in the system, the best choice for the patient is a licensed mental health practitioner, and the best governmental  choice is to continue and strengthen licensing requirements.      



Tuesday, June 2, 2015

Why Can't They Tell Which Patient Will Kill Somebody?

Recently, someone commenting on a post on this blog asked me to explain why I had said that diagnosis of mental illness in research did not have to be, or at least was not, as accurate as was needed in treatment of an individual. The writer pointed out that therapists may make a diagnosis not so much because it is accurate but because it allows particular treatments or services to begin. This is certainly true, and it’s also true that psychosocial treatments are often directed at specific symptoms that are troubling rather than at some underlying condition that has been diagnosed. That’s a good idea in many cases, especially when the proposed condition, like Reactive Attachment Disorder, does not necessarily have the causes that are posited for it.

My remarks were not about how things actually are, or about the best they can be in light of various social and political pressures. Instead, I was thinking about the kinds of questions researchers and therapists are asking, and the ways these questions differ from each other. Researchers are almost invariably asking whether one group of people is different from another, or about what will happen to a group given one treatment, as compared with a group given another treatment. They expect some variability within groups and would be surprised and even suspicious if everyone in a group acted the same way. They also accept the fact that diagnostic measures vary in their accuracy.

Therapists, on the other hand, want to know what will be the effect on a particular person of a treatment or experience. They have much less wiggle room than researchers do, especially in cases where a patient may or may not behave violently. We are all aghast every time we read that a formerly violent patient was allowed a weekend pass from a hospital, went home, and chopped up his mother with an ax. “Why didn’t they know that would happen?," we demand.

A useful article in Science (“What is the question?, by Jeffrey Leek and Roger Peng, 20 March 2015, pp. 1314-1315) provides some ways of thinking about these issues. Leek and Peng even give a great flowchart, and I am going to shamelessly follow their description of making decisions about the kinds of questions that are being asked by researchers, therapists, and lots of other people.

The first question Leek and Peng ask about how people think about information they have available is, “did you summarize the data?” If this hasn’t been done--  for example, if there are only anecdotes or testimonials in use—there is no data analysis, and no prediction can be done. (For example, about whether a particular treatment produced a better outcome than another did. )

If the information was summarized, but reported without any interpretation, this was a descriptive approach, but again no prediction can be done.

What if the information was not only summarized, but interpreted—but there was no attempt to decide whether the patterns seen would be repeated in other circumstances? Work of this kind is exploratory. Whatever patterns or connections exist between factors (like treatments experienced), they still need to be confirmed by more work.

Did the study quantify the differences observed and calculate the probability that they would be repeated? If so, there are further questions to be asked. The first one is whether someone is trying to figure out how the average of one measurement affects another measurement. If this is not being done, the next question is whether the goal is to predict measurements for individuals. No? Then the study is an inferential one, which just looks for relationships between factors. Yes? The study is a predictive one. It attempts to predict what will happen with a single individual--  but without being able to understand how or why effects occur, and therefore without real certainty.

Suppose there is an effort to find out how changing the average of one measurement changes another? This may be a study that is causal in nature. It can demonstrate that a group of people receiving a treatment do better on average than a group receiving a different treatment, but is not able to predict which people will do well or poorly—only the average change in risk or benefit is calculated. Leek and Peng give the example of smoking as a risk factor for lung cancer. As we all know, some people who smoke will be very badly affected, and others affected very little, but the whole group of smokers will be more likely to have lung cancer than the whole group of non-smokers (some of whom will get lung cancer too). To take a psychological example, we have the evidence that of depressed people taking antidepressants, many will do better than a matched group without the medication, but some in both groups may kill themselves.

The highest level of explanation involves a deterministic or mechanistic analysis. In this case, the evidence shows that changing one measurement is reliably and exclusively followed by a specific change in another measurement. As Leek and Peng put it, “Outside of engineering, mechanistic data analysis is extremely challenging and rarely achievable.”

When researchers are working on psychological changes in groups as a result of treatments or experiences, they may be working at anywhere from an inferential to a causal level, but their concern is still about average changes in groups. If therapists are trying to be predictive, they may not be able to do a good job of prediction if (as is common) they really do not understand how or why certain results are brought about. Without understanding what events lead to the patient chopping up Ma with the ax, predicting that event is hard; it may be right most of the time, and most weekend passes do not lead to mayhem, but the predictive failure makes it clear that the cause of the behavior is not well understood. However, the more accurate the information is—for example, the better the diagnosis—the better the chances that the individual prediction will be correct.

But human behavior rarely involves a single event that is always and exclusively followed by another specific event. Instead, a broad range of events work together to bring about most outcomes, even those that seem quite isolated, like an ax murder. In aeronautical engineering, factors like wing design can directly affect air flow, but human behavior probably has few factors that are the sole cause of an event. Predicting individual human behavior is much more like meteorology, in which a broad range of factors can determine thunderstorms (does that cold front keep moving or not?) or ax murders (does Ma take the opportunity to tell the patient who his real father is?).  Not all of these are known—or even can be known—at the time of the prediction.


Wednesday, May 20, 2015

Why Was Xenia Antonova Placed in a Mental Hospital?


Yesterday I commented on the conviction and sentencing of a Georgia man, Michael Grismore, for the sexual abuse of his Russian adopted daughter, Xenia Antonova. Xenia was born in 1994 and had been in the United States since 2001, when she had been adopted by Grismore’s wife’s sister. In 2009, she was “re-homed” to live with Grismore and his wife. In 2010, when she was not yet 16, she was sexually abused by her adoptive father, and her teachers were fortunately attentive enough to notice that something was wrong and to bring the police into the picture. (That there was physical evidence of molestation on Xenia when she went to school suggests that Grismore had done his thing just before she left home; I’ve always felt uneasy about the song “Good Morning, Little Schoolgirl”, but now I don’t think I’ll care to hear it at all.)

According to Russian sources, Xenia was placed in a mental hospital until the age of 21. Not surprisingly, considering Xenia’s right to privacy, there are few specifics about this on the Internet, but the original placement was said to be in an orphanage in Georgia. Whether this actually meant a group home or therapeutic foster home has never been clear. If one of those was the placement, I would have expected the placement to end when she was 18. However, she is now either 21 or soon to be 21, so we can expect that she will be leaving any placement in short order.

Why was she placed in a hospital at all? Her story up to the time of the revealed abuse does not indicate mental illness that would need to be treated at an inpatient level. Because of her cleft palate history, she may well have needed speech therapy, but she appears to have been attending school normally, and her relationships with her teachers were good enough that the teachers noticed her distress. Her background was certainly a difficult one, but severe mental illness is not simply the result of such a background. Her experiences with Grismore could have produced PTSD or depression, but these would not normally be treated by hospitalization.

What I am about to say is the purest speculation, but as an explanation of this unusual move to hospitalize a teenager, I would submit that there may have been reasons other than Xenia’s best interests at work. To put it bluntly, who wanted her--  or perhaps I should say, who wanted her and could be considered to be suitable caregivers for her? Her first adoptive mother had already relinquished her and could not be expected to come forward at this point. The second adoptive mother, Mary Grismore, would ideally have cared for Xenia, but perhaps she can be forgiven for failing to help the girl who, she may have felt, had broken up her marriage and sent her husband to prison. (However untrue this was, it is the kind of thing people think as they strive to put together the wreckage of their lives.) Indeed, what would have happened if Xenia had stayed in the same community and continued to attend the same school—a girl of unusual background, possibly with some speech impairment, and now labeled as sexually experienced and vulnerable? As for a new adoptive family, there are few who would care to take on this set of potential problems, and those who felt they would be interested might well be too na├»ve to know what they might be getting into--  or might have motives that are all too easily guessed.  

Hospitalization may have been a solution that removed Xenia from the scene and allowed the community, including her adoptive mother(s), to forget what had happened.

However, there are other issues to consider. A group foster home might have been the right answer for Xenia, but because she was already in the Georgia system, this would have had to be in the state of Georgia (and the Internet indications are that she has remained in Georgia). Georgia, however, has been a hotbed of the “alternative” attachment therapy/holding therapy beliefs. In 2009, a year before the revelation of Xenia’s abuse, Georgia social workers published  an article approving the use of attachment therapy (Wimmer, J., Vonk, M.E., & Bordnick,P. (2009). A preliminary investigation of the effectiveness of attachment therapy for children with reactive attachment disorder. Child and Adolescent Social Work Journal,26, 351-360). In this article, and elsewhere, there is reference to a state program teaching social workers a view of attachment and of attachment disorders that is not based on evidence or conventional theory.

Contrary to the recommendations of Chaffin et al (2006), in the report of the APSAC task force on attachment issues, the Georgia version stressed the importance of early experience over actual symptoms of mental illness, encouraging parents and adoption workers to assume that if a child had been adopted, he or she was very likely to have Reactive Attachment Disorder. Xenia, of course, was adopted, and although she had been with her birth mother for the first five years of her life, her physical problems may well have entailed separations and discomfort--  events that proponents of attachment therapy consider to be causes of attachment disorders. It is certainly true that children who have certain symptoms are likely to have had problematic early histories, but it is not equally true or logical that children with problematic early histories necessarily show symptoms of any mental illness. But it has been common for adoptive parents and adoption workers to make that assumption, and therefore to attribute to adoptive children mental disorders that they do not actually have.

What if someone with authority assumed that Xenia had an attachment disorder? This might mean that she would also be expected to show some undesirable behaviors, like sexual acting-out, lying, and making false complaints of abuse. These are not actually symptoms of attachment problems, but they are believed to be so by proponents of attachment therapy/holding therapy. People holding such a belief system might well see Xenia as the instigator of her adoptive family’s problems and prefer to send her for “treatment” rather than consider what she would need in the following years in order to become an independent adult. I also have to wonder whether Xenia’s story shares some aspects with the 19th century attitude toward female sexuality that committed to mental hospitals women whose sexual lives broke the rules--  whether at the women’s desire, or otherwise.


I am hoping that when Xenia emerges from her incarceration—longer than her adoptive father’s prison sentence, by the way—that she will tell her own story. But I think we must expect that her educational opportunities and chances for normal world experience may have been few, and her wish may be only to hide for a while.

5/26/15: an e-mail from a person who claims to be familiar with Xenia's situation states that there was no "mental hospital", but instead some "therapeutic foster homes". I inquired what sorts of places these were and what treatment Xenia received, but got no answer on this. My impression is that this term, when it is used with respect to psychological treatment, often implies an "attachment therapy" viewpoint, coupled with related treatments.