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Concerned About Unconventional Mental Health Interventions?

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

Monday, June 22, 2020

Interview With Susan Gerbic About Parental Alienation

This is a little over an hour long:


https://youtu.be/pD4CTPG-HAI

ADHD, FDA, and Video Games


Recently the Food and Drug Administration approved a video game that is purported to be helpful as a treatment for attention deficit hyperactivity disorder (ADHD). Parents and teachers are often concerned about kids whose behavior indicates ADHD, as their inattentiveness and high activity level combine to cause problems for their learning at school and at home, and serves as distractions to their teachers and parents as well as to other kids. The adults are bound to find attractive the idea that having the children play a video game can help improve their focus and self-control.

I’m not going to state the manufacturer or name of the specific game that was approved by the FDA. It doesn’t really matter, and I’m not in the business of telling people what to buy or not to buy. What is important is that people always need to find out certain things before they decide to put their resources into a treatment.

An important question is, who paid for the research? Obviously, research funding can come from neutral, objective sources who have no reason to want one outcome or another. But it can also come from highly interested parties—and in this case that’s what happened. The manufacturer paid for the research and got the outcome they wanted. When we say that a treatment is evidence-based, however, we ask for two independent researchers both to show the beneficial effects of the treatment. If someone unconnected with the manufacturer got the same results as the people funded by the manufacturer, that would be something to encourage us to use the treatment.

A second important question is, what does the outcome have to do with the original problem? Lots of treatments have effects, and it can be seen that they make a difference of some kind. The question is whether the difference they make is relevant to the problem everyone was worried about. In this case, that has not happened. The kids played one video game and their attentiveness was measured. Then they played another game 100 times, went back to the first one, and their attentiveness had improved—voila, a desirable outcome. However, none of the ratings by their parents, of attentiveness and so on, were improved. If the wish had been to create a treatment that would help the kids play video games better, this one would be good, but of course that was not the point of treating ADHD.

Just because we (in general) always hope for a pill or a potion to “fix” problems of development and behavior, rather than to have to do any difficult work, there will always be offerings of this kind. I mentioned one a while ago: “Forbrain” , which according to its website “energizes” the brain when you speak using a bone conduction headset. How you know whether your brain has or has not been energized is not mentioned. That’s typical of devices offered to treat autism, speech and hearing problems, and attention difficulties—even some that seem highly plausible and were created by very knowledgeable people.

The difference between the ADHD video game and the others is that in the ADHD case the FDA has approved, suggesting that the game has been found both safe for use and effective. That last part is questionable, as I have pointed out. And this is a prescription game, sounding very impressive and encouraging parents and teachers to see it as worth a try, whatever it costs.

It all amounts to caveat emptor. Ask the right questions!

Wednesday, June 17, 2020

The "American Psychological Association Review"


A colleague recently called my attention to the website https://americanpsychologicalass.com/. This is one of many Internet sites that argue in highly personal terms against “parental alienation” and claim that a former spouse and a judge have interfered with the author’s relationship with his [usually] children. Kenneth Gottfried was told he could not have contact with his children following a psychological evaluation. The two teenage girls had stated that they did not want to see him, a situation that Gottfried attributed to “alienation” on the part of the girls’ mother.

This is a sad and all too common situation, and I would say nothing about it except for the fact that the unfortunate Gottfried has become a megaphone for spreading the questionable views of the “parental alienation” advocate Craig Childress. I think I am right in assuming that Gottfried has not spent his time studying the various aspects of psychology he mentions, but that he has picked up his claims from Childress, either directly or via Internet.

The thrust of Gottfried’s statement is that the American Psychological Association is responsible for “countless” deaths associated with judges’ decisions not to give custody of children to one of their parents.  The deaths he refers to are said to include a case of what he apparently means to call “self-immolation”.  Gottfried claims that he has personally witnessed 30 deaths of separated parents in the last 4 years, but does not provide any evidence for this statement. He also appears to think that such deaths would not occur if APA were to recognize “parental alienation”; he does not say how such recognition would affect courts or parents. It may be that Gottfried confuses the American Psychological Association with the American Psychiatric Association, both confusingly referred to as APA. The latter is responsible for DSM, the Diagnostic and Statistical Manual of Mental Disorders, and in preparation of the 2013 edition declined to include “parental alienation” as a diagnosis. No actions by the American Psychological Association would determine inclusion of a disorder in DSM.

Gottfried uses a letter written by APA to argue that the organization knows it is contributing to causing deaths. The letter, however, is on the subject of separation of immigrant children from their parents, and refers to suicides in that group. Although abuse of analogies is common in arguments about “parental alienation”, to conflate families where children avoid one parent with parents and children involuntarily separated (and poorly treated)  is surely the achievement of a new rhetorical low.

I am a member of APA (the psychology one) but hold no particular brief for the organization and would like to see quite a few changes in it. However, although I see no way APA can or should make the moves Gottfried proposes, I think I can guess why he thinks what he does. His positions stem from those of Craig Childress. It’s my opinion that these Gottfired charges against APA stem from the events two years ago when Childress and some of his adherents delivered a petition to the APA headquarters in Washington, DC. Childress had made excited announcements on the Internet about how they were going to do this and what APA might do in response. I wasn’t present at the delivery, but what I have gathered is that someone in the office took the petition and said “thank you” and the Childress group then left. That was, not surprisingly, the end of that. But Childress has been muttering about this for two years. He has also been muttering about the events involving his presentation at a conference of the Association of Family and Conciliation Courts group, which culminated in having APA cancel the continuing professional education units that had been planned for presentation attendees. This led to even more fulmination against APA, and more recently against AFCC, with some special personal remarks about the AFCC head Matthew Sullivan.

What do I see on americanpsychologicalass that makes me so sure that Childress is behind this? For one thing, there is the very fact that Childress is referred to. He is barely mentioned in the literature about “parental alienation”, although Jennifer Harman (not Harmon, that’s someone else) in 2018 said she thought there should be some empirical research into his ideas.  Gottfried did not come across Childress by picking up a professional journal article, but by seeing and being drawn into Childress’s and his followers’ large and noisy Internet presence.

I also see Childress in a number of references made by Gottfried. Anyone who has read Childress’s self-published work will recognize the tireless repetition of certain names: Bowlby, Bowen, Minuchin, Madanes--- and then more recently, van der Kolk and Tronick. The connection of specific ideas to Childress’s work is not elaborated  anywhere, and connections are made by jumping rather than step by step. For example, citing Bowlby’s discussion of attachment, Childress arrives quickly at the conclusion that a child who avoids one parent has had his or her attachment system suppressed.

There’s more Childress in this site, but I’ll just point to the lengthy and meaningless discussion of APA ethics guidelines by Gottfried. Childress rather specializes in describing how unethical other professionals are, especially with respect to the use of the best science. Those who disagree on various points with the “parental alienation” approach are said to be  outside the boundaries of their competence and therefore in violation of ethical guidelines.

It would be easy to look at americanpsychologicalass and conclude that it was the work of an individual angry and frustrated man, and of course it is. But there is more to it than that. On that site we see an amplification of the views of a psychologist whose claims about parents and children are recognized as concerning by many professionals but few laypeople. These views are potentially harmful to children and families because they encourage courts to order unnecessary separations and ineffective treatments. Please, readers, if you find yourselves confronted with the Gottfried site or anything like it, understand that there is more here than fury and goofy ideas. These arguments have the power to do harm and need to be countered.  





Attachment and "Parental Alienation"


When thinking about parental alienation (PA) issues in the United States, I usually think it makes sense to consider a child age range of about 9-17 years. It’s rare in the U.S. to have a child less than 9 who is claimed to show PA when he or she avoids one parent. This narrow age range is one in which issues about attachment—if any—are much different from those we see in infants and toddlers. Some PA advocates, like Craig Childress, propose that when a child avoids a parent this means that something has damaged her attachment to that parent, or even “suppressed” her whole attachment system [don’t ask me, I’m just reporting the news here], but this is hardly likely for 9-17-year-olds, whose social focus is less and less on their parents and more and more on their peers.

However, it does seem that in some cases PA concepts are applied to much younger children. My first introduction to PA occurred when I was contacted by the grandmother of two preschoolers who had been taken from the mother on the grounds that she had caused their avoidance of their father. Those children were certainly at ages when attachment to a familiar caregiver is the focus of a child’s life and when abrupt, long-term separation from that person causes deep distress, grief, and lethargy that may last for months.

Some European colleagues are also telling me that they see PA allegations in situations where toddlers and preschoolers are concerned. They express concern over the impacts on young children of being forcibly removed from a familiar parent and placed in the custody of one whom they essentially do not know (their biological relationship being of little import here). Others have argued, to the contrary, that one parent may prevent the child from having contact with the other on the grounds that their attachment will be harmed if that happens.

I want to comment on these highly fraught situations where parents are in enormous conflict over the custody or parenting of a preschool or younger child. First, though, I want to say that I am going to talk only about the role of attachment in parenting decisions when all else is equal. I mean: this is not about situations where there has been domestic violence, or physical or psychological child abuse, or child sexual abuse. Those all create their own unique dangers. I am going to talk only about situations where one parent wants more contact with the child , the child seems reluctant, and the other parent is resisting the change in contact--  but nothing else is wrong.

Point 1: How the child acts, and how parents can handle this, depends largely on how old the child is.

 A baby under 6 months of age is usually quite ready to socialize with whoever comes along and has not yet formed an emotional attachment to any individual. The young baby may object if handled clumsily by someone, or if someone fails to pick up on cues about what the baby needs, but this is not about attachment or about fear. However, even at 4 months or so, the baby may be quite distressed if someone stares blankly at her and does not change expression or move in response to the baby’s social signals.

After 6 months, but usually before 12 months, babies begin to form emotional attachments to people whom they see frequently and who behave toward them in sensitive and responsive ways. They often indicate that this developmental change is occurring by showing fear of strange things and even by being startled and frightened by some things that have happened before (noisy garbage trucks, jumping dogs). They try to stay near familiar people and avoid strangers—often, they will not look at a friendly stranger who approaches them, and will even cry if the person keeps looking at them. If left in a strange place without a familiar person, they cry and will not look around with interest or try to explore, even though they will explore the same place if a familiar person is there.

Babies of 10 or 12 months and toddlers also show a behavior called “social referencing”. If they meet a new person or a new kind of object, they look at the face of a nearby familiar person. If that person looks frightened and seems to be looking at the new person or object , the baby backs off and will not approach the unfamiliar thing. If the familiar person smiles and looks relaxed, the baby goes ahead to explore the new person or object.

As toddlers get to be two or three years old, and as they learn to understand and use language, they can cope much better with unfamiliar situations. They may go to child care or preschool, encounter new babysitters, and develop better social skills. If they are tired or hungry or sick, however, they still seek familiar people and reject everyone else. (Of course, when sufficiently cross they may reject a familiar person too!) If they cannot find the familiar person, or if their separation goes on for a long time (weeks), they may show serious distress and take many weeks to recover; even if reunited with the familiar person become clingy and anxious.

Some children are much more intense in their negative reactions than others. They have temperamental differences that are biologically determined. A child who takes a long time to adapt to child care or who is predictably seriously frightened of clowns or masks or large groups of people is also likely to show more intense reactions than others to separation or to strange people and places.

Point 2: Can knowing about attachment behavior help people?

 Yes, knowing these things helps parents know how to handle the distress of young children as they visit a parent they do not live with—if the parents give it some thought. The awareness that such distress is natural may (I hope) prevent suspicions or allegations that one parent is causing the child to hate or fear the other. Let’s look at possible things to do for different ages.

For the youngest babies, under 6 months, if the baby is getting distressed about clumsiness or a withdrawn expression, the solution is for the adult to learn to behave differently. More contact and more daily care will help the adult learn to engage the baby in care routines to the satisfaction of both. “Staring” or looking withdrawn is a different problem. Some adults can do better if they know they are looking a certain way, but others may be depressed, anxious, or distracted, and those things are harder to handle. It will be helpful to everyone to know that the baby is responding to the facial expression and not to the individual, however.

For older babies and toddlers, there are a lot of issues that may need work by the adults. If one parent is actually frightened of the other, a toddler doing social referencing may quickly catch on to this and also be frightened, even though the frightened person has no wish for this to happen. An older baby or toddler may also be frightened and resist a parent who is not often present and may become distraught when approached—and even more so if taken away from home. These are normal behaviors of typically developing children and are not taught or caused by one of the parents. There can be improvement if both parents behave calmly and give the child plenty of time to warm up; there can also be worsening if people are hasty, argue, or are demanding or rough. Toddlers are most comfortable in familiar places, so if it is possible for the child to stay at home and the parents to switch places for a time, the child will be more comfortable and will more quickly come to accept both parents as familiar attachment figures.

Times of transition, including bed time, are always the most difficult for toddlers and preschoolers to handle, even if there is no family separation or conflict going on. In perfectly happy families, young children may respond to a transition by pushing away one parent and saying they want the other; the next day they may reverse who they want. It’s the transition that’s the problem. So, when transferring a young child from one parent to the other after divirce, it would be surprising if everything always went smoothly. Crying when going from father to mother probably does not mean that father abused the child. Crying when going from mother to father probably does not mean that the mother has brainwashed the child to make her afraid of father.

The very difficult problem here is that in a few cases these things have happened, and it can be difficult to know what is distress caused by bad events and what is normal transition complaining. But following the “black swan” rule, our first assumption should be that things belong to the more frequent category of events. If parents are prepared to deal calmly with times of transition, knowing that they are likely to include child crying and distress, everyone will be able to do better—to the advantage of the child, who is not helped if adults feel and show their own upset. If this does not help, it's time to explore carefully to see whether there is something one or both parents are doing to distress the child.

 It’s true that one of the real difficulties of divorcing parents is the attachment-related reaction of young children. They cry, they cling, they demand attention, they avoid unfamiliar people even more than usual, they need a lot of emotional support as they struggle to feel secure with both parents. This is all occurring at a time when one or both of the parents may be completely stunned by what is happening and want nothing more than to pull the covers over their head and hide for a month. One of the natural problems of being a parent is that the less you want demands placed on you, the more demands your young child will place. You have “gone away” from your usual availability, and the child wants you back.

It's tough on everybody. But let’s be careful about interpreting normal child separation behaviors as “parental alienation” or thinking that somehow the child’s internal working model of attachment has been smashed by a visit or the lack of a visit. Jumping to those conclusions only makes things worse in the long run.


  


Thursday, May 21, 2020

Disinformation about Attachment Disorders on "Grey's Anatomy"


A few days ago I was involved in a discussion about a “therapy” for children that featured rhythmic movement and was claimed to be effective for ADHD. In the course of that conversation, someone happened to mention that he had seen on the program “Grey’s Anatomy” a scene where a little girl was crawling on the floor in a hospital. When asked by a doctor what was happening, the mother replied that the child had an attachment disorder after being adopted from China and the crawling on command was part of her treatment. The doctor took this as perfectly ordinary and went on about his business.

I was shocked and disgusted at the presentation of this episode, which had nothing to do with the story line. I cannot think of any good reason why the scriptwriters would have inserted it. and I am concerned about its potential for harm to children and families.

I wrote the following to the contact people listed for this program by ABC:


"I am writing to express my concern about some misinformation conveyed on an episode of "Grey's Anatomy" that was aired on Jan. 20 of this year. The specific material that concerns me is summarized at https:/greysanatomy.fandom.com/wiki/Suzanne_Britland.


There are many wrong ideas in circulation about attachment, attachment disorders, and possible problems of adopted children. When adoptive parents believe incorrectly that their children are likely to have certain problems, they may seek treatments that are unnecessary and that may cause both direct and indirect harm. Unfortunately, the episode in this case may well have reinforced some of those mistaken expectations.

Here are points of particular concern:

  1. The child is described as adopted from China and  as having an undefined "attachment disorder". Adopted children, from China or elsewhere, are no more likely than others to have any form of attachment disorder provided that they are adopted early and well cared for by their adoptive parents. To suggest that there is an obvious connection between being adopted and having an attachment disorder is a mistake. The suggestion conveys to naive adoptive parents the idea that they should expect their adopted child to have such a disorder and perhaps should seek preemptive treatment even though there are no signs of difficulty in development. There is a cottage industry of "coaches" and "educators" who will be happy to take the parents' money and in some cases to use treatment methods that are potentially harmful. If the children do have other problems, for example speech and hearing disorders, seeking treatment for attachment problems will delay the interventions they really need.
Incidentally, the child's behavior, clinging to her mother in this frightening situation, would indicate that there is no problem of attachment at work; this is what we would expect of a typically-developing child of her age.

2. The treatment for the notional attachment disorder is represented as involving crawling on command.  There are several problems here. One is that a self-described parent educator and therapist who claims to work with attachment disorders has asserted that she is able to diagnose attachment disorders readily because the children cannot crawl backward when told to do so. There is no evidence that crawling either backward or forward is in any way associated with disorders of attachment, and I wonder whether the use of this idea in the episode indicates the influence of the "educator". Second, the idea of crawling as a therapeutic method is connected with the "patterning" fringe theory of the 1970s, which asserted that the act of crawling in some way replicated early brain development and insured that the two sides of the brain worked in coordination. This idea was a fad for a while among educators and some parents, who accepted without evidence the belief that crawling could cure autism, cerebral palsy, and other serious physical and mental problems. Third, that the child should crawl or do other things upon command is an aspect of  a fringe theory that mistakenly equates attachment with obedience to adult authority.

I realize that the purpose of "Grey's Anatomy" is entertainment and not education, but I believe that entertainment can work very well without introducing unnecessary misinformation--  even disinformation-- into the minds of some viewers who may because of their own situations be all too ready to accept and even act on it. If the program had introduced similar misinformation about physical illness, I am sure there would have been prompt complaints and an effort to correct what had been done wrong.

I would really like to hear from you that the same sort of response will occur in this case, where the issue is the treatment of children who cannot act to protect themselves.


“Grey’s Anatomy” and other entertaining programs can do a real service by presenting accurate information, although of course that is not their major purpose. But there is no real excuse for their including false beliefs. Wrong information about attachment and attachment disorders has been on television programs for years, of course. If I remember correctly, “CSI” had an episode based on Candace Newmaker’s death, but they changed the cause of death to an allergic reaction (nobody’s fault) rather than the actual asphyxia, so the presentation of the treatment was inaccurate. “Child of Rage” is still showing regularly and convincing the na├»ve, including quite a few of my own students, who were convinced it was a real documentary. Go back far enough and you will see Elvis Pressley in “Changes of Habit”, curing an autistic child by holding therapy.  It’s time this stopped, however.

It will be interesting to see what response I get from ABC.

Saturday, May 16, 2020

The Fable of the Bears and the Holding Therapist (Long After Aesop)


Once upon a time there was a holding therapist who was convinced that all problems were due to brain chemistry; at least, that was what he told people who came to him for help. He advertised that he could do great things for adopted children, and as the parents had been warned by their adoption agencies that the children would probably have certain mental problems, many of them sought the therapist’s help even though their children seemed fine, out of fear that terrible symptoms would show up later. “It’s simple”, the holding therapist told the parents. “Your children are dependent on cortisol, the stress hormone. They like to be stressed so they do things that will disturb other people. And, because you are living with them, you have become addicted to cortisol too.” “Hmm! “ said one parent. “Then why don’t we like all the stress the children cause?” “You only think you don’t like it, “ replied the therapist. “Actually you and the children need your brain chemistry fixed and I will fix it by showing you how to hug correctly. That will shift your brains from cortisol to oxytocin. Oxytocin is the love hormone and it will make your children attached to you and you will all be happy.”

Then the holding therapist set off to walk home through the forest. He was pleased with his day’s work. But after a while he came upon a mother bear and her two cubs. The mother bear was eating raspberries on one side of the path and the cubs were eating blackberries on the other side. Just as the holding therapist came near, the mother bear began to growl loudly and the cubs growled too in their squeaky voices. The holding therapist was not afraid, because he knew how to replace their cortisol with oxytocin. “Look! “ he said to the mother bear. “I’ll show you how to hug your cubs and then you will all be happy and loving.” So he went toward the cubs. The mother bear knocked him down with one swipe of her furry paw and the bears ate him up, all except the teeth and the buttons. The cubs took turns wearing his spectacles. They were all very full and happy and loving to each other.

So the holding therapist was quite right, he did know how to replace cortisol with oxytocin, but the information was no longer very useful to him. Unfortunately he had forgotten that the mother bear’s high level of oxytocin made her very aggressive toward others as well as loving to her cubs. Also, the bears were hungry, so there was more at work than just stress hormones.

MORAL:  Hormones and behavior are a lot more complicated than holding therapists tell you.

Here is an illustration to this fable: https://en.wikipedia.org/wiki/Morning_in_a_Pine_Forest
This shows the part after the holding therapist was devoured, so you will not see him. The artist regrettably forgot to put in the spectacles, or the buttons.

Friday, May 15, 2020

Yet More on Attachment Therapy in Russia


If you have read my last two posts about current attachment therapy events in Russia, you might be wondering whether the Frohock “seminars” are about something new, or whether their material is related to the attachment therapy versions of years gone by. 

I  have no intention of claiming that Frohock’s methods cause deaths or even injuries as we used to see resulting from holding therapy in the 199s and early 2000s. This is admittedly a low bar, of course, but it is a good idea to be clear on this. However, failing to kill anyone is not exactly evidence of effective treatment or even of the absence of injury.

Following the deaths of Candace Newmaker in 2000  and of other children in treatments associated with holding therapy, a number of practitioners asserted that they did not use any coercive methods. It became more common to speak of attachment therapy rather than holding therapy. The organization ATTACh stated that children were not held without their permission (although to what extent a child could freely make a decision about this is questionable), and Daniel Hughes together for a time with Arthur Becker-Weidman, spoke of using Dyadic Developmental Psychotherapy, a non-evidence-based method that uses holding but is said not to be coercive. Those practitioners who admitted to using holding at all reframed the practice as “hugs” or “loving embraces”. Their basic philosophy remained the same, however--  the children had problems, the parents were good, and the job of the practitioner was to make the child be different. Explanations of problems and treatments were characteristically treated reductionistically, as related to one or two aspects of brain chemistry like cortisol or oxytocin; physical contact was a key to causing changes in the child.

Frohock’s presentations in Russia may be advertised as the work of an extraordinary new thinker. The man himself presents his approach as derived from his experiences treating drug addicts and therefore as a novel way to work with children whose parents are concerned about him. On examination, though, we see the same old same old.

The concentration on adopted children is characteristic of the views of holding therapists from the early days onward. This has to do with their misunderstanding of attachment. In reality, emotional attachment, as seen in toddlers’ desire to be near a familiar person and willingness to explore only one such a person is close by, develops in the fourth quarter of the first year and in the second year. Attachment occurs readily under the tight circumstances but requires sensitive, responsive caregiving and limited numbers of caregivers. In contrast, the view of attachment given by Frohock and others is that it begins prenatally and is disrupted by adoption. Such disruption is followed by noncompliance, overt disobedience, and a lack of gratitude or affection for caregivers. Adopted children are thought to lack attachment even though they were with sensitive, responsive caregivers during the sensitive period for attachment, and therefore are expected to show attitude and behavioral problems. The recommended response to the problems (perhaps only anticipated rather than observed) is to apply treatments like holding to the child , rather than helping parents change so they can support the child’s development.

Frohock and his colleagues share those views with other attachment therapy proponents. They are not independent thinkers or originators of new approaches. For example, in 2016 Frohock was named an “ATN angel” by the attachment trauma network (https://www.attachmenttraumanetwork.org/atn-angels-kenneth-frohock-and-peg-kirby/ , as have other holding therapists before him.

As I have mentioned before, the reason for concern about spreading misinformation in these ways—whether in Russia or elsewhere—is not simply that direct harm may be done to children by holding therapy. Indirect harm to children and families is also done when family resources of time and money are expended on ineffective and possibly unnecessary treatment. Indirect harm comes not just from the use of these treatments, but from the expectations that adopting parents are given, leading them to look for “RAD symptoms” in their children and to be ready to seek “attachment” treatment whether the children need that (or indeed, whether they need any treatment) or not.

I hope that Russian adoptive parents will give some thought to this whole picture before they sign on to the Frohock seminars.

Wednesday, May 13, 2020

More on Attachment Therapy in Russia



Yesterday I wrote about the exportation to Russia of practices related to the “attachment therapy belief system” (ATBS) by Kenneth Frohock of the Attachment Institute of New England and his colleagues. I thank my Russian colleague Dr. Yulia Massino for the information she has provided about this matter. What I write today will be drawn from what she has shown me.
Further material from Frohock’s Russian presentations is at

Frohock asserts that problems of adopted children, as complained of by the adoptive parents, are in part due to their dependence on or addiction to the stress hormone cortisol. Prenatally exposed to high levels of cortisol, they have become dependent on it and seek stress in order to maintain the cortisol levels they are accustomed to. Thus, they need to be treated as if they were drug addicts—an analogy that enables AT proponents to assume that the children are manipulative, are liars, and are determined to have their own ways without consideration of others or even of their own long-term best interests. (It also brings in Frohock’s stated earlier work with addicts.)

Have many adopted children experienced high levels of cortisol in their prenatal lives? Yes, they probably have, as their biological mothers were often in high-stress situations and produced cortisol that circulated in the bloodstream and reached the fetus. Adoption stories always involve some sort of stress or even tragedy, without which no adoption would have occurred. It’s the rare case nowadays when a baby is adopted because the mother died in childbirth, or both parents were killed soon after the birth. Generally, the adoption occurs because the mother cannot care for her baby for various reasons, those reasons being present and causing stress throughout the pregnancy.

However, to blame concerns about adopted children on cortisol dependence is a bit like thinking that “anatomy is destiny”. Whatever brain chemistry is like at birth, it can and usually will change as a result of care experiences. The role of cortisol during birth is in fact paradoxical. Babies born vaginally have a peak of stress hormones during birth, and these hormones act to marshal the baby’s adaptations to life outside the womb—helping, for example, to change the prenatal arrangement of blood vessels around the heart and to make it possible to get oxygen effectively from the lungs to the rest of the body. Babies born by Caesarian section do not have the same experience, do not produce that peak of stress hormones, and are less alert and well-organized shortly after birth than they would otherwise be. This suggests that early experiences with stress and hormonal responses should not all be interpreted in the same way.

Newborn babies are usually not very good at self-calming. They lack the abilities to position themselves comfortably or to get the thumb to the mouth to suck. When stressed, they cry themselves to exhaustion unless a caregiver helps them calm. But after weeks or months of help in calming, well-cared-for babies develop their own self-calming methods and are no longer at the mercy of stress experiences. Whatever their prenatal experiences with cortisol may have been, they now have an opportunity to over-ride those effects and organize themselves to work with a lower level of stress. Of course, if they are sick or injured or poorly cared for, they may not succeed as well in learning how to regulate their emotions.  This suggests that even if stress has played an important role in a baby’s prenatal life, as is common in adoption cases, most adopted babies will be helped to overcome this problem, although it is reasonable to think that a baby who experienced prenatal stress and then did not receive sensitive, responsive care might have continuing difficulty.

Frohock suggests that adopted babies have special problems self-calming and basically do not want to be calm. This idea is rather difficult to test, as there are so many other factors such as temperament or drug or alcohol exposure that determine how fussy or difficult a baby may be. However, it is a huge mistake to assume that early experiences are “destiny”. Whatever actual harm to brain physiology or chemistry a baby may have experienced, its development does not stop at that point. Overemphasis on brain processes ignores the high plasticity of young children’s brain development—loss of a brain hemisphere in the early months is soon overcome by reorganization and development of the remaining hemisphere, compensating for most of the loss. 

Good experiences with caregivers can guide development in very positive ways, and experiences continue to shape development throughout childhood, adolescence, and even adulthood. Even when caregivers have not been managing well, both parent and child can get back on the best developmental track through evidence-based treatments like Parent-Child Interaction Therapy (PCIT).

Frohock’s view of stress-induced problems of infants is thus not in line with much of what is known about brain development. His further claims about stress effects are even farther off the mark. Having asserted that children are in essence “addicted” to stress hormones and behave in such a way that they experience high levels of these hormones, Frohock goes on to claim that adoptive parents develop a similar addiction as a result of being with their “addicted” children. Indeed, he says he becomes similarly dependent as a result of working with such families! It’s curious that he attributes such a high level of plasticity (the tendency to be affected by the environment) to human beings on the one hand, but on the other hand denies the possibility that normal family life can be a strong influence on the development of adopted children. These children, he seems to say, have low plasticity in this one area and must be treated with “intensive” methods including physical restraint. It's also curious that "addicted" parents (and "addicted" Frohock) are unhappy about the children's behavior-- surely, if they are dependent on cortisol, they would prefer for the children to create a high level of stress in order to keep themselves and the adults comfortable?

It’s all a bit contradictory and confusing, and suggests that Frohock’s experience treating drug addicts has provided him with a large hammer and the tendency to look for objects that need to be banged with it. Regrettably, he has found people who support his banging methods. For example,the organization of his seminars found funding not only from the Russian government fund, but from the charitable foundation "Arithmetic of Goodness",  created by  a vastly wealthy Russian businessman, Roman Avdeev, https://www.a-dobra.ru/wp-content/uploads/Aprel_2_compressed_min_min_1.pdf , which advertises Frohock’s seminars. ( My thanks to Dr. Yulia Massino for this source and translation.)

Is Avdeev a “true believer” in the Frohock claims? He may be, but my bet is that he has simply been persuaded by Frohock’s confident statements of success. Surprisingly few people understand the first thing about attachment, and surprisingly many are willing to accept almost any statement that references attachment. Unfortunately, they are deeply convinced that they know all about it. (If you say bonding, they’ll go for that too.) I was recently asked by a U.S. attorney, one very involved in child maltreatment issues, whether attachment theory was not based on a nursing mother’s care for her baby. Like many people, she mistook the adult side of the parent-child attachment relationship for the child’s side. I assured her that attachment theory was not based on parent behavior (however important it may be for guiding development), but on the infant-toddler pattern of staying close to a familiar person and protesting against separation. I am not really sure that she believed me! And I am not at all sure that Avdeev does not have similar—or equally inaccurate—beliefs about early development.

Some readers may be asking, "Why is this so important? Are people not allowed to believe what they want to believe and to make the choices they want?" Yes, of course, they are allowed to believe and choose for themselves. Whether they should be allowed to do this for their children is another matter-- and what about the choices people make that are not even about their own children? Spreading misinformation about child development and parenting has a number of possible bad consequences. One is that children may be mistreated, and it seems possible that Frohock's methods are mistreatment, as older forms of holding/attachment therapy certainly were. Less directly, misinformation may have two ill effects related to adoption. One is to make adoptive parents expect that children will show some unwanted behavior and signs of serious mental and behavioral problems, when this is not necessarily the case. These parents may see ordinary age-appropriate behavior and believe that it is simply the first symptom of real problems. A second issue is that people considering adoption may believe that any problem a child has can be treated successfully, and they may thus commit themselves to adopting more children than they can effectively care for and children with serious difficulties that will not be helped by treatments like Frohock's. These problems can result even for families that do not seek Frohock's treatment for their children. 


Tuesday, May 12, 2020

Attachment Therapy Goes to Russia


For quite a long time now, most of my posts have been about “parental alienation”. There are so many current PA events that it has been hard to ignore what’s happening there. However, there are a lot of potentially harmful treatments for children, and one of them is our old friend attachment therapy, AKA holding therapy. It has by no means disappeared.

Please do note that I am not talking about conventional attachment theory or about the thousands of research articles on the topic of developmental changes in social relationships. Attachment therapy (AT) is a fringe practice based on a couple of spurious ideas. One is that most behavioral problems in children, including disobedience, stem from a failure of emotional attachment in infancy and the toddler period. A second idea is that adopted children are most likely to display attachment problems, even if they were adopted on the day of birth and have never experienced problematic separations. Third, children who are noncompliant and aggressive are said to have Reactive Attachment Disorder, even though this real diagnosis has much different symptoms. Fourth, children said to have Reactive Attachment Disorder are supposed to be effectively treated by methods that include physical restraint, the restraint being thought to create attachment through a display of adult power and authority. These are the major tenets of what we might call the “attachment therapy belief system” (ATBS), a set of ideas that has existed on the fringes of mental health treatments since the 1970s.

Although professional organizations in the United States and elsewhere have officially rejected ATBS, nevertheless some practitioners go right on using and teaching it. My Russian colleague Yulia Massino tells me that ATBS is presently being taught in Russia by a group led by an American, Kenneth Frohock of the Attachment Institute of New England in Worcester, Massachusetts. Frohock and his followers have posted a number of YouTube pieces that give some insights into the kind of misinformation they are providing to adoptive parents and others in Russia.  Their presentations are apparently supported by a Russian government grant.

At various places among the presentations, Frohock states the need for holding (physical restraint) as a way to treat adopted children whose parents are concerned about their behavior and development. He suggests that holding may be required for children of all ages. As there has never been any empirical evidence that holding therapy is effective as a treatment for any childhood mental disorder, and as the safety of holding procedures is very much in question because of some past fatalities associated with it, I can say unequivocally that this is a mistaken  position for Frohock to take, and that it is regrettable that he is spreading misinformation to other countries.

His support of holding as a therapy is not the only problem in evidence in the YouTube presentations. My long-term colleague Linda Rosa kindly transcribed one of the presentations for me to use in discussion here. This presentation is at https://www.youtube.com/watch?v=9YPRHNRCV_Y.  In this presentation, Frohock describes his way of “reading” a child.

 First, he rejects the idea that the expression of the mouth is of value. The mouth, he says, indicates what a person wants you to think that they feel, rather than what they actually do feel. He attributes to children the ability to have enough cognitive empathy to understand how another person will respond to a given facial expression, and enough acting ability to change the expression to indicate some feeling that the child wants to convey to the observer. This would seem to be a tall order, especially for younger children, and Frohock does not indicate why he thinks they can do this.

Frohock goes on to say how he knows what the child is really feeling. He asserts that the eyes are important indicators, and the larger, rounder, and more infantile they are, the more they show a source of trouble that occurred early in development. Why this should be is not made clear, but perhaps we are looking at a concrete representation of the idea of fixation at or regression to an earlier stage—of course, I am only guessing at Frohock’s thinking. With respect to the eyes, Frohock also states that where the pupils are small, fear is indicated. It may well be that children in this form of treatment have good reason to be frightened, but ordinarily dilation of the pupils goes with fear (dilation  allows more light into the eye and may be helpful in a threatening situation).

Frohock also claims that kids can cry only on one side, the side being significant, and that they can “suck: back a tear that has brimmed over. Further, he associates shoulder posture with specific feelings--  “straight across” means that the child is scared, “slanted” means sad or shamed. Frohock remarks that he was not taught this, which indeed I can well believe, but figured it out for himself when working with addicts and gangs.

In this video and elsewhere, we have evidence that Frohock’s work jibes with the ATBS. He stresses adult authority as exemplified by holding and the focus on the child rather than a family system. He focuses on adopted children as likely to have attachment problems, to which he ascribes any later difficulties. In addition to these non-evidence-based claims, he thinks he has the ”art to find the mind’s construction in the face”—which he did not learn from anyone but invented for himself. Like other AT proponents, he presents himself as the only one who knows how to do these things—and like other pseudoscientific “alternative therapists”, warns that conventional treatment simply worsens problems.

There is a good deal more to be said about this Russian venture and I will comment further in the next few days.

N.B. The question is sure to arise: is what Frohock does actually holding therapy in the usual sense? The website of the Attachment Institute of New England mentions holding as a treatment. Frohock in his Russian presentations refers to "loving embraces" using language similar to that of Dyadic Developmental Psychotherapy. It would seem that these "loving embraces" must be enforced, as Frohock refers to continuing or threatening to continue the treatment for many hours. In my opinion, however good the intention, an artificially initiated embrace in which one person  is reluctant, however "lovingly" it is done, is not the same thing as a genuine loving embrace and has much in common with physical restraint in the form of holding. On the other hand, I have no reason to think that Frohock uses painful poking or tickling as part of the treatment, or that he shouts and demands that children shout, as was the case for the holding therapy prescribed by Foster Cline.