Thursday, July 2, 2015
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
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
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
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 naïve 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.
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.
Tuesday, May 19, 2015
I cannot find any U.S. news sources reporting on this story, but a Russian source (http://www.rapsinews.com/judicial_news/20150519/273744378.html) reports that a Cherokee County, Georgia man has been sentenced to three years in prison after conviction on three counts of sexual abuse of his Russian adopted daughter, Xenia Antonova. The Russian children’s ombudsman, Pavel Astakhov, testified in this case. Astakhov has pointed out that if Russia had been notified of the transfer of custody and parental rights that took place in this girl’s case, the tragedy might have been prevented.
Xenia was born in 1994 and was adopted in 2001 by Marta Blandford, a single woman living in Georgia, who already had one biological child and three adopted children.. Xenia apparently had some special needs associated with cleft palate and was small and thin at the time of the adoption. In 2009, for unknown reasons, Marta relinquished her parental rights in connection with Xenia and the girl was adopted by Marta’s sister Mary and her husband, Michael Grismore. In 2010, Xenia’s teachers noticed that something was wrong, and Xenia disclosed that Michael had beaten her and had oral sex with her (an act that might be expected to be especially distressing to a young girl with a history of cleft palate). Forensic tests confirmed that this was the case. Xenia was removed from the Grismore home and placed in a facility referred to as an orphanage by Russian sources. Grismore acknowledged the sexual acts (he could hardly deny them in the face of the existing evidence), but claimed that he had documents showing Xenia to be 16, the age of consent to sexual acts in Georgia, and stated that the acts had been consensual. Later investigation showed that Xenia was in fact still 15 at the time of the abuse.
This was clearly not a he-said/she-said situation. If Xenia did indeed consent to sexual acts with Grismore, which can’t be known, her consent was not valid because of Georgia law. In addition, the report of beating would seem to make her consent unlikely.
However, the question that crossed my mind when I read about this case was this: was the adoptive relationship not sufficient to make the sexual relationship incestuous and therefore illegal? In the United States, of course, Federal law does not govern issues of this kind. State laws all consider some sexual relationships to be criminal incest (see www.ndaa.org/pdf/criminal_incest%20chart%20_2010.pdf), but they do not all have the same rules about this crime. Some states describe certain relationships as being incestuous without regard to illegitimacy or adoption. Others list pairings that are illegal, such as stepfather and stepdaughter, with or without mentioning adoption as an issue. Some states consider criminal incest to have occurred only if the couple marry; others list a variety of sexual acts as incestuous, including oral-sexual contact and sexual insertion of an object. Some states include penalties for persons who might reasonably know that incest would occur and fail to prevent it.
The state of Georgia defines as criminally incestuous sexual relations between “Persons known to be (by blood or marriage): (1) Father and daughter or stepdaughter; (2) Mother and son or stepson; (3) Brother and sister of the whole blood or the half blood; (4) Grandparent and grandchild; (5) Aunt and nephew; (6) Uncle and niece.” The incestuous act is described simply as “sexual intercourse”. Georgia law thus fails to state specifically that sex, consensual or otherwise, with an adopted child is criminal incest, and also leaves it open to question what types of sexual activities would be included as incestuous in any case.
Georgia law requires imprisonment of an offender convicted of incest for not less than ten nor more than thirty years, a substantially longer period of imprisonment than Michael Grismore has been sentenced to. It’s important to realize that the apparent “slap on the wrist” of this relatively brief sentence is not an indication that the judge had a cavalier attitude toward Grismore’s crimes. In fact, the law as it exists in the state of Georgia determined how long the sentence might be. In Montana, life imprisonment might have been the sentence in this case. It may be hard for people accustomed to a more uniform criminal code to understand the varying laws of the somewhat loosely federated United States, but attitudes as shown by sentences in one state should not necessarily be taken as “American attitudes” in general.
Be all this as it may, Grismore’s crimes might have been prevented if Xenia had not been subjected to “re-homing” either completely informally or with rubber-stamping by caseworkers and the judiciary. I fully support the Russian request to be kept informed of the whereabouts of Russian adoptees in the United States. However, I must point out the number of times these informal transfers occur with American-born children as well. The recent case of Justin Harris in Arkansas involved such an exchange and came to light only when one of the little girls was molested by her “new daddy”. In the Harris case, the transfer was casual; in Xenia’s case, there seems to have been some legal processing of the change, but apparently not one that started from scratch with a home study. It’s time to do much, much better on these matters.
An unanswered question: where is Xenia now?
Sunday, May 17, 2015
A piece in the Week in Review section of the Sunday Times today described how the writer visited a New York post office, and looking at the rubber stamps available, discovered one marked PRETENTIOUSLY HAZARDOUS. I can’t let this golden trouvaille go to waste. It is the perfect category description for the whole attachment therapy-holding therapy- Nancy Thomas parenting-industrial complex, as well as for more than a few other treatment methods.
Some years ago, the clinical psychologist Scott Lilienfeld introduced the term potentially harmful treatment (PHT), to describe therapies that were already known to have caused harm to patients, or which might logically be expected to do so. This term, of course, did not mean that every use of a treatment would end in harm to a patient, simply that there was a reasonable possibility that this would occur. The PHT concept stressed the fact that despite the etymology of their name, “therapies” might actually do harm—that safety as well as effectiveness could be issues for psychological treatments. The idea of a PHT was not obvious to a Georgia attorney who cross-examined me in a holding therapy case; he argued that no harm had apparently been done, until I gave him the example of running across a busy highway and by some miracle not getting hit by a car-- he had to agree that this was a potentially harmful act that should be prevented, even though the runner came through unscathed this time.
The psychologist Michael Linden added to the PHT concept by pointing out that various types of harm could be associated with misconceived psychotherapies—for example, that the “emotional burden” of feeling distressed during treatment was harmful and should be avoided if at all possible.
So, why am I not content to call AT-HT-NTP potentially harmful treatments? Why not just point out the emotional burdens children experience when subjected to these methods? In fact, why not stick to the term “alternative psychotherapies”, which I have used myself to designate treatments that are without an empirical evidence basis, that are incongruent with established information about human development, and that are potentially harmful?
PRETENTIOUSLY HAZARDOUS treatments display problems in addition to those just stated as they retrofit theory and diagnosis to support treatment methods that are in fact derived from old ways of punishing children (perhaps even from the old German “black pedagogy”). Proponents of these treatments have spun out of straw a prosperous belief system which meets the definition of pretentiousness given by my big old Webster’s: “making claims, explicit or implicit, to some distinction, importance, dignity, or excellence”. The claims include the putting forward of an unfounded “attachment cycle” theory that states that attachment is affected by caregivers’ boundary-setting in the second year of a child’s life (such boundary-setting is important, but is not a factor in attachment). The “attachment cycle” concept is used to justify age-inappropriate actions like insisting on bottle-feeding a ten-year-old or hand-feeding sweets to a child. It is also used to justify intrusive and rigidly-controlling actions toward children that are defined as equivalent to boundary-setting.
The “attachment cycle” concept and related adult actions make the explicit claims to importance mentioned in the Webster’s definition of pretentiousness. But they in turn are based on an implicit claim that is all too easily swallowed by parents and other caregivers—in fact, that may be believed to a considerable extent by many adults. This is the claim of recapitulation, the repetition of earlier events, but it is not the old familiar but faulty idea that the development of the individual repeats events in the development of the species. This concept of recapitulation holds that it is possible to magically cause the recapitulation of past development, and to make it come right where it has gone wrong, simply by ritually re-enacting some past events that might be associated with the desired developmental change. For example, if a child is thought to have problems with attachment because she was not sufficiently cuddled as an infant, cuddling her now, feeding her with a baby bottle, and gazing into her eyes are thought of as ways to recapitulate and correct her early emotional life. If a child’s problems are thought to have come from failures of limit-setting in the second year, rituals of demanding that the child ask for everything he needs or sit motionless for long periods are considered to recapitulate and correct the earlier problems.
There are several problems that make such treatments PRETENTIOUSLY HAZARDOUS. One is that it is very unlikely that attachment does result from feeding experiences per se, and it is particularly unlikely that ingestion of sweet things is related to attachment in infancy. It is similarly unlikely that attachment is the aspect of development affected by boundary-setting. But suppose for the sake of argument we were to assume that those events did cause attachment in infancy? Why would we think that experiences characteristic of infancy would have the same effects on older children as they do on infants? To imagine that would be like thinking that an all-milk diet, healthy and appropriate for young infants, would also be suitable for older children with different nutritional needs and growth patterns. Magical recapitulation rituals cannot return children to the developmental needs and patterns of an earlier stage of life, and it is pretentious to claim that they do. In fact, one might well argue that it is fraudulent to do so.
It’s clear that AT-HT-NTP methods are PRETENTIOUS. Need I also argue that they are HAZARDOUS? Proponents of these methods have stated that they no longer lie down on top of children or do other things that have caused death by asphyxia in the past, and perhaps they do not. Nevertheless, the recent license revocation case of “Kali” Miller in Oregon has shown the suicidal response of a boy to treatments that did not risk suffocation but appear to have carried an unbearable emotional burden. In my opinion, this is hazardous enough to argue against use of any such methods.
These treatments are not prohibited, in spite of all we know about them. But there should be large PRETENTIOUSLY HAZARDOUS stamps on all their websites.
Friday, May 15, 2015
Periodically other people and I refer to an article purporting to discuss Reactive Attachment Disorder, published by Keith A. Reber in 1996 in a journal called Progress. This paper was cited as a foundation of the attachment therapy belief system by Chaffin et al in the 2006 APSAC task force report on attachment therapy and attachment disorders, a report that rejected the use of holding therapy and related methods. Reber’s paper used to be readily available on line, but is no longer easily to be found, and although I have it I can’t post it without exposing myself to complaints about copyright violation. However, I can write about the paper and about its author and his sources.
Let’s start by considering who Keith Reber is and what his professional history has been. He was at one time a marriage and family therapist and was associated in some way with the Phillips Graduate Institute in California (this institute was the publisher of Progress). From 1999 to 2001, Reber was a licensed MFT in Oregon, and in 2001 he was served with a notice of proposed revocation by the Board of Licensed Professional Counselors and Therapists for that state. In 2003, his license was revoked. The explanation for this decision can be seen at www.oregon.gov/oblpct/BoardAction/Reber.pdf.
According to the Board’s statement, Reber had agreed not to use holding therapy (HT) with children referred to him by a state agency, but did indeed use HT with three children who were temporarily placed with foster or potential adoptive parents. To place this action in historical context, I should point out what is not mentioned in the license revocation material: Candace Newmaker had died at the hands of HT practitioners in 2000, and this fact was widely known and of considerable concern, but Reber continued to use this dangerous and unsubstantiated approach despite state agency warnings and his own agreement not to use HT. Reber’s methods, according to the Board statement, were not the “nurturing, cradling hold” often mentioned in more recent times, but included wrapping the child tightly in a sheet, lying on top of the child, and thrusting his fist up into the child’s rib cage. These techniques were used with a child who had been sexually abused as well as with others.
To quote the Board report directly: “Licensee treated SM and VM (from approximately 1999 through 2000) and used holding therapy including wrapping them in a sheet and blanket, laying (sic) with his body on top of the children, pushing his elbow into their abdomen and/or stomach area so hard at times causing vomiting, and occasionally required the children to try to gain freedom from the blanket wrapping themselves, despite the fact that they were wrapped tightly”. [Candace Newmaker died from suffocation while trying to escape from such a wrap.—JM] In addition, Reber refused to release the children or stop the treatment when asked, but instead berated them.
The Board was also concerned that during its disciplinary proceedings, Reber, who had been given notice of a proposed license revocation, had applied for a MFT license in Utah and represented the license matter in Oregon as having been resolved, when it was not. (A curious bit of HT history intrudes here: Reber’s file was reviewed by David Ziegler, who stated that HT was not acceptable-- at almost the same time that he himself was publishing a paper that cited a number of European practitioners who were and still are strong supporters of HT! But-- am I just revealing that I have one of those small minds for which consistency is a bugaboo?)
So what happened next? The next part of Reber’s story is told at www.deseretnews.com/article/1001664/Orem-therapist-lost-license-over-controversial-methods.html?pg=all. Leaving the unappreciative state of Oregon, he went to Idaho and got a job as a counselor at a clinic associated with a child’s death through forced water drinking. Without his MFT license, Reber had claimed pastoral licensing through the Universal Life Church. Presently, it appears that Reber is licensed in Utah as a hearing aid specialist.
There we have a history of weak or nonexistent professional ethical standards—a background for the Reber 1996 paper itself. I will select some intriguing bits from that document.
Reber starts early in the paper to show that his assumptions are not those of conventional attachment theory, in spite of his attempts to use conventional terms and concepts. He cites Verney and Kelly, two APPPAH stalwarts, to the effect that “attachment begins with connectedness in utero”, starting before birth “on a neurological and emotional level”. He states that without critical interactions with the mother, the baby may “lose interest in the world, become ‘insecure’ or ‘anxiously attached’, or even die.” Even omitting the mistaken claim of prenatal attachment, we see here a peculiar list of problems. Insecure or anxious attachment, while not ideal, is well within the normal range and probably was the condition in early childhood of a large number of the people reading this. Losing interest in the world is a far more serious problem, but even maltreated children with disorganized attachment patterns do not show this. As for death—yes, emotionally-neglected children may die, but the causes of these deaths are much more complex than Reber implies. On the second page, we see the interesting statement that attachments “fall on a continuum between secure and insecure, with the normal child falling somewhere in the middle”. This seems to suggest that insecure attachment is really all right, even though it was ranked earlier along with apathy and with death.
But let’s abandon this entertaining journey through Reber’s ideas about attachment and move on to the specific misunderstandings this paper introduced into discussions of Reactive Attachment Disorder. After saying correctly that RAD is difficult to diagnose, Reber provides on his fourth page a table giving symptoms of RAD as collected from the files of the Family Attachment Center in Salt Lake City, Utah. Here we see the first claims in a supposedly peer-reviewed publication of the RAD characteristics that now turn up in newspaper articles. These include superficial engagement and charm, refusal to make eye contact, incessant chatter, fighting for control, indiscriminately affection with strangers but not cuddly with parents, destructiveness, cruelty to children and animals, stealing, lying, hoarding and gorging on food, preoccupation with fire, blood, or gore [I’ve always wondered what the difference may be between blood and gore—JM], lack of cause and effect thinking, lack of conscience, and abnormal speech patterns.
No doubt many children seen at the Family Attachment Center did have one or more of these characteristics. But where is the evidence that they had Reactive Attachment Disorder, alone or in addition to some other diagnosis? Answer comes there none, it would appear. Reber’s paper provides no reason to think that any of the concerning symptoms were in fact indications of RAD. In fact, other authors associated with this belief system, like Elizabeth Randolph, have specifically said that these symptoms do not indicate RAD, but instead a posited “Attachment Disorder” which is different. Not only does this symptom list have no part in descriptions of RAD in DSM-IV, DSM-IV-Tr, or DSM-5—even other proponents of HT did not accept Reber’s association of the list with RAD. But this has not stopped the constant repetition of claims about RAD symptoms, right up to the present day. As an example, I can point to the 2014 doctoral dissertation by Vasquez which I discussed earlier this month, a document that includes items from Reber’s list, and which gives a muddled in-text citation of Reber’s paper.
Where did Reber get his ideas? His table of information from an unpublished sources is one we can’t check on, but a look at his reference section tells a good deal. Here we see some errors suggesting that Reber is not on top of his material: the name of the psychoanalytic theorist Erik Erikson is spelled Erickson, suggesting that Reber has him confused with Milton Erickson, who advised sitting on recalcitrant children and feeding them cold oatmeal; even that ur-holding-therapist Robert Zaslow has his name misspelled. Other sources are Foster Cline, Rick Delaney (who needs discussion in himself, as he has “gone straight” but never really explained why), Jirina Prekopova, and Martha Welch-- all proponents of the most rigorous physical restraint techniques like those that got Reber’s license revoked. Finally, Reber quotes Robert Karen, the 1990s popularizer of attachment theory, and attributes to Karen the statement that in New York City there are one million children with Reactive Attachment Disorder-- this out of a population of 6 million!
Ordinarily, it might not seem very important to go over the mistaken statements of an obscure writer from 20 years ago, especially as his publication does not seem to be available on line any longer. However, the fact that Reber’s claims have been spread as factual through Internet and print journalism, and have been immortalized as checklists for diagnosis of attachment disorders, makes it necessary to trace those claims to their highly unreliable source. Even though, by a sort of psychological Gresham’s law, bad information remains likely to drive out good, it may be that a better understanding of background may help fight the misunderstandings that have spread and continue to spread.