Concerned About Unconventional Mental Health Interventions?

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

Wednesday, July 21, 2010

Potentially Harmful Therapies: Don't "Misunderestimate" the Problem

I was taken aback by a question I was asked a few days ago. This surprising question emerged in the course of my testimony as an expert witness in a juvenile court matter that focused on Holding Therapy, the physically-intrusive “complementary and alternative” treatment for childhood mental health problems. My interlocutor, the attorney representing one of the parties involved in the matter, first asked an ordinary question: was I familiar with a journal article from 2007 that discussed potentially harmful treatments? I asked whether he mean the article by Scott Lilienfeld (the man who has been called the Ralph Nader of psychology, but we can count on him not to be a third-party candidate for president). Yes, that was the one (Lilienfeld, S.O. [2007]. Psychological treatments that cause harm. Perspectives on Psychological Science, 2, 53-70). Lilienfeld had listed Holding Therapy as one of a group of potentially harmful treatments (PHTs).

Now came the surprising question. Well, said the attorney, what was the problem if the treatment was only potentially harmful? Lilienfeld had not said it was actually harmful; didn’t that mean he thought Holding Therapy was all right? My off-the-top-of the-head answer was that walking into the street in the face of heavy traffic is only potentially harmful to the individual who hasn’t done it yet, but it’s still inadvisable. And someone who tells you it’s potentially harmful does not mean it’s all right.

What does it mean to say that a treatment is potentially harmful? The dictionary definition says “potential” refers to something that hasn’t happened yet; it’s not “actual” (presently happening, or presently showing the effects of having happened.) “Potential” is “power”-- the power to have a certain effect. But how would we know that potential exists? What facts suggest that a treatment has the potential to do harm?

There are a couple of ways we would be likely to tag a therapy as a potentially harmful treatment or PHT. One is by making a comparison to the known outcomes of similar actions. Knowing other outcomes, or using logic, can we conclude that it is plausible that a treatment will be safe? For example, how about “compression therapy”, a CAM treatment that involves having an adult lie down on top of a child? What do we know that is relevant to the safety of this kind of treatment? We certainly know that it’s possible for a person to be crushed or asphyxiated by a heavy weight on the chest and abdomen. Crushing of this kind was even used as a method of execution in the past (see Arthur Miller’s play The Crucible for a dramatic example). Using the outcomes of similar events, and knowing that not everyone with heavy weights on the chest has died, we can legitimately label “compression therapy” as potentially harmful. It has the power or possibility to do severe harm, although it does not always do so.

But what if there is no comparable event that we can use to assess the potential for harm in a treatment? We are left with the more difficult task of watching for adverse events from the treatment and collecting that information. Given that psychotherapies are not expected to have harmful effects, one or two adverse events are enough for us to point out the potential for harm associated with a treatment. Where any such events exist (and some have occurred), we need to investigate them carefully. This is no time for what a formerly-prominent political figure used to call “misunderestimation”.

What sort of adverse events are we talking about here? The obvious ones are death or serious physical injury, but we should also pay attention to incidents like weight loss or inadequate growth. Emotional trauma is less easy to ascertain unless a concerned adult calls attention to a child’s condition, or unless an adult is able to complain of the effects of a treatment in the recent or distant past.

Adverse events can be less obvious, as well. PHTs may do harm by interfering with a child’s education, thus limiting his or her options in adulthood. They may limit social interactions and prevent the development of normal social skills. And, of course, they may use up a family’s energy and resources and prevent the use of safe and effective treatments. All these problems may emerge from the social pressures of a cult-like network in which a family becomes intensely committed to participation in a treatment that should properly be called “potentially harmful”.

Most people are still getting used to the idea that psychotherapies can have real potential for harm. But no one should assume that “potential” mean “unfounded speculation” or “fantasy”.

Wednesday, July 14, 2010

Partnering With Parents: Difficult Decisions About CAM

In a calm and reasonable discussion in the Brown University Child and Adolescent Behavior Letter, Dr. Margaret Klitzke has commented on the difficulties pediatricians and child psychiatrists encounter when parents want to use CAM (complementary and alternative medicine) treatments for their children’s mental health problems. In this article (“CAM in child mental health: Partnering with parents”, CABL, August 2010, p. 1, pp. 5-6), Dr. Klitzke defines CAM as “those healing modalities that provide supplemental treatments in addition to conventional treatments”, but she suggests that parents may consider CAM out of concern that conventional treatments are ineffective or have too many side effects, which impliess that the CAM treatments in question are seen as alternatives, not actually as “complementary” additional methods.

Dr. Klitzke’s discussion focuses on dietary supplements like flax oil and herbal remedies like St.John’s wort as well as on melatonin. She also notes the use of special diets, for example a gluten-free casein-free diet, and points out that the findings on the effectiveness of any of these are “equivocal”. With respect to these treatments, Dr. Klitzke suggests that practitioners need to be informed, be open to families’ inquiries, cultivate a partnership with families , and know their professional limitations.

It’s clear that practitioners are worried that apparent rejection of CAM treatments may cause parents to abandon conventional methods and commit their children to exclusive CAM care. As a result of this worry, they are inclined to seek ways to stay on good terms with parents, and to follow the methods parents want as far as they can ethically and scientifically justify this. And there would be little reason to criticize this approach as long as the CAM treatments are harmless, and as long as conventional treatment is also ongoing. (With respect to harmlessness, by the way, Dr. Klitzke points out the lack of FDA supervision of dietary supplements and herbal remedies, and the related issues of possible contamination or dosage problems.)

But what happens when CAM treatments for child mental health problems are demonstrably harmful? Not just ineffective, not just fraught with side effects, but potentially harmful treatments in and of themselves? A number of CAM treatments for child mental health issues come into this category. For example, there have been examples recently of parents advised to make their children’s food largely contingent on desirable behavior, and associated weight loss, in some cases producing permanent physical effects. I recently had a conversation with a young woman who as a four-year-old had been subjected to almost daily “holding therapy” over the course of a year; she is now being treated for serious anxiety, a reaction that may well be based on that early “therapeutic” experience. Child deaths have been associated with physically-intrusive treatments such as forced consumption of food or liquid, claimed by CAM practitioners to be effective with Reactive Attachment Disorder or any behavior problem of an adopted child.

At a more obviously physical level, avoidance of immunization, argued by CAM practitioners to prevent autism, does not prevent autism but does make children vulnerable to potentially fatal diseases. Chelation, a treatment with oral or infused medication, can have minor or occasionally serious side effects, and has not been shown to be an effective method of treating mental health problems.

How can conventional practitioners “partner” with parents who have committed to these types of treatments? No doubt criticism of dangerous CAM techniques is likely to cause some parents to leave conventional treatment and never come back, or to withhold accurate information about CAM treatments from a psychologist or pediatrician. (Because CAM treatments may in some cases interact with conventional treatments such as anti-depressant medication, the absence of accurate information may in itself create a dangerous situation. ) Nevertheless, there are several real problems that can result from failing to criticize CAM methods when it is appropriate to do so. One is that lack of criticism may be read by parents as actual approval of methods that are known to be dangerous, or ineffective, or both; parents may pass on to others this piece of “information”, thus making it more probable that other families will become engaged with CAM. Another is that it is conceivable that parents’ commitment to CAM is shaky. Criticism by a knowledgeable person might carry enough weight to alter a decision that would be maintained if left uncriticized. Finally, there is the point that professions involving responsible stewardship of others’ lives all have some ethical requirement for active engagement to prevent harm.

No one expects practitioners to partner with parents and facilitate abusive or neglectful treatment where it is not defined as part of a CAM treatment. Why is this “partnering” expected when harmful treatments are given the CAM label? It seems to be time for professionals working with children and families to re-think this matter and to differentiate between tolerating the harmless and encouraging the harmful.

Thursday, July 8, 2010

To Bed Without Supper

Being sent to bed without supper as a punishment--- this old-fashioned idea seems to have a certain charm. It’s much less violent than spanking, but still conveys a strong sense of adult authority. Doing it every now and then is not likely to do much harm to a healthy child. Nevertheless, we don’t hear of many ordinary parents using this punishment nowadays. They might deprive children of dessert, or “ground” them, or take away a toy or a week’s allowance, but meals are provided regularly, no matter what. And although those ordinary parents may get annoyed at children who won’t eat something, it’s rare for them to attempt to force eating. Withholding or forcing food or drink are not part of most families’ child-rearing or discipline methods.

Unfortunately, what I just said is true only of “ordinary” parents. The Philadelphia Inquirer this morning described the conviction of a Baltimore cult leader who had advised a mother not to give her toddler son food or drink because he was “rebellious” and did not say “Amen” after meals (www.philly.com/inquirer/local/20100519_Cult_leader_gets_50_years_in_child_death.html#axzzOoNjtuU5x) . The child died of hunger and thirst after a week of deprivation. The child’s mother, who still believes he will be resurrected, is in a residential treatment program for young women.

The conviction of the cult leader on second-degree murder and child-abuse charges may be a breakthrough in this area. People who practice as therapists or parenting coaches or educators have advised parents to limit food and have not been held liable for child injuries or deaths; it was the parents who were convicted. For example, in the death some years ago of Viktor Matthey in New Jersey (http://dartcenter.org/content/short-life-Viktor-Matthey-8), Viktor’s adoptive parents were convicted and sent to prison for the child’s death from multiple causes. Among other things, they had “punished” Viktor by forcing him to eat a mixture of uncooked beans and barley; if he did not finish it in time, he was not allowed to drink. Did the Mattheys invent this punishment for themselves? It seems unlikely, because punishment by means of forcing or limiting food is suggested in various publications advocating unconventional child-rearing or discipline methods. But no advisors were charged in the Matthey case.

Similarly, Cassandra Killpack’s mother was convicted after she forced the 4-year-old to drink a large amount of water, causing brain swelling and the child’s death (www.deseretnews.com/article/1,5143,515037467,00.html). Mrs. Killpack said that this punishment for having “sneaked” some of a sister’s fruit juice had been advised by a therapist she consulted. The therapist denied this, saying he was only there to support the parents. The therapist , who had lost his license in another state because of inappropriate practices, was not charged.

Why do I suggest that unconventional therapists advise withholding or forcing food, rather than thinking that parents invent these practices for themselves? After all, most of us are aware of the “bed without supper” tradition, and some people may convince themselves that serious deprivations are really no worse than that. But what makes me think that therapists (like that Baltiomore cult leader) may be giving this advice is that there are published materials that suggest food deprivation as part of the “treatment” for Reactive Attachment Disorder or other problems. This idea goes back to the generally-respected psychologist Milton Erickson [N.B.not Erik Erikson!) who advised a diet of cold oatmeal, and periods of physical restraint, for a disobedient boy, and noted with approval that after a time on this regimen the child trembled when his mother spoke to him ( Erickson, M.H. [1962]. The identification of a secure reality. Family Process, Vol. 1(2), pp. 294-303). The parenting “educator” or “coach” Nancy Thomas has more recently advised limiting of food to peanut butter sandwiches and milk for weeks at a time, with a more nourishing diet dependent on pleasing the parents (Thomas, N. [2000]. Parenting children with attachment disorders. In T.M. Levy [Ed.], Handbook of attachment interventions. San Diego: Academic Press). (Thomas, incidentally, claims that feeding caramels to children fosters attachment, because caramels contain milk, etc., etc.-- you fill in the rationale.) There is no evidence that such treatment is either safe or effective as a way of dealing with discipline or mental health problems, but there the advice is in print, and the First Amendment protects it.

Although I believe it would be highly appropriate to charge therapists and other advisors whose counsel encourages parents to harm children, I recognize the legal complications here. If I tell someone to shoplift, that other person has the responsibility for recognizing that the action is wrong and refraining from doing it. However, the conviction of the Baltimore cult leader suggests that authorities are beginning to see the importance of the roles played by givers of advice, whose words may encourage parents to perform acts that they would otherwise only have considered. In the Baltimore case, the judge described the cult leader as a manipulator of lost souls. Perhaps we are on the way to recognizing that such manipulators may appear in professional or quasi-professional guises, and that harmful advice from such people merits punishment as much as if they were leaders of cults.

Why Not Withhold Children's Food As Discipline?

I’ve had a lot to say recently about suggestions that children’s food supply should be contingent on their behavior. Many parents may feel a little uneasy about this topic, because most of us have used dessert as a negotiable item in efforts to get children to stop dawdling or to use reasonable table manners. Of course, when I refer to withholding food as a way to discipline children,I’m not just talking about whether they get a piece of lemon meringue pie tonight or not. I’m talking about reducing the available food to a small number of items and a smaller number of calories than the child usually consumes, with normal types and amounts of food given only if the child complies with parents’ wishes, and continuing that regimen for weeks or months. The effects of this kind of food withholding come on gradually but are very real.

If a child misses some food on one day-- as a punishment or because of a tummy-ache-- he or she generally makes up for it the next day. There’s no real need for food, or food intake, to be “balanced” over a 24-hour period, and there’s no long-term effect if it isn’t.

But a long period of time with less food than normal, as well as fewer nutrients than normal, is a different matter. This condition has been referred to as semi-starvation by some nutritionists. The starving person does not die within a week, as would be the case if all food and liquids were withheld, but gradually experiences both physical and mental effects.

Understanding the effects of gradual starvation is a matter that requires some tricky research approaches. Although all too many people in the real world are suffering from being underfed, most of them have other health problems-- contagious and chronic diseases, parasites, untreated injuries--- all of which may affect them physically and mentally in ways that are easily confused with the effects of lack of food. There are few circumstances in which experimental work can be carried out on the impact of semi-starvation; only adult volunteers could be used in this kind of investigation. The most famous experimental investigation of semi-starvation took place toward the end of World War II and used volunteers who were conscientious objectors to the war (Keys, A., et al. [1950] The biology of human starvation. University of Minnesota Press; Kalm, L.M., & Semba, R.D. [2005]. They starved that others be better fed: Remembering Ancel Keys and the Minnesota experiment. Journal of Nutrition, Vol. 135, pp. 1347-1352). These healthy young volunteers agreed to be subjected to months of calorie restriction and continuing physical exercise. They became emaciated, irritable, apprehensive, and moody, and were preoccupied with food; some ended up eating garbage or items like raw rutabagas, even though they were strongly committed to the program in terms of what its data could do to help people who were involuntarily starving in war zones. Not only were their bodies affected in complex ways beyond simple weight loss, but personality changes appeared.

Of course no experimental work of this kind would be done on children. But there is some related information which was secretly collected in the Warsaw ghetto, again during World War II. A lecture by Myron Winick on this sad topic can be found at www.columbia.edu/cu/epic/winick_lecture_2005.pdf. Winick reports the studies of what was called “hunger disease” in Jewish children confined and semi-starved in a section of Warsaw. Obviously, weight loss and growth failure resulted from their experience, but there were other effects as well. Low blood pressure and other cardiovascular effects were a consequence of slow starvation, as were cataracts (changes in the lens of the eye that prevent light from entering). The children reported being always cold.

It’s well known that infants, toddlers, and preschoolers, if subjected to poor nutrition for a period of time, are likely to be badly affected. Kwashiorkor, a nutritional deficiency disease resulting from lack of protein, causes slowing of brain development, among other things. Malnourished young children are reduced in stature and brain size.

These physical effects are all excellent reasons for avoiding the use of serious, long-term food withholding as a technique for disciplining children. But let’s consider the mental and personality effects in addition. Parents who consider using these techniques are usually concerned with what they consider to be serious behavioral problems. They may be dealing with an emotionally disturbed child whose irritability, aggressiveness, or tantrum behavior are trying or even frightening. They may begin a regimen that makes a normal amount of food dependent on behaving well-- but if the child is really not able to improve, or if other aspects of the environment reward the behavior, semi-starvation may go on for many weeks. Then what can we expect to happen? Looking at the World War II study of adult volunteers, we see that characteristically, this food regimen made them more irritable, apprehensive, and moody. If this effect generalizes to children-- and we might plausibly predict that the effect would actually be greater in children than in adults-- the impact of a period of reduced food intake would be to worsen the undesirable behavior that triggered this form of discipline to begin with.

Making a normal diet depend on a child’s behavior may cause behavior to get worse over time, and is certainly potentially dangerous from the physical viewpoint. But this doesn’t mean that negotiating behavior with the help of that slice of pie is necessarily a bad idea, if it seems to work in your family. If you’re worried about using that method too much, make sure that the pie-less child can have seconds on the main course if still hungry, and you can be sure that nobody is semi-starving.

Tuesday, July 6, 2010

Child Death By A Thousand Cuts in California

Not long before the return of the Russian adoptee to his homeland, an event that received enormous media attention, another foreign-born child died at the hands of her foster parents—and almost nothing has been said about this. In February, Lydia Schatz, an almost-8-year-old child from Liberia, died an appalling death, whipped for hours with a thin plastic plumbing supply line until vital organs were damaged by the effects of muscle damage. Lydia’s “mother” held her down while her “father” applied this punishment for a minor mistake in English. More details about this matter can be seen at www.icrawl.org/44034264874-jane-schatz-8-yo-paradise-ca, or on the web site of the Paradise (CA) Post, although you’ll have to pay to get at the archives of the latter.

I don’t want to dwell on this child’s experience, as anyone with the slightest imagination will be able to envision her pain and terror all too clearly. What I want to do in this post is to consider the sources of these parents’ actions, which were not impulsive but instead were based on a philosophy of child discipline. It appears that Lydia’s guardians were followers of the Tennessee fundamentalist child-rearing gurus, Debi and Michael Pearl. The Pearls are authors of “To Train Up a Child”, a publication whose first part appears on line at www.gospeltruth.net/children/pearl_tuac.htm. I have discussed the Pearls’ book in detail in my article “Destructive trends in alternative infant mental health approaches”, Scientific Review of Mental Health Practice, 2007, Vol 5(2), 44-58.

While Lydia’s guardians certainly must take full responsibility for their decision to whip the child, it is also important for people concerned with child welfare to note that there are sources of bad advice that are never forced to take any esponsibility. The Pearls are among these. They share the view I mentioned in a post a few days ago, that children are basically bad and must be forced into obedience; like some other authors since the early days of this country, the Pearls put this belief into a religious context so that it becomes the parents’ responsibility to make children submit utterly to adult expectations.

The Pearls advise that submission to parental wishes should be forced in infants as young as four months of age (these babies, by the way, would be too young to be able to sit up unsupported or to recognize their names when spoken). The primary method for achieving submission is pain, and this is produced by whipping either with the old-fashioned willow switch or with quarter-inch-diameter plastic plumbing supply line. Whipping is advised as a way to make children stop crying or to persuade them to do something that is wanted, or to refrain from doing something unwanted. For example, Debi Pearl recounts a situation in which a toddler was left in her care for a few hours-- the first separation from his mother this child had ever experienced. Although other children were playing around him, the little boy did not eat or play, even though Mrs. Pearl offered him a roller skate and showed him how the wheels spun. When she told him directly to play with the wheels, he “defied” her and did not do so. She whipped him on the leg, but he still did not obey; this continued for ten whippings, until he did put his hand on the wheel, and was described as content now that he had yielded to someone higher than himself.

The Pearls advise that whipping should be done without any indication of anger and with a friendly facial expression, an extraordinarily confusing situation for young children who use social referencing-- checking of faces and voices-- to understand the intentions of adults. Although their stress is on whipping, there are other physical punishments they approve, for example, yanking the hair of a nursing baby if he or she bites the mother.

No doubt the Pearls will say that they never told anyone to whip a child to death, or even to continue whipping for hours. However, advising that pain is the major tool in child discipline opens the door to such actions, particularly when the pain is not to be withdrawn until the child obeys and/or stops crying. The Pearls’ advice, when combined with the belief that children can obey but are wickedly choosing not to, sets the stage for a frustrated or mentally ill adult to injure or kill the child who is being “disciplined”. Such an outcome may seem justified to those who are convinced of the religious value of these actions.

I challenge both mainstream and fundamentalist religious groups to come forward and make clear their rejection of the Pearls’ methods. Some fundamentalist organizations have done this in a quiet way, but a loud shout is needed. I also challenge neighbors and police to be aware of the Pearls’ advice and to try to prevent child injury and death that might otherwise result from systematic whipping.

Any Treatment Is Better Than No Treatment At All

“Any treatment is better than no treatment at all.” I’ve drawn that quotation from the published work of an unconventional therapist who shall be nameless. It’s not just his idea-- plenty of people believe that this is a true statement about psychotherapies. It’s common to think that those who “seek help” always get help, rather than hindrance. But is it true?

Let’s just consider the logic of the whole thing. There are three logical possibilities for the outcome of psychotherapy. One is that the person being treated gets much better, and is both happier and more effective in his or her life. Another is that there’s really no change-- the patient is neither better nor worse during or following the therapy. And the third is that the treatment has an effect opposite from what was wanted: the person who was treated ends up in worse condition than before.

The clinical psychologist Scott Lilienfeld and others have referred to this third possibility as a matter of “potentially harmful treatments” (PHTs). Although a PHT may not harm everyone who experiences it, there is clear evidence that some persons treated in that way have suffered real worsening of their situations-- in some cases even dying as a result. It’s not too difficult to see that physical treatments could have harmful effects, because although medications may benefit people, they can also have adverse effects. Chelation therapy for autism and restraint therapies for “attachment disorders” are understandably potentially harmful. But people may have more trouble understanding how a non-physical psychotherapy of any kind could be a potentially harmful treatment. Cynics are far more likely to expect psychotherapies to be useless than to think they might cause emotional or other damage.

“Recovered memory’ treatments are a very good example of psychotherapies that are potentially harmful. When therapists suggest to patients that their symptoms must be the result of some long-repressed memory of abusive treatment or even of “Satanic rituals”, and when the patients then “recover” such memories with therapist encouragement--- in the absence of confirming evidence, or even the presence of disconfirming evidence----- harm to the individual, friends, and family can be very real. There are many substantiated cases of patients who “recovered memories” that accused family members of horrendously abusive behavior, followed by family alienation, divorce, criminal charges, and so on--- and in some cases eventually followed by the patient’s awareness that in fact the memory had been suggested by the therapist, not actually “recovered”. The potential for harm in this kind of treatment has become pretty clear over the years, although it was not necessarily obvious to the first therapists and patients who used it.

Programs like “boot camps” and “Scared Straight” programs, which lack evidence of effectiveness, may also be PHTs because of their deliberately traumatic components. It’s curious, isn’t it, that our society currently has so much concern with post-traumatic stress disorders, yet we accept some treatment programs based on trauma! It’s especially curious that we want young people from backgrounds of poverty and family dysfunction, who have already been exposed to emotional trauma in many cases and may be sensitized to it, to attend “boot camps” where programs will intentionally frighten and disturb them. (Surely the closest analogy would be a situation where traumatized combat veterans would be exposed to more fear and stress in the bizarre expectation that their original trauma would be defused by this.)

If adults want to choose PHTs, they have the right to do so. Under the First Amendment, advocates of PHTs have the right to state what they consider the strong points of their treatments, and those of us who oppose those treatments can only exercise our own First Amendment rights to state what we consider the problems of those treatments. When it comes to PHTs for children and adolescents, the matter is more complicated. Adults who make choices or recommendations about psychotherapy for children need to remember that they have a fiduciary responsibility-- not one that necessarily involves money, but one that involves guardianship or stewardship of a child’s developmental pathway. Choosing for another, dependent person, who may suffer from our mistakes, feels much more difficult to most of us than choices that affect ourselves alone. One of the first steps in such a choice should involve making sure that PHTs are not among the options we are considering.

In fact, some treatments for mental health problems appear to be potentially worse than no treatment at all, and not all psychotherapies are therapeutic. Let’s not fall for the idea that anything described as an intervention must either do good or do nothing.