Concerned About Unconventional Mental Health Interventions?

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

Thursday, June 16, 2011

Gotta Pass the Physical: Child Psychotherapy as a Contact Sport

A friend recently passed on to me some interesting information about some Ohio practitioners who employ holding therapy (HT), a physically-intrusive procedure, as a method of purportedly establishing a child’s emotional attachment to his or her parents. Like many proponents of the Attachment Therapy approach, these particular people attribute a great many childhood problems to a lack of attachment, believe that establishing attachment will solve the problems, and also believe that their HT methods create attachment.

There are quite a few proponents of this unconventional form of treatment, in spite of the fact that HT, a type of physical restraint, has been associated with injuries and even deaths of children, and is remembered with terror by adults who were formerly subjected to it. (For more information on this point, see Attachment Therapy on Trial [Mercer, Sarner, & Rosa; Praeger, 2003]). What makes the subjects of today’s post a bit different is that they require a physical examination before accepting a child into their treatment program. Children aren’t treated unless there’s medical evidence that they can stand the treatment.

I will bet a large amount of money-- even the amount an unconventional practitioner recently sued me for unsuccessfully-- that nobody can find me a conventional psychotherapist who has this requirement for treating a child. (Asking for a general medical exam, to make sure there is no physical reason for mood or behavior problems, is not the same thing.)

The HT practitioners in question are at an Ohio counseling center ( Here is what they say about the need for a preliminary physical examination: “… some attachment and bonding interventions evoke anger or anxiety responses similar to those found after exercise. … at times during the treatment process elevated emotional states are expected. If at any time a participant’s behavior creates a risk of physical harm to themselves or others, brief periods of physical holding (i.e., several minutes) to ensure safety may be indicated. In order to further ensure the safety and wellbeing of all participants in attachment therapy using holding interventions, we require participants to pass a physical exam from their medical provider (similar to those given for sports activities) prior to participation.” (Incidentally, these practitioners also state that they abide by the safety standards of ATTACh, the Association for Treatment and Training of Attachment in Children (, a group that has been stating that its members use only mild holding since shortly after the 2000 death of 10-year-old Candace Newmaker at the hands of holding therapists.)

Let’s examine the claims of the Ohio therapists under a strong light. “Anger or anxiety responses similar to those found after exercise.” What anger or anxiety responses are found after exercise and actually caused by exercise, as opposed to anger at getting a red card or anxiety that your ankle injury will sideline you for the season? As an every-other-day gym attender, and mother or grandmother of four sports enthusiasts, one whom lifts 500 pounds, I have never seen or heard of exercise-caused anger or exercise-caused anxiety. On the contrary, exercise is usually thought of as having a calming effect. Why would we contribute to the YMCA swim team if it made kids unnecessarily upset? Wouldn’t there be a nation-wide anti-youth-sports movement if there were any truth to this idea?

So what’s the point of making this claim, equating exercise and sports activities with the experience of being restrained? It would appear that the goal here is to “normalize” the use of physical restraint in child psychotherapy, to make it appear to be common and acceptable, just like Little League-- when in fact it is not only unconventional but has been established as a potentially harmful treatment as defined by the Emory University psychologist Scott Lilienfeld. By introducing the exercise concept early in their discussion of HT, these practitioners pave the way for their later statement requiring a physical examination, and they close the persuasive bracket by another reference to sports. The "logic" then becomes the following: childhood sports are normal and acceptable; childhood sports require a physical examination; HT requires a physical examination; therefore HT is, like childhood sports, normal and acceptable…. so don’t be alarmed at the idea that there might be some potential for harm in HT; there’s some risk in everything, even being on the swim team.

This is really quite a beautiful and expert use of persuasive techniques, and one almost has to admire the author of the document. Almost--- until it’s remembered that HT is a method whose effectiveness is unsupported by research evidence and which is potentially harmful. It doesn’t work, it can do harm; doesn’t this tell us something important? Of course, the document doesn’t address either of these concerns.

One query: what about the physicians who do these physical exams? What do they think if and when they’re told that the exam is in preparation for psychotherapy? Pediatricians, if you’ve received such a request, did you think of discussing it with child protective services?

A few additional points of interest: the Ohio therapists state that they may have parents hold their children for diagnostic purposes. Now, any behavior sample can contribute to a diagnosis, but it’s deceptive to suggest that observations of holding are in any way standardized, or that any systematic research has connected holding behaviors to one diagnostic category or another. This claim is not surprising, though, in light of the therapists’ use of the Randolph Attachment Disorder Questionnaire (RADQ), a poorly-developed and unstandardized test whose creator, Elizabeth Randolph (California psychology license revoked some years ago) states that it diagnoses “Attachment Disorder”, a disorder never described or used in any conventional work.


  1. The info out there on so-called RAD is very confusing and subjective…thank you for attempting to clear some of it up.

    I was wondering if you might one day be inspired to clear up some confusion about the differences between “attachment parenting”, “therapeutic parenting” and “attachment therapy”, while you are on the subject of “RAD”?

  2. I don't know how inspired I am, but here's how I would define them:

    "Attachment parenting" is a style advocated by William Sears and his friends and relations. It's intended for typically-developing babies and their families. It assumes that a good deal of effort is needed in order to cause emotional attachment to form, and suggests care methods like constant carrying and skin-to-skin contact, as well as favoring co-sleeping and "family bed" arrangements. These methods are certainly harmless unless they cause marital or other social conflict, but they are not necessary for the development of secure attachments, nor will they overcome serious problems like autism. There is no systematic evidence about the effect (if any) of this parenting style, and my guess is that it's chosen because it's fashionable more than for any other reason.

    "Therapeutic parenting" is a method of treatment for children who are thought to have emotional disorders. It's a form of milieu therapy in which the child is exposed to interventional techniques most of the time rather than just at the therapist's office. To the best of my knowledge, therapeutic parenting is most often associated with treatments that are supposed to address attachment-related disorders (although I see that ATTACh is now claiming that they are dealing with the notional Developmental Trauma Disorder proposed by Bessell van der Kolk, so there may be a change in how this is discussed). Therapeutic parenting may be carried out by a child's own (usually adoptive) parents or by "respite parents" or foster parents who specialize in this work. Nancy Thomas, the best-known proponent of therapeutic parenting, claims that this intervention must stress the absolute authority of the adults, including their power over information such as when the child will go home. Limiting or withholding food and toilet access, and requiring tedious, meaningless work for no reason except to show authority, are aspects of therapeutic parenting. These methods have never been systematically investigated, and it is far from clear which techniques have emerged from misunderstandings of attachment theory and which are simply old-fashioned methods of discipline akin to sending to bed without supper or washing out the mouth with soap.

    "Attachment therapy" is an unconventional method of treatment for children who are thought to have disturbed forms of attachment to caregivers (although, as above, we may begin to hear that "DTD" is the problem). Certainly in the past, and to some extent still in the present, attachment therapy included and stressed holding therapy, a method of physical restraint of children that was accompanied by shouting, intimidation, and demands for statements that were thought to create catharsis of negative feelings ("I hate my mother!"). Since the death of the 10-year-old Candace Newmaker at the hands of attachment therapists in 2000, ATTACh (the main organization advocating attachment therapy) has claimed that attachment therapy now involves physical cuddling that is not restraining and that is agreed to by the child. There has been no systematic investigation or even description of attachment therapy in recent years, but a study of holding therapy over ten years ago provided only very weak evidence for its effectiveness.

    So, to sum up, attachment parenting has nothing to do with the other two, but attachment therapy and therapeutic parenting are closely associated. All of them are argued to derive from John Bowlby's attachment theory, but none of them actually does so except in the most minimal way.

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