Concerned About Unconventional Mental Health Interventions?

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

Friday, February 25, 2011

Attachment and "Bonding": The Mainstream and Some Eddies

Psychologists and clinical social workers will be surprised at my bothering to talk about the subject of this post, but if they look back over some recent comments they’ll see why this needs to be done. I’m going to review historical changes in ideas about emotional attachment and show where the mainstream is today.

Sigmund Freud’s discussion of attachment assumed that a child’s preference for a familiar caregiver depended on experiences of feeding-- a sort of “cupboard love”. He also considered that attachment could not begin until the end of the first year, when necessary cognitive abilities developed. While Freud considered early experiences essential in the shaping of personality, he focused on oral experiences rather than attachment per se as the important factor in early life.

A second generation of psychoanalysts in the 1930s included some whom Freud labeled “wild psychoanalysts”. These were people like Georg Groddeck and Sandor Ferenczi who emphasized the role of the body in emotional life. Ferenczi re-enacted parent-child caregiving actions with his patients, a method later advocated by the 1970s “antipsychiatrist” R.D. Laing. Without specifically discussing attachment, these therapists focused on early interactions that can be interpreted as related to attachment, and were concerned with earlier events than Freud usually focused on. One psychoanalyst, Otto Rank, pursued earlier and earlier causes of emotional problems and eventually held that birth itself was a traumatic event.

In the 1940s, therapists using hypnosis claimed that they could use a process of regression to return patients to early periods of development, and that this process could correct the impact of early problems. Within a few years, a popular book, The Search for Bridey Murphy, suggested to the public that hypnotic regression could return a person not just to an earlier stage of his or her development, but to a past life. Scientologists at about the same time contributed to this belief by stating that under their guidance it was possible to remember not only prenatal life but the moment of one’s conception. Popular acceptance of these ideas was not diminished by various studies like those of T.X. Barber, who showed that in fact age-regressed hypnotic subjects were no more accurate in their depiction of what they had been like at age 3 than they were when told they were now 90 (which they had not yet been). However, belief in memory of prenatal or pre-conception life was not part of mainstream psychological thinking about attachment or any other part of development.

With the publication of John Bowlby’s theory of attachment in the 1960s, ‘70s, and ‘80s , mainstream psychology developed an intense interest in attachment, and focused on the timing of this emotional process toward the end of the first year, as Bowlby suggested-- a schedule not very different from the one Freud had originally described. A small number of dissidents offered alternative claims about timing and causes of attachment. W. Ernst Freud (born Halberstadt; the son of Sigmund Freud’s daughter Sophie) published a chapter on “Prenatal Attachment” in a 1980 volume, The Course of Life, edited by Stanley Greenspan and George Pollock.

W.E. Freud’s claims were similar to those made by individuals such as William Emerson, a leader of the Association for Pre- and Perinatal Psychology and Health (APPPAH). Emerson has advocated the use of head and neck massage as a corrective for babies he considers to be influenced by their prenatal and birth circumstances. APPPAH was much influenced by the publications of Stanislav Grof, a psychiatrist, and Frank Lake, a psychiatrist and theologian, both of whom considered experiences induced by LSD to provide useful evidence about the nature of prenatal and birth experiences. These views, while considerably outside the mainstream of psychological thought, were treated with interest by the “psychohistory” school of historians. APPPAH also influenced the suggestion by Nancy Verrier that adopted children experience a “primal wound”.

In the 1970s, the “primal therapy” advocated by Arthur Janov contributed to this picture by its assumption that memory is not confined to the functioning of the nervous system, but is instead a biological function of all cells. Once again, this echoed some thinking of Scientologists and others outside the psychological mainstream.

In the early 1980s, work by M.H. Klaus and J.H.Kennell investigated maternal attitudes and referred to the strong preference of mothers for their babies, and their preoccupation with their babies, as “bonding”. This term was often confused with the term “attachment”, which is properly applied to babies and children, not to adults. Because in Klaus and Kennell’s original work “bonding” appeared to occur shortly after birth, lay readers may have come to believe that attachment occurs shortly after, or even before, birth. As a matter of fact, later work indicated that “bonding” often develops much more gradually than Klaus and Kennel originally reported--- and, to repeat the point, is in any case not an infant process, however much it may influence the infant.

Today, mainstream psychology continues to consider that emotional attachment arises as a result of experiences with a consistent, sensitive, responsive caregiver, and that this becomes evident only in the second half of the first year. For example, the University of Delaware clinician-researcher Mary Dozier, writing in Zero to Three for January 2011, refers to the new attachment concerns of foster children who are more than 10 or 11 months old when they are placed with a caregiver. Dozier and her co-authors also reject the biological factors suggested by Janov , Verrier, and others, stating that “the experience of loss is just as devastating when the infant is moved from a loving, committed foster parent as when he or she is moved from a committed biological parent… From an infant’s point of view, biological relatedness is inconsequential."

Wednesday, February 23, 2011

Comparing Families: "Between" and "Within"

A person commenting on this blog recently complained about the suggestion she felt I’d made, that adoptive and non-adoptive families are “just alike”. Of course they aren’t because no two groups of families are just alike. There are large differences between families, just as there are large differences between individuals.

But here’s the tricky part: the differences between families are actually smaller than the differences WITHIN families! Figuring out all the differences between groups and individuals shows that the average difference between two children in a family is bigger than the average difference between children of two different families. (Please note that I’m talking about the average difference; choose your families or your children, and of course you can find families that are very different, and brothers and sisters who are very similar.)

How can this be? Don’t we blame-- or credit-- families for making people who they are? How can one family make children who are very different, but different families not have such a big impact?

The answer is that it’s a mistake to assume that family experiences in and of themselves are the sole, or even the primary, shapers of human personality. This is the case even when the family experience includes a factor we think of as unusual and powerful, such as separation from the birth parents. Michael Rutter, a leading researcher whose group has investigated the development of children adopted to England from the appalling Romanian orphanages, wrote in 2002 that “it is clear that parental loss or separation carries quite mild developmental risks unless the loss leads to impaired parenting or other forms of family maladaptation”. Although severe neglect or abuse in families can influence children’s development, the many “good enough” (though different) ways to care for young human beings do not seem to have specifically different outcomes.

One reason that family experiences alone seem to have fewer predictable effects than you would expect is that children bring something to the table too. Individual differences between children mean different ways of responding to the same experiences. For example, firm discipline may work very well with most children, but may be so overwhelming to the unusually sensitive child that he or she learns nothing but to be frightened. Children within a given family may respond quite differently to the parents’ preferred approach; they can be different to begin with, and their different responses (although to the same treatment) can make them even more different than they were .

Children’s individual differences include differences in temperament, a term that describes personality characteristics that have biological causes. For example, children who have perfectly normal activity levels may still be quite different from each other, with some much higher and others much lower in their preferred amounts of activity. Depending on the family and its circumstances, either a high or a low activity level can make for either a good or a poor developmental outcome. One important factor is what is called “goodness of fit” between the child’s temperament and those of the parents. Active, sports-oriented parents may be very pleased with a lively child, but it’s possible that quiet, scholarly parents will find it easier to get along with a less active son or daughter, and would find themselves scolding and disapproving of a more active child, even against their own intentions.

The temperaments and past experiences of child and of parent can make a major difference to their understanding of each other’s communications. For instance, in the American Psychologist for February-March 2011, an issue focused on infant mental health, Ed Tronick and Marjorie Beeghly show a series of photographs of an interaction between a mother and baby. Mother bends down to tickle the baby with her hair, and the baby grabs the hair and won’t let go. Mother raises her head with a brief, unintentional expression of anger and pain, and baby flings its hands across its face in a gesture as if to ward off attack. In a few seconds, they are both smiling and returning to normal. But what if the baby’s temperament was such that it took more than a few seconds to recover from the “threat”? Mother might become discouraged about playing, and be less likely to start a play sequence. What if mother’s temperament made it easy for her to interpret the baby’s “attack” as intentional, so she continued to look angry for several seconds? Baby might become wary of interactions that led to scary situations. In both cases, a member of the pair might misinterpret the other’s communication, and their attitudes toward each other would change. Such very brief interchanges can establish better or worse ways of thinking about each other and getting along.

Psychological and behavioral differences can create different experiences for both children and parents. But it’s important to remember that while people live in families, families live in houses or apartments, that are in neighborhoods, in countries, and in economic circumstances. Just as the quieter parents may scold the lively child, so may parents living in an upstairs apartment scold the child who disturbs the neighbors, and the father who works the night shift may have a different attitude toward rough and tumble play than the one who can count on sleeping at night. Active parents with a big house in a mild climate, and plenty of time and money for sports, have different attitudes toward their active children than quiet parents living in a crowded apartment with crotchety relatives, especially if the neighborhood is not safe for playing outside. Poverty brings down punishment on the heads of children who are careless about possessions, while affluent parents may not find it worthwhile to fuss.

No, adoptive and birth families are not just alike, but neither are two random birth families or two adoptive families. They can’t be just alike, because the initial differences between parents and babies are woven into greater and greater individuality within the families. A long list of factors helps to determine how babies and parents develop their relationships. As is so often said in infant mental health circles, it’s not rocket science-- it’s a lot more complicated than that.

Monday, February 14, 2011

Is It Kin, or Is It Skin? Conclusions About Skin-to-Skin Contact for Low-Birth-Weight Babies

The Huffington Post blogger Jennifer Lauck has done a piece arguing that separation of very young babies from their mothers is traumatic for the babies, and that, therefore, adoption policies need to be changed dramatically (see http://www.huffingtonpost.com/jennifer-lauck/adoption-myth-buster-what_b_822175.html). (And thank you to J.P. for giving me a noodge about this post.) Lauck refers to her own children as evidence for her position, but she also cites a study by the South African physician Nils Bergman (http://www.ncbi.nlm.nih.gov/pubmed/1524427).

The Bergman study took 34 low-birth-weight babies and randomized them to two groups shortly after birth. Half of the babies were randomly assigned to incubator care, the standard method of caring for them. The other babies were placed skin-to-skin with their mothers. The incubator babies did less well in terms of breathing and heart rate and were more likely to experience low body temperatures (which, incidentally, can trigger a cascade of harmful events in LBW or even average babies).

So far, so good. Bergman’s study agrees with much older work that the ordinary isolette is not best-suited for premature or LBW infants. Other researchers, like Tiffany Field, have shown the advantages of devices like water beds or sheepskin pads for these small infants. Human skin-to- skin contact has a whole list of advantageous characteristics—skin is not only warm, but movement of the adult and the baby can make sure that as much of the baby’s skin is kept warm as possible; a human caregiver will shift position from time to time, keeping persistent pressure from being uncomfortable to the baby as it might be if the baby were lying on a firm surface; human voices provide a background of mild stimulation that works better for the baby than quiet; human breathing and heartbeat help entrain the baby’s breathing into appropriate rhythms. It’s all good. But is it about the mother?

Lauck and Bergman both seem convinced that the birthmother is the important factor here. Lauck uses the study to draw conclusions about adoption reform. Bergman says “The cardio-respiratory instability seen in separated infants… is consistent with mammalian ‘protest-despair’ biology, and with ‘hyper-arousal and dissociation’ response patterns described in human infants: newborns should not be separated from their mothers.” In both cases, the conclusion seems to be that the birthmother plays a role that cannot be performed in any other way.

I’m sure most readers will see where I’m going with this. Both Lauck and Bergman are having trouble interpreting confounded variables. They are confusing the effect of skin-to-skin contact with the effect of separation from the birthmother specifically. This confusion is present because Bergman did not design the study to discriminate between experiences of warmth, movement, and good breath and heart patterns, and experiences of being with the mother (what Lauck calls “bonding”). Even more confusingly, Bergman uses terms like “protest-despair” and “dissociation” that imply subjective experiences rather than the objective measures of body temperature, breathing, and heart rate that were actually measured. These terms are especially questionable when applied to low-birth-weight babies who may have had many other developmental problems, as such babies often do. The Bergman study does not support either Lauck’s conclusions, or the implications that the researcher suggests. It’s neither good science nor good policy to jump to conclusions that have little to do with what was studied.

Let me hasten to point out that I am all for whatever makes life more pleasing for both babies and mothers. I spent some time many years ago studying the painful procedures used with pre-term babies and collecting evidence that even babies born at less than 30 weeks’ gestational age showed reactions to pain. In the course of those studies, I reported that procedures were often much longer and more painful than they sounded. (In one case, I observed a heel-stick for a blood sample that took 17 minutes and more than half a dozen sticks to get a few drops of blood.) I noticed that some NICUs were very cautious about keeping things quiet and dimly lighted, and staff spoke in low voices to each other and to the babies. In others, bright lights, loud voices, and constant alarm bells provided exactly the wrong situation for babies trying to live and parents trying to understand and help with medical care. I will always remember seeing a nurse vigorously clean and diaper a pre-term baby with a horrible diaper rash, then perch the agitated baby on her knee and thrust a bottle into her mouth while talking to another adult.

I remain very concerned that babies, full term or pre-term, be treated with as much care as we can manage in all cases, and left primarily to their parents’ care whenever that is possible. There are many reasons why this is beneficial, and some of the reasons gave rise to the British “care-by-parent” pediatric unit several decades ago. But it is not to anyone’s benefit that we exaggerate the role of the birthmother in necessary care or that we draw less-than-warranted conclusions about family relationships, including adoption.

Saturday, February 12, 2011

Adult Adoptee Unhappiness: An Alternative to Primal Wounds

Much discussion over the last several months has been devoted to the Primal Wound idea. A number of adult adoptees have stated that because they are unhappy with family relationships now, and because they were separated from their birthmothers, the unhappiness must have been caused by the separation. I, on the other hand, have suggested some other factors that could have the same effect and that I believe to be much more likely than Primal Wounds. I also expressed concern for adoptive parents who are given the idea that their children have an almost untreatable emotional scar.

Neither side has convinced the other, and I really wasn’t going to mention this matter again, but today I read a very relevant article about an issue for adoptive families, and I want to summarize and quote some parts of it. The article is in the January 2011 issue of “Zero to Three” and is by Eda Spielman of the Center for Early Relationship Support in Boston. The title is “Post-Adoption Depression: Clinical Windows on an Emerging Concept” (pp. 35-40). Spielman discusses in detail this possible cause for difficulties in adoptive relationships.

Spielman notes the many experiences of powerlessness that accompany the decision to adopt and the process of adoption, and describes the physical and emotional reactions that June Bond has n called post-adoption depression syndrome. These reactions, which Spielman calls “a salient descriptor of a significant minority of newly adoptive parents”, have many parallels to the perinatal mood disorders sometimes experienced by birth parents. The parents’ emotional reactions can be both caused by the challenges of parenting, and themselves causes of challenging developmental difficulties.

Spielman mentions as a particularly challenging area the use of abilities for mentalization or reflective function. These abilities have to do with a person’s capacity to observe another’s experience, to know that experience is separate from one’s own, and to be interested in the experience and thoughts that lie behind behavior. Spielman suggests that these functions may be particularly difficult for adoptive parents: “To fully consider the early experience of their child is to ‘think about the unthinkable’-- namely, what it may feel like to be abandoned, given up, or left by a birth parent; what the early period of life may have been like; and, possibly, what it may feel like to then leave again the orphanage or foster home that was home for weeks, months, or years.”

Commenting on adoptive parents who do not feel depressed but irritable and disconnected, Spielman notes, ”These parents can be seen as particularly vulnerable to acting out on their feelings because they have no perspective on them.” She goes on to say, “Other adoptive parents are haunted by their imaginings of their child’s past to the point of preoccupation and confusion about whose experiences belong to whom. They may have difficulty finding the boundary between being open to considering potentially painful questions and assuming the meanings and reverberations of these early experiences, An adoptive mother sought help around sleep problems. She had her own early loss issues and was overwhelmed by the pain she imagined her child felt at having been abandoned at 3 months of age. If she put him down to sleep and he expressed any distress, she felt she was repeating his early abandonment. She found herself preoccupied with thoughts of his early suffering and felt paralyzed with fear that she was causing him more anguish. The challenge of mentalizing is to balance empathic understanding and separateness, to feel for the other but know one’s own experience as distinct from that: “I will try to understand your feelings but know they are not my feelings.’ “ (Nor, I may add, are the infant’s feelings the same as the feelings the adult would have if now placed in the same situation.)

Post-adoptive depression, and the constraints it puts on parent-infant interaction, may have impacts on the development of communication, social relationships, and attitudes toward other people and toward the self. As more is understood about this problem, it’s to be hoped that vulnerability to depression in adoptive parents can be detected early and support systems can be put in place, just as we would try to do for a birthmother with signs of a perinatal mood disorder. One useful step that could take place right now is to stop claiming that Primal Wounds curse all or many adoptive families-- a piece of disinformation that may be more than a parent with post-adoption depression can cope with.

Friday, February 11, 2011

Cross about the Cross-Crawl

The myth of the cross-crawl has been with us for at least 50 years now, and I for one am tired of the claims that are made about it. This belief, initially (as far as I know) promulgated by Glen Doman and Carl Delacato, a physical therapist and an educational psychologist respectively, assumes that when an older child or adult imitates the typical movement patterns of a young infant, his or her brain is in some way restructured and begins to function more effectively. There is, however, no evidence to suggest that this is anything but a myth.

Doman and Delacato put great emphasis on repetition of infantile movement patterns like those of the asymmetrical tonic neck reflex, in which head, arms, and legs all move predictably and reciprocally. The arm and leg movements of this reflex are to some extent repeated as a baby begins to crawl on the stomach and to creep on all fours; the right arm and left leg move forward together as the left arm and right leg are extended, and vice versa. In ordinary movement, this movement pattern has the great advantage of stabilizing the baby’s posture while allowing forward motion, because to move both arm and leg forward on the same side would throw weight to one side, a difficult situation for a child too young to shift weight to maintain balance.

The “cross-crawl” movement, with movement of legs and arms as described above, is an activity that older children and adults can do for themselves. As such, it has been recommended by unconventional therapists as a way to achieve better communication between brain hemispheres and to “rebuild” compromised brain functions. Now, such practitioners are suggesting that the “cross-crawl”-like movements of a trotting horse will have the same function as cross-crawling (a function which, by the way, has yet to be established on any evidentiary foundation).

Examples of these claims can be seen at http://www.hoofbeatstohealing.com/, which states that the method is “Based on the theory of cross hemispheric integration. Which is if a child didn’t crawl correctly their brain may not be mapped correctly” (punctuation sic). The method is said to be effective for the following: Reactive Attachment Disorder, visual impairment, hearing impairment, spina bifida, emotional disabilities, and other problems. In a 2006 article in Western Horseman, to be found at http://tswf.org/Happy-Trotting.pdf, the reporter tells the story of a child riding a horse with a particular gait for the first time. The instructor noticed that the child’s pupils were dilated, but rather than interpreting this as a sign of pleasure and approval, she “could tell there was something going on in his brain neurologically. The dilation meant that his brain was downloading the patterning of the horse’s gait”, the instructor later said, and she continued, “Downloading that patterning can reveal the rider’s emotional, physical and neurological issues, making it seem like the rider’s getting worse, not better.”

Having fun and good physical exercise, and learning to communicate with a large animal, are all great things for children to be doing. For children who have handicapping conditions that limit muscle strength and movement, the physical stretching associated with horseback riding can be very beneficial. But this whole business about the cross-crawl, about downloading the horse’s gait, and so on, is the purest nonsense.

An injury to a developing brain does not mean that the brain stops or gets “stuck” in its development. Uninjured parts of the nervous system continue to grow and form connections with other uninjured parts. Typical functions may appear, even though the connections that cause them are not themselves typical. Re-enacting early behavior patterns affects the brain through the sensory systems, but it does not drive the brain back through early development; the brain is no longer at that early stage, has different structures than it did, and can no longer act as it used to act. In any case, the problems listed as treatable by horseback riding would all have occurred at different points in development.

I should also point out that the reciprocal crawling pattern does not cause brain development. This is clear because although that crawl pattern is typical of human infants, and although it is “average” (statistically most common), it is not the only normal developmental pattern—that is, a pattern that leads to good later development. Many babies use this crawl pattern and develop very well. Some babies use the crawl pattern and do not develop very well. Some babies just sit around for months or scoot on their bottoms to where they want to go, and then one day stand up and walk. It’s true that when a baby’s crawl is one-sided, developmental problems are more likely than when both sides are used. However, a typical crawl does not necessarily predict good development, nor does a failure to crawl at all predict developmental problems. If crawling caused early brain development, we would see big differences between those who crawled before walking and those who did not.

Here’s an interesting further piece of evidence. In some parts of the world (for instance, traditional Bali), babies were not allowed to crawl. They were considered to have come straight from Heaven and it would be shocking to let them go on all fours like animals, so they were carried until ready to walk. Yet no unusual number of developmental problems were to be seen.

If failure to crawl doesn’t really cause problems, what are the chances that the cross-crawl movement, self- or horse-produced, can solve them? (And what would happen if someone drove a pacer, which moves the legs on the same side together?)

Wednesday, February 9, 2011

Clever Hans Rides Again: Equestrian Therapy for RAD?

Do you remember Clever Hans (or Kluge Hans without translation)? This early- 20th- century performing horse almost certainly turned up in your introductory psychology textbook, if you had one-- and he’s usually seen in sociology and education books too. Hans, a handsome stallion, was exhibited by his owner because he could do arithmetic. The owner would ask audiences to present Hans with arithmetic problems. (These were simple number problems, not compound interest or anything very serious; still, they were more than you’d expect of the average horse.) Hans would listen, and then stamp out the answer with his forefoot: 22 + 11= 33 stamps. The owner had no idea how Hans managed this.

Careful observation, of course, showed that Hans really couldn’t do arithmetic. Instead, his owner, unaware of his own actions, was signaling to Hans by tiny movements when to stomp and when to stop. If the owner didn’t know the answer, Hans couldn’t do that problem.

The message that textbooks have passed on from Clever Hans is that it’s all too easy to influence behavior and to bias the results of an experiment, even if you are trying to be perfectly honest. That’s one of the reasons why people like me keep on and on about the (admittedly dreary) rules of empirical research. It’s also why we find it so difficult to accept personal experiences as evidence, in the absence of more reliable information.

But here’s the real reason I thought of Clever Hans today. I received an e-mail from a colleague, giving me another e-mail from a person I don’t know. (I’m not going to name either of these people, so I can’t cite a source on this one.) The two of them had been discussing the “fringe” child psychotherapy called Attachment Therapy and the fact that a leader in that treatment was going to run a “camp” in their state. One of the correspondents, a conventional psychotherapist, noted that she had a child patient who attended “equestrian therapy” sessions recommended by Attachment Therapists for children with Reactive Attachment Disorder. The treatment was paid for by the state family services department. The therapist recounted the story told her by this child and the child’s mother:

“The instructor reports herself as having been a RAD kid [that is, she believes she had reactive Attachment Disorder as a child]. She puts kids on different horses because each horse can perceive what the child is thinking and feeling. Then she stops the horse and asks the child ‘Is there anything you need to tell me?’ According to the parent of my client, the horse nods his head ‘yes’ if the child lies. Then they pry until the child tells the truth. She has told my client that she [the child] does not have bipolar disorder (she has [five diagnoses] and is on medication and was in residential [treatment] for 2 years but is instead ‘just RAD’. … She keeps nagging my client to talk about her childhood (client is adopted) and client refuses. My client told her, ‘You are not my therapist’. The instructor told her, ‘When you are here I am your therapist.’ She also has client do her dishes and light housework as client likes to hang out there after school. This instructor referred them to a RAD group in [a neighboring town]. “

It would appear that family services ought to be paying for this treatment in oats and sugar lumps, as the horse is supposed to be a co-therapist! But, folks, let’s think it through. Clever Hans couldn’t really do arithmetic. Can this therapy horse actually tell whether someone is lying? Isn’t it more likely that a signal, possibly unintentional, from the instructor, determines whether the horse nods or not? And what is the effect on the child’s trust in other people and understanding of the world when she’s informed that horses know whether you tell the truth? If a family chose to pay for this experience on their own, there’s little anyone can or perhaps should do about it. But how is it that public money can be spent on such an enterprise?

Here is a list of my concerns. 1. Obviously, the instructor is not being truthful about the horse’s behavior, although I suppose she may think she is. 2. The instructor does not understand the differences between her training and abilities and those of a professional; this is why we have licensing and supervision. 3. The instructor is taking advantage of her position to make inappropriate statements contradicting the information the family has received from knowledgeable persons. 4. The instructor wants to be in the position of a therapist, but lacks understanding of professional ethics, as we see in her dual relationship with the child; it is not suitable for her to allow the child to hang around, and certainly not for her to put the child to work. A neighbor might do this, but a professional therapist would not. 5. The instructor appears to believe that her own childhood experiences are relevant and appropriate information to disclose to clients, whereas they are neither. 6. The instructor makes the common mistake of assuming that all emotional disturbances have a background in early childhood. 7. Equestrian therapy was devised for children with physical disorders like cerebral palsy, who benefited from the stretching involved; that does not mean that all disorders of mind and nervous system can be treated this way.

My horse says this is a bad deal.