Concerned About Unconventional Mental Health Interventions?

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

Monday, November 26, 2012

They Don't Do That Any More: Attachment Therapy/Holding Therapy



Everybody knows the story of the tippler who declared that he didn’t drink any more. Caught with a bottle of beer in his hand, he explained: “I don’t drink any less, either!” That seems to be the possible position of the Association for Treatment and Training of Attachment in Children (ATTACh). Following the deaths of Candace Newmaker and other children in situations associated with holding therapy, ATTACh announced early in the 2000 decade that its members would no longer use coercive methods or physically restrain children in treatment.  By the present year, 2012, we would expect all practitioners who consider themselves to be doing “attachment therapy” to have gotten this message--  if indeed it is being sent. (The continuing presence at www.attach.org of misinformation about Reactive Attachment Disorder raises questions about exactly what is being communicated.)

Nevertheless, here we are seeing the same old same old story being told in the blog http://adoptingspecialneeds.wordpress.com. This blogger has apparently spent her adult life adopting extremely difficult children and now has, among others, a 6-year-old who bites and fights. With this child, the adoptive mother is following the advice of the attachment therapy guru-ess, Nancy Thomas, and also displays a table of “facts” about Reactive Attachment Disorder that looks quite official but is in fact not based on any genuine information about that disorder as it is described in DSM (see p. 17 of her blog). Adoptive Mother has also sought an “attachment therapist” who will do an intensive treatment, many hours a day, with a method that is only vaguely described but appears to involve coercive restraint and other “holding therapy” techniques.

Adoptive Mother identifies herself with the Trauma Mamas (other adoptive mothers of children from severely traumatic backgrounds)  and believes that she and they are a special breed whose experiences and qualities no one else can understand. One of the reasons Adoptive Mother and others seek out “attachment therapists” is that such practitioners encourage the view that only people with similar experiences can “get it”, and that conventional therapists are critical and rejecting of parents and simply “make the children worse”. These parents may also welcome a belief system that stresses escalation of intrusive parental control--  whether they welcome it or not, they buy into it when they choose a method that emphasizes coercion. Someone has said that “attachment therapy” is a way for parents to have children punished without doing it themselves, and this may be the reason we see Adoptive Mother writing “While Hope is clearly RAD, and I am committed to her without reservation, there are too many times when I simply do not like her” (but I quote this remark in full awareness of the genuine ambivalence that may cause some of the intensity of parental love).

How do I know that the treatment Adoptive Mother has sought is a coercive one? Not having been in the treatment room, of course, I don’t. Adoptive Mother mentioned wanting to find an AT (attachment therapist) trained by Daniel Hughes, and Hughes, in spite of his earlier admiration of holding therapy, has stated that he does not use coercion. However, Adoptive Mother does refer to children who have died in the course of holding, and states that she and her husband are present in the treatment room and would not permit anything abusive to happen, so it appears that she recognizes at least some element of coercion. In addition, the treatment she describes involves insistence on eye contact, and how this would be achieved without some degree of coercion or intimidation is not clear to me.

In addition to her choice of therapists, Adoptive Mother comments frequently on the use of physical force in dealing with the child. This ranges from the “strong sitting” demands advised by Nancy Thomas to a physical takedown and pindown to the use of a papoose board, a padded wooden restraint board used in painful or frightening medical and dental procedures, the use of which by professionals should receive documentation. (She notes 30 minutes of restraint of the child on the papoose board at one point.)

It appears that in spite of the claims of ATTACh that they "don't do it any more", “attachment therapy” in its “holding” form is alive and well and maintaining its position in the forefront of unconventional psychotherapies for children.

Not surprisingly, Adoptive Mother is also attracted to other alternative, unorthodox treatments. She is enthusiastic about having a chiropractor treat a child for bed-wetting. She employs a “tapping” technique (see http://childmyths.blogspot.com/2012/11/fun-with-thought-field-therapy-why-some.html) with one of her other children. She refers to the use of “sensory activities” and of “therapeutic holding”, both approaches with little or no evidence supporting them. She seems to be an easy sell for the AT practitioner who tells her that her child is in terrible shape, but that a tiny “spark” remains in spite of all. Wouldn’t it be nice if screening of adoptive parents looked into their ability to detect snake oil? But, until caseworkers can detect it themselves, I don’t suppose such screening is about to happen.


29 comments:

  1. I read a few years' worth of posts at the linked blog recently and my heart goes out to the family. While physically dominating a terrified child seems cruel and dangerous from the outside, it made me think - I wouldn't know what else to do. "Attachment" seems like the wrong objective with many traumatized children - but what about "safety"? How could a parent prevent a child in a dissociative rage from harming herself or other members of the family without some form of physical restraint?

    And if I felt that way just *reading* it, I can't imagine what it would be like to live inside that, in fear for all my childrens' health (as well as my own). I would probably be grateful for anyone who said "this is the path you can follow to success."

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    1. Your points are well taken-- the problem to my mind is the belief that restraint by a parent or a therapist is "therapeutic" in its effects, not just a safety measure. No one is saying that restraint is never necessary for reasons of safety, simply that it is not part of a suitable therapeutic approach.

      It's natural to be relieved and grateful when someone tells us a way that may solve a problem, but we need to think our way past those emotional responses and find out what the actual outcome is likely to be. If that person is wrong, we end up not only with the old problem, but with some new ones too.

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    2. Sorry to digress, but have you ever posted on "Neurological Reorganization" therapy? I kind of feel for the families that have fallen into that trap. It seems like the program was designed to be so intensive that few people could stick to it 100%--which is great if you're a practitioner needing an excuse for the patient not showing progress. They can always say the family didn't do it enough, stick with it long enough, etc.

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    3. I don't think this is a digression-- AT is only one example of this kind of thing. Could you give a source of information about the treatment you mention?

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    4. I just did a search of my Google Reader feed and realized I haven't read a post on NR in about 2-3 years. Maybe it was just a fad that ran its course quickly...

      Basically the premise was that the kids' troubles were due to their brains not organizing right during critical developmental stages. Kind of like all the theories about midline/cross-lateral movements. The kids were prescribed these exercises to do every day, such as army-crawling, etc. The thing is, typically parents were seeking out help because there were already power struggles in the relationships, so it could be hard to get their kids to do the exercises as prescribed....

      The two blogs where I read about it the most are no longer up . . . What had alerted my BS-meter was when a mom reported that the NR practitioner told her that her daughter was having problems due to something that happened at some ridiculously early stage of fetal development... I don't remember how early exactly, but I'm pretty sure it would've been within the first trimester. Something to do with the pons stage...

      Sorry I don't have more info, though

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    5. Here is one blog post I found. The comments are instructive too. http://nineisenough.wordpress.com/2009/05/07/neurological-reorganization-update/

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    6. Thanks for this information. I did a post about "crossinology" and the "cross-crawl" some time ago, and I think it's the same basic idea... same as good old "patterning" too. When I look at the search terms that have brought people to this blog, I'm always surprised to see how many are looking for "cross-crawl" information. So I guess it's still out there.

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    7. What so many of these "alternative" treatments have in common is the element of sympathetic magic. By ritual re-enactment of some past or future event, the practitioner attempts to change the present situation. It doesn't even matter whether the past event is really known to have influenced the present-- it's the ritual that makes somebody feel better (not necessarily the afflicted person, if indeed there is any affliction).

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    8. Neurological Reorganization therapy is alive and well. In fact there is a school in Washington that claims huge success using the method: http://www.canlearnacademy.org/

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    9. And it's a public school, free of charge, too-- which appears to enroll 10 kids. It would be interesting to see the data they've collected before making their claim of success.

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  2. I find it interesting that you use my bog and my family to support your beliefs with out truly understanding what we are living. You seem to be one of those professionals who have to rely on your beliefs and theories because you have never actually lived it. Perhaps you opinion would carry more weight if it was backed by actually having raised a child from the hard places, as our current attachment therapist has.

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    1. Oh,I don't know--- I expect it would only carry weight with you if it was in agreement with your own opinion. If you are actually in an accredited Ph.D. program,you may find that critical thinking skills are required of you, and that personal experience is not the foundation of general conclusions.

      By the way,how would you know what I have actually lived?

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  3. Advertisement for your second edition, perhaps?

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    1. Perhaps not a very complete source. But it doesn't matter, because my statements are not based on my personal experiences alone.

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  4. I am horrified when I hear of restraints (or "takedowns") being used by professionals or parents in response to a child's refusal to follow a direction. I am aghast when "safety" is defined in such a way as to include almost any action that causes a disturbance of any kind.

    I have had, in my home, a child who threw heavily weighted objects at my head; that was unsafe. But I didn't need to restrain her to make the situation safe. All I had to do was leave the room.

    Other times, the same child came running at me in an rage, head down, fists swinging, and jumped on me while I was sitting on my bed, my back against a a corner, with nowhere to go. At that time, I restrained her by sloppily doing a basket hold (which I'd seen described but never done before); she squirmed mightily and kicked me, and successfully bit me a few times. I think it would've gone better (i.e., I wouldn't have been hurt so badly) if I'd curled up into a ball, protected my head, and whispered "You're hurting me; please stop."

    Often, the act of restraining a child is enraging. And, by refusing to restrain her, at least I would have been modeling the kind of nonviolent behavior I expected from her.

    Residential treatment centers often use prone restraints on children to enforce compliance with "safety" rules that are akin to the jumping jacks scenario of some attachment therapists: "Do it my way, the right way and snappy, to demonstrate that you are being safe by being 100% compliant with my demands, or you will be thrown down and restrained until you, essentially, cry Uncle. Safety is determined always and forever by me alone, and each time you do not do precisely what I ask you to do, you are being unsafe. And in the name of safety, I can violate your physical boundaries, your sense of trust, any common sense of decency, and treat you like a violent inmate of my prison."

    Because, you know, it's not safe when a child doesn't obey.

    Are we really, still, hearing support for this Dickensian abusiveness from professionals and parents in the 21st century? Did nothing of Gandhi's and MLK's teachings on nonviolence penetrate our consciousness?

    There is no original sin in children, nor is there any attachment evil in them. We must stop acting like exorcists. It is all insane.

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    1. Meanwhile, we also have people like Martha Welch and Jirina Prekop advising parents to restrain children daily-- in their views, restraint re-enacts some early experience that causes love.

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    2. Your comments are such an eloquent statement, and I think the "quotation" is a true reflection of the position taken by restraint aficionados.

      This all reminds me of people's comments 12 or 13 years ago when the new restraint and seclusion guidelines came out. Staff at special ed day care centers were terrified at the loss of the use of restraint (often by fastening the child into a car seat), but found that in fact behavior was better and the atmosphere improved when restraint was no longer used. I think there was an article in "Zero to Three" (?) in which a day care staff member described how they took the car seat/restraint and made it into a flower planter, and everyone was pleased with the outcome.

      I'm sure that neither you nor I would say that restraint should not be used when there are genuine safety concerns, so there really will be no need for restraint enthusiasts to tell us how naive we are. The point is that obedience and safety are not usually the same thing.

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    3. I remember reading a study of children in day care a few years ago. It was conducted in the 80's and one of the things mentioned was children being restrained in car seats. One girl had it happen so often she got panic attacks whenever she had to go somewhere in a car.

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  5. ATTACh's white paper on coercion isn't convincing. I think the public is getting a big dose of double-talk. Take a look:

    www.attach.org/resources/forms/papers/CoersionPosition.pdf

    Note that in their position statement on coercion, ATTACh claims that Victoria Kelly's paper “Theoretical Rationale for the Treatment of Disorders of Attachment” [provides the] "theoretical rationale for this position statement."

    But look at Kelly's paper...

    www.instituteforattachment.org/THEORETICAL%20RATIONALE.pdf

    In it she states: "ATTACh accepts that the use of nurturing holding...as a specific intervention..."

    How nurturing? She describes "nurturing holding":

    "[T]he use of touch and physical holding in attachment therapy is utilized to create a context that facilitates access to these defensively excluded components. First, physical closeness of the head in the parent’s lap, coupled with encouraged eye contact, recreates a sense of dependency and vulnerability in the child. It is these feelings and the fears they induce that are often so heavily defended against in attachment disorders."

    I put it to you: Is this not a description of classic Holding Therapy? Inducing fears, vulnerability, defensiveness with physical "containment" as Kelly calls it elsewhere?

    This double-talk satisfies some child welfare departments enough to continue using Attachment Therapists who claim, "We don't do that anymore." But if they spent even ten minutes checking further, they would see that there is real cause for concern for the children subjected to "nurturing containment."

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  6. What I would like to see is not a theoretical rationale, but a rationale based on empirical evidence for these claims. Do physical closeness and eye contact actually create (forget re-create, that opens a different can of worms) a sense of dependency and vulnerability in the child? And if they do, what is the reason for asserting that such experiences cause fears? If they do cause fears, in what way would that be beneficial, either with respect to attachment or to mood and behavior in general?

    Kelly's assertions are not empirically-based, but are derived from psychoanalytic concepts about repression and other defense mechanisms --ideas that are difficult or impossible to substantiate, but which have become such an integral part of vernacular psychology that they are instantly accepted by most parents.

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  7. That blog represents a major failure of the adoption system and a showcase of pure selfishness. Adoptive mother is mid-50s with severe health problems. She adopted the "RAD" child as a young child, when she was already caring for multiple special needs children. One adult child who can not function on her own and now has a child and the girl called GB who is really her son's daughter. Who let the adoption occur with these circumstances? These parents were unfit. Furthermore, the lack of awareness of the Adoptive Mother to recognize that she should not be parenting another child under her current circumstances is frightening.

    Restraining a child is a psychologically degrading practice that only produces more anger. There is no scientific evidence that restraint heals "RAD." It is simply a tool for parents who are incapable of parenting their children.

    Since when is being held against your will nurturing? Attachment grows from safe holding and loving contact; not restrained holding and emotionless contact or contact focused on restraining the child. I doubt the eye contact achieved in restrain and holding promotes attachment, considering both sets of eyes are under stress.

    Adoptive Mother should stop wasting time on a blog and start reading the science behind helping children, otherwise multiple children are doomed. More time spent with her children and less on herself and her blog would help the attachment she is seeking.


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    1. In my opinion,much of this difficulty is due to a failure of adoption workers to screen adequately, and to the common myth that people who adopt a lot of special-needs children are unusually virtuous and should be rewarded with more child placements.

      Social workers, isn't it time for curriculum revisions and continuing education courses that can help change the contributions caseworkers are making to adoption problems?

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  8. Hmmm ... Stumbled upon another Trauma Mama blog whose author is discussing how Fetal Alcohol Spectrum Disorder can lead to an inability to "attach." No source cited, but she says this (which rang all sorts of alarm bells for me): "Some of the most common characteristics of alcohol related brain-damage include: poor impulse control and poor problem solving skills, inability to predict what may happen next, difficulty linking actions to consequences, poor social communication (inability to read environments and adapt behavior accordingly), limited abstract reasoning and lack of trial and error learning. In addition, people with FAS/FAE have great difficulty internalizing values, feelings and laws. Therefore, they do not feel empathy for others or have a sense of justice. They can be entirely unattached, feeling nothing, even for the people who raise them. Because of these deficits, they have no internalized sense of right and wrong. A person with no morals, empathy, values or feelings can be a danger to themselves and to society." Her blog is "Sherific." The Trauma Mama stuff is nothing you haven't read before, but the linkage between FASD and "attachment" is interesting---and frightening.

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    1. The implied definition of attachment is affection, gratitude, and obedience to the caregivers, and these characteristics seem to be equated with "an internalized sense of right and wrong". Not only that, people who are not "attached" (as defined) are not only without morals or empathy, but without feelings! Presumably they can then be treated in any way the caregivers choose, because they are incapable of suffering.

      Caregivers who have these beliefs might be good candidates for the various programs like Mary Dozier's that try to make them sensitive to the attachment cues the children are actually presenting, but which the caregivers ignore or misinterpret. Of course, this wouldn't satisfy the wish to "fix" the child.

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    2. Oops,she's into tapping too, isn't she?

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  9. I am an adoptive mom with a 7 year old son we have had in our home since birth - I held him when he was 14 hours old. He has had "rage attacks" (for lack of a better description) for his whole life. We sought help from a therapist who was recommended by someone we trust and some of what she is doing with him/us is along the lines of attachment therapy. I am not comfortable with how it has progressed and would like to explore other options. How can I determine what type of help/therapy/approach is truly helpful and what is not? What alternatives to "holding/attachment therapy" is there for a child who is violent and abusive at home and disruptive in school? How do you know when attachment is the issue or if it might be something else - neurological etc? We have 2 different appointments scheduled for various additional assessments and evaluations. I know in my gut that this therapists methods are disturbing and not helping my son. But there is something seriously wrong with the way he thinks and behaves. Any help would be greatly appreciated.

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  10. Dear Karen-- I am not a licensed clinical psychologist,and even if I were I could not give specific advice without having seen the family.I can make some general comments, though, and I hope they will be helpful.

    I don't know where you live or what services are available for you, so I am just going to say what could be done in ideal circumstances. The first issue would be to have a complete evaluation by an experienced child psychiatrist like Dr. Charles Zeanah at Tulane. Zeanah has an entire program that deals with attachment issues, but also has the skills to consider neurological issues or other biological problems. (Zeanah doesn't know I'm saying this, and probably is too busy to see you anyway-- I'm just giving his name as an example of the kind of person who would be best to seek-- that is,someone capable of evaluating the medical possibilities, and someone at a teaching hospital.)

    Given that there are no medical problems,or that they are treated if they exist, the next step would be to seek a therapist who uses an evidence-based approach. I would recommend that if you can find a group that does Parent-Child Interaction Therapy (PCIT), that would be ideal for you. PCIT is intended for parents and children where oppositional behavior and "rage" are the major issues, and it concentrates on working with parent and child together and helping the parent shape the child's behavior.

    Unfortunately,people we trust don't necessarily know what therapies are effective, or even what the qualifications of a good therapist might be. I would suggest that if you cannot find PCIT close to your home, you should at least seek a therapist with good credentials. These would not include the "Registered Attachment Therapist" certified by the organization ATTACh, nor would it be best to go with a clinical social worker,counselor, mental health professional, etc., or (generally speaking) someone whose degree is Ed.D. If I were you, I would look for a therapist who has a Ph.D. in clinical psychology from an accredited university and is licensed as a clinical psychologist. You can tell that person you are interested in the PCIT model (and there is a lot about it online, so you can explore it yourself).

    Your son's behavior difficulties sound concerning, and if they are not resolved they will stand in the way of his education and development. However, as you say, they may have nothing to do with attachment... and even if they did, holding therapy is certainly not the solution.

    Best wishes for an improved situation--

    Jean

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  11. Thanks. We are in Northeast Ohio and one of his scheduled evaluations is with the Psychology staff at Case Western Reserve University, the other with a Child Psychiatrist (MD) in private practice. I do believe that because of my sons pre-natal experiences, he does have some deep issues of grief, anger and loss connected to his adoption, but I don't think it is helpful for a therapist to purposefully aggravate an already agitated child and repeatedly yell at him that his birth mother didn't want him. My heart was breaking and I feel terrible that I did not intervene in that moment to stop it. I have since talked with my son about what happened and how I should have intervened and am sorry I did not. He agreed and heard what I said and continued to express great displeasure with the therapist. That said, this has not been the bulk of the work she has done with him and us in our time working with her and most of what she has provided has been very helpful. I am going to speak with her and determine how we are going to proceed after that. I appreciate your quick response.

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  12. These plans sound good.

    I do want you to think over what you've said about your son's deep issues of grief. Are you sure that your assessment is not related to your own feelings about what happened to him? Typically, infants do not show much concern about separation from familiar people until they are at least 6 months old (and usually older), so it does not seem likely that they can have such feelings at birth, or even before birth.

    It's common for attachment therapists to encourage adoptive parents to think that their children are angry and grieving about the loss of the birth mother,but I think this is a real mistake. Of course as they get older adopted children do have concerns about their histories and need help in coming to terms with the past, but this is a far cry from thinking that they have suffered a devastating emotional loss as newborns.

    I don't want to say that the attachment therapist can provide no help at all-- it sounds as though some things have helped you, certainly. But the provocation and yelling about the birth mother may well cancel out any help that has been given.

    You may want to speak with the evaluators about the experiences your son has had with his therapist. This is not "tattling", but may help the evaluators understand all the sources of his present behavior. Attachment therapy has been classified as a potentially harmful treatment, and one of its outcomes may be to increase a child's anxiety and anger.

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