Concerned About Unconventional Mental Health Interventions?

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

Thursday, May 31, 2012

Spanking, Aggression, and the Claims of Alice Miller


Of all the posts I’ve ever done on this blog, the ones most likely to be commented on have been those dealing with the claim that spanking children causes them to be violently aggressive, either then or in later life. This idea received much elaboration from the late Alice Miller, a strongly psychoanalytically-oriented scholar and popular author, and her fans continue to pursue the same way of thinking. (I must say I give credit to both Miller and her followers for their wish to find ways to moderate human violence--  at the same time that I am compelled to say that they are wrong in their understanding of aggressive behavior.)

I am bringing up this topic again today because of an interesting issue of the magazine Science, the house organ of the American Association for the Advancement of Science. This issue (18 May 2012) focuses on the topic of human conflict. In a special section, authors discuss the aggressive behavior of our pre-human ancestors, issues about ethnic and cultural conflict and racism, the evolution of empathy, the treatment of PTSD among veterans of Iraq and Afghanistan, and the possibility of life without war as modeled by societies in the past and present. Does anyone notice what topic is not here? That’s right--  there is no discussion of the origins of human aggression in childhood experience. A group of authors examining various aspects of human conflict did not look to spanking as a cause of violence. Instead, they assumed that aggressive behavior is one aspect of human life, just as it is a natural aspect for all our primate relatives.

Humans are able to be aggressive in various ways, as is the case for all mammals, however peaceful and long-suffering they may be. Like other mammals, humans can show aggression impulsively and under the motivation of anger or fear. They can also show instrumental aggression, by harming or distressing other creatures without being angry or afraid, but instead motivated by the wish to create a desirable outcome. Organized societies use instrumental aggression for various reasons. They appoint soldiers to aggress against other people with whom they may not be angry (as Muhammad Ali famously said when refusing induction into the army, “I ain’t got nothing against them Viet Congs”) but who may pose some imminent or remote threat to the group. They choose police officers to arrest and incarcerate people who have harmed or threatened others, usually not the police themselves. They employ judges to decide what punishment should be received by convicted criminals who generally are no threat to the judges.

Spanking or other physical punishments of children can be matters of impulsive, angry, or fearful emotionally-driven behavior--  and when they are of this type, they may or may not cause serious physical harm. They may also be instrumental aggression, designed to bring about a desired result such as changes in child behavior. Followers of Alice Miller tend to emphasize repressed motives of pleasure in causing pain to a child--  and obviously these can be present and guide the adult’s actions--  but it is also possible that physical punishment is considered by the adult as simply a means to an end, no more associated with anger or fear than is the prick of the vaccination needle intended to protect the child from disease.

But if everyone shares a human capacity to behave aggressively, why is it that some are so much more aggressive than others? In a recent paper, the well-known developmental psychologist Theodore Beauchaine discussed how genetic predispositions interact with family behavior to create problem outcomes in the form of externalizing disorders--  emotional disturbances that lead to unjustified attacks on other people. (Beauchaine’s paper, “Physiological markers of emotion and behavior dysregulation in externalizing psychopathology”, is in a monograph of the Society for Research on Child Development, Physiological measures of emotion from a developmental perspective: State of the science, 2012; edited by T.A. Dennis, K.A. Buss, and P.D. Hastings.) Beauchaine suggested that neither a genetic tendency toward impulsiveness nor poor family experiences created a strong tendency toward delinquent or aggressive behavior--  but a combination of the two is necessary before externalizing problems are likely to develop. Children who are constitutionally impulsive learn in their families good or poor ways to regulate themselves emotionally, and those whose emotional regulation is poor are likely to be inappropriately aggressive as they suffer for long periods from sadness, fear, or anger that they have not learned to cope with.

Beauchaine’s work shows how other issues connected with physical punishment could be causes of  later aggressive behavior--  parents who rely primarily on spanking to control child behavior may not supply any help in learning emotional regulation, whereas those who spank less or not at all  may offer guidance in emotional regulation. For example, the non-spankers may do more talking about emotion, offer words to describe emotions, and point out how they or others are made to feel if the child misbehaves. The child in turn can use self-talk about emotion to reduce persistent and uncomfortable negative feelings—a strategy that would not be learned in a family that depended on physical punishment for discipline.

Following this line of thought, we seem to arrive at the idea that basic human characteristics cause aggression, but that appropriate family experiences can modulate aggressive tendencies and guide them along appropriate pathways. The issue may not be whether or not to spank children, but instead what positive and helpful experiences children need in order to develop good self-regulation and control over aggressive impulses. Prohibiting spanking may not be an effective strategy after all.  Our efforts may best be put into offering parents guidance about supporting their children’s development of emotional regulation.


Saturday, May 12, 2012

The Myth About Crawling Creeps In Again


You think mistakes have gone away--  then they crop up again as vigorously as weeds in the garden! That’s what I’ve just found at http://stellarcaterpillar.com. This web site has a great name, and no doubt contains some valuable material (like a video of how a baby climbs out of his crib). BUT… it also reiterates the Myth About Crawling.

This myth states that babies must crawl, and do so for some period of time, in order to cause the brain to develop properly. It’s a myth because it doesn’t happen to be true, and unfortunately it’s also a piece of folklore, which by definition goes without critical examination by most of its hearers.

Here’s what the stellarcaterpillar author says: “Sometimes baby learns to pull up to a standing position too soon, before his bones and muscles are strong enough to support him. In this situation, it is best for the parent to take his hands back down to the floor and tell him it is not time to stand, and it is still time to crawl. It is very beneficial for baby to crawl for several weeks before standing up. For many years, experts have researched and shown that crawling is very important for the development of the brain.” This author, a dance therapist, goes on to say that babies try to stand “too soon” because of imitating an older sibling, attending day care where older babies walk, or being put in a jumper “too soon”. (Don’t their parents walk, by the way?) She implies without directly stating it that such babies are at risk for inappropriate brain development if not discouraged from standing and receiving praise for crawling. And I must say that she does not “show her work” as she engages in this confident speculation.

So, what about all this? Let’s look at some important issues. The first one is the idea that actions stimulate the parts of the brain that produce them--  for example, that as I use my right hand to type, I am stimulating the left side of the brain, the side that is doing much to control the right hand’s movements.  (By the way, see my previous post about brain functions for some comments about the right-brain/left-brain distinction.) The logic is this: activity of the left hemisphere causes the right hand to move, therefore the movement of the right  hand causes activity in the LH. To put it more generally, this statement is that if A causes B, B causes A. Does anyone recognize this error of critical thinking? It’s called “affirming the consequent”, and it’s the cause of a lot of mistakes in logic. By this fallacy, if the cow jumped over the moon, the moon also jumped over the cow! Of course there can be situations where two factors are mutually causal, but showing that requires a lot more information than a simple statement.

What’s so concerning about the stellarcaterpillar author’s affirmation of the consequent? Well, there are several erroneous conclusions that can be reached if you start with this mistake. One , the practice of “patterning”, goes back to about 1960 and is still advocated by the Institute for Human Potential in Philadelphia—despite two position statements of the American Academy of Pediatrics rejecting it. “Patterning” is a practice based on the idea that  moving on all fours provides not just stimulation to the brain (see previous paragraph), but a pattern of stimulation that affects the right and left hemispheres simultaneously and therefore is asserted to have a special benefit (for which no systematic evidence has been offered). “Patterning” advocates are best known for claiming that repeatedly moving the limbs and head of a brain-injured person would cause the brain to re-develop normally. They have also claimed that forcing school-age children to crawl would repair a range of problems from cerebral palsy to dyslexia. Not only does “patterning” not accomplish these goals, it costs families a good deal in terms of time, money, and other resources. I don’t doubt that “patterning” believers are sincere, but I do consider them deluded.

Having assumed that crawling benefits brain development, the stellarcaterpillar author has to deal with how a child who wants to stand can be prevented from doing so. She suggests discouragement of standing and praise for crawling--  apparently assuming that infants’ primary motivation is social approval or disapproval, and possibly forgetting how they throw food on the floor in spite of their mothers’ negative responses. In fact, the stellarcaterpillar author has forgotten the insight of infant mental health researchers into the fact that mastery motivation is of critical importance in determining infant and toddler behavior. Babies and young children want to master skills and accomplish things. That’s why they work hard and often seem to lose interest in anything they’ve mastered, why they no sooner walk than they have to try walking backwards. Interfering with the baby’s own developmental goals will be extraordinarily frustrating for baby and parent both, and by the way, if the adult succeeds in making the baby stop trying a new skill, it will not be so easy to reverse the attitude when the parent decides there’s been enough crawling. (ANECDOTE WARNING: Some years ago I was consulted about a baby who was not sitting up unsupported at the typical age. Turned out his family day-care provider didn’t have enough cribs to go around, so she put him to nap in a baby carriage. She stayed near, and if he tried to sit up, she pushed him back down. He learned not to sit, and had to be worked with a good deal before he tried it again.)

A final point about the assumptions made by the stellarcaterpillar author: it’s a big mistake to think that development occurs only because of specific experiences a child has. Many aspects of development simply unfold in the course of maturation and are supported by everyday events that usually go unnoticed by adults. A certain amount of motor development has to do with the baby’s muscle strength and position of the center of gravity. Esther Thelen, the great motor development researcher, showed that Down syndrome babies walked earlier when they had a chance to exercise on a “baby treadmill” and strengthen their muscles. But babies can’t and don’t “walk too early” and harm their brain or bone development, any more than they hurt themselves by “talking too early” or “reading too early”. If they try something they’re not ready to do, they fall down, literally or figuratively.

In the days when rickets was common, legs may have become bowed in the course of early walking. But the belief that brains can be “bowed” in this way is simply modern folklore.



Monday, May 7, 2012

Brains: Right v. Left, Top v. Bottom


“Everybody knows” that the brain is divided into right and left halves, clearly demarcated by a fissure down the middle, much like a walnut. And “everybody knows” that that division is a visual reminder of a division of functions--  that those two halves do different jobs, and whichever of them is more active determines not only functioning but personality. People proudly declare themselves to be “right-brain” types (i.e., creative; unbound by all that linear restrictiveness of the left hemisphere) or (sometimes apologetically) “left-brain” types--  linear, detail-oriented, thinking mainly inside the box. Left and right are such important categories, for handedness, driving, even politics, that we’re ready to accept the idea that the brain works that way too.

The right/left brain emphasis was strengthened by popular books like Drawing on the right side of the brain---  but this did not make the idea a better description of human functioning.  When you “draw on the right side of the brain”, you may be using methods that will create better art, but you are not actually putting a separate brain function to work. The book Drawing on the right side of the brain offered some excellent exercises for improving drawing skills, but the exercises would have worked just as well if the word “brain” had never been mentioned at all. (Although no doubt fewer copies of the book would have been sold.)

However, although I suppose it’s not too good to be true, the right-left brain distinction is too simple to be true. As Borst, Thompson, and Kosslyn (writing in the American Psychologist in 2011) have put it, “one could argue that for the most part, the left and right halves of the brain may be more like the kidneys or the lungs: There are two of them, but they are redundant. In some respects the hemispheres are different, but most of those differences appear to be quantitative (e.g., affecting the amount of time required to perform a task), not qualitative. “ If this were not true, people deprived of speech by a stroke on the left side would not be able to regain their ability.

Like other researchers on the topic of brain functions and anatomy, Borst and his colleagues described a different brain division—one that’s not so obvious, or so reminiscent of the everyday walnut. That division is into top and bottom--  dorsal and ventral parts of the cortex.

Basing their statements on analyses of many brain studies, Borst et al proposed that the dorsal and ventral areas are different in terms of their ways of processing information. The dorsal system, they suggested, is expectation driven. This means that the dorsal system functions in specific ways and uses them to make predictions about what happens next, or about what happened in the past. It processes sensory information in an orderly fashion, paying attention to time of events. It remembers information in terms of relationships between places or between times. It pays attention to movement, and the differences in place and time that go along with it. It encodes changes in spatial relations between two objects as they occur over time, and so has an important role in control over body movements.

Borst  et al also proposed that the ventral system  is classification driven. It works to identify what is seen, heard, or felt, and does this by concentrating on individual objects rather than looking for relationships between objects. It examines characteristics like color, texture, sound frequency, and loudness, but not movements.

When people embrace the right hemisphere/left hemisphere distinction, it’s easy for them to imagine each hemisphere operating independently of the other. The obvious metaphor is the two hands, which can co-operate but which can also make independent movements. But in fact, unless you’re one of those unfortunate split-brain patients (who already had serious damage to one hemisphere), the two sides of your brain always work together. For that matter, so do your hands, which is why patting your head and rubbing your tummy is so difficult.

It’s a lot more difficult to imagine dorsal and ventral functions occurring independently, and we don’t have any common metaphors that seem relevant, other than perhaps that “top” is better than “bottom”. It’s obvious that the posited dorsal and ventral functions work together under normal circumstances. Dorsal functions guide your movements as you prepare to catch a ball--  but you wouldn’t be trying to catch it if you didn’t  know it was a ball. You wouldn’t want to hurt a bird flying wildly toward you, or to be hurt by catching a hand grenade.

Understanding dorsal and ventral functions is not as much fun as interpreting all human actions in terms of those freestanding right and left hemispheres. I don’t expect ever to hear anyone say “I’m just a dorsal kind of guy.” Nor is this view of the brain as easily oversimplified as the hemispheric approach. In fact, Borst and his colleagues point out that the next step is to track down functions by looking not just at dorsal and ventral events, but at the anterior and posterior areas of both systems. Real neuroscience offers more and more insight into the complexity of the brain and is not about to offer us easy explanations of education, personality, or the arts.

Wednesday, May 2, 2012

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.

Book Reviews: Alternative Therapies for Children


Two books published by Jessica Kingsley Publishers will be of interest to students of complementary and alternative treatments for disorders of childhood mental health or educational progress. Dyslexia and alternative therapies by Maria Chivers (London: Jessica Kingsley, 2006) focuses on treatments for reading problems, but includes a variety of CAM approaches covering a spectrum of methods from physical manipulation to stress reduction.Understanding controversial therapies for children with autism, Attention Deficit Disorder, and other learning disabilities, by Lisa A. Kurtz (London: Jessica Kingsley, 2008) reviews a much broader range of problems and treatments, as its title suggests.
The Chivers book is notable for its completely uncritical consideration of an extensive list of dyslexia treatments. The author concedes that “tried and tested teaching methods should not be replaced, and… alternative approaches should be treated as complementary”. She asks readers to judge for themselves but notes that “it will pay dividends to keep an open mind”. She applies this approach even to “distant healing” methods, about which she remarks that “some people are skeptical about therapists who state they can cure them without touching or even seeing the clients themselves. But as with many therapies in this book they may be worth trying.” About one method, Chivers says, “This definitely works for me.” She advises that “it is healthy to maintain a critical faculty and to question what you are told, but equally make sure this does not prevent you from being open to some of the valuable treatments that are out there.” Clearly, Chivers is not one to concern herself with the evidence basis for a practice.

Chivers provides no discussion whatever of issues concerning research design or the concept of evidence-based practice, but simply presents a list of CAM treatments and summarizes the claims made by their proponents. She includes a bibliography with a small number of articles from peer-reviewed journals, a very few of which report randomized controlled trials; most of the resources listed are non-technical or even speculative in nature. The book also features a list of organizations whose websites offer either general information or advocacy for specific methods such as chiropractic treatment.

Chivers’ book is not a resource for those who are interested in evidence-based practice, but it does provide a lengthy and sometimes surprising list of CAM methods that have been put forward as potential treatments for reading disabilities. These include acupuncture, hypnotherapy, and nutritional supplements as well as “visual” treatments like the use of colored overlays. The suggested treatments resemble each other, not only in the absence of empirical support for their usefulness, but in their complete lack of plausibility. Curiously, the one highly plausible, although little-supported, method of treating dyslexia, FastForWord, is omitted from the list.

The Kurtz book makes a somewhat better effort to deal with the issue of evidentiary foundations for CAM therapies. One reason for this may be the fact that Kurtz is looking at treatments for psychiatrically-diagnosed conditions as well as for educational problems. The higher cost and insurance-related decisions of the former suggest the need to focus on efficacy, whereas the effectiveness of educational methods is less frequently subjected to serious evaluation. Kurtz presents reference lists for treatments, including outcome research in some cases, but providing only occasional and cursory guidance about conclusions to be drawn; much more space is devoted to methods for training practitioners than to the evidence bases of these treatments. As was the case for the Chivers title, plausibility is not mentioned as a concern, and the completely implausible “Bach flower remedies” receive the same attention as the quite plausible but weakly supported FastForWord.

Kurtz’s discussion of several methods involves notable omissions. The reference list for the Doman-Delacato “patterning” technique includes a reference to the 1999 policy statement of the American Academy of Pediatrics on this method, but the text does not note that this statement was the second of two by this group, both rejecting the use of “patterning”. The discussion of Facilitated Communication refers in passing to the possible influence of the practitioner on this method, but does not discuss some of the serious accusations families have suffered as a result of the assumption that the technique yields accurate information about a child’s intention.

Kurtz’s discussion of Holding Therapy is problematic in that it describes only one of the several approaches that would be categorized under that label. In addition, the description fails to explain the length or frequency of sessions, a point that would do much to communicate the intense experiences characteristic of the specific treatment described (the Welch method). Kurtz does not mention that Holding Therapy has been classed as a potentially harmful treatment.

It was a surprise to this reader to see DIR/Floortime listed as a CAM treatment by Kurtz. DIR (Developmental, Individual-difference, Relationship-based therapy ) is indeed lacking in an established evidentiary foundation, and it uses some of the problematic methods associated with Sensory Integration. However, DIR has a highly plausible theoretical basis and there is ongoing work aimed at outcome evaluation, so DIR would seem to stand in considerable contrast to other methods discussed by Kurtz.
Like some other Jessica Kingsley publications, the Chivers and Kurtz books give the reader a certain sense of incompleteness, as if no reviewer or copy editor had acted to jog the authors’ memories and remind them to include or elaborate on various points. As simple lists of treatments, or as compilations of resources for further study, however, they provide well-organized though unevaluated information for the interested researcher.

Tuesday, May 1, 2012

Mermaid Spirits Rejoice! Ukpabio Cancels Visit


Does anyone remember Helen Ukpabio? She’s the Nigerian “lady apostle” who was scheduled to visit Houston, first in March, then later in May. But now she’s not coming at all.

Ukpabio was going to do a “marathon deliverance” at Houston’s Liberty Gospel Church. She was offering her services to those plagued with “mermaid spirits”--- pesky water creatures that can give you worldly prosperity but also cause infertility and unhappiness in marriage. (As I mentioned at http://childmyths.blogspot.com/2012/02/child-witches-in-america-and-related.html, some of these beliefs have been described by David Tonghou Ngong in his The Holy Spirit and Salvation in African Christian Theology.) The mermaid spirit belief is not far from the “prosperity theology” offered in some years ago by Oral Roberts and others, but it involves an integration of the messages of American Pentecostal missionaries with African traditional religions.

It’s easy to make fun of mermaid spirits and similar beliefs, but there’s much more to the story than that. The events that led up to Ukpabio’s cancellation were not about deliverance from those spirits, however reprehensible it might be to exploit unhappy people who think they have water spirits distressing them. In fact, the objections to Ukpabio’s visit had to do with her role as an accuser of “child witches”--  ordinary children whose parents became convinced that the children flew off at night to meet in covens, children thought to enjoy the power to kill, to injure, and perhaps most importantly, to make electrical and electronic appliances break down.  

Ukpabio’s accusations, and her film called The End of the Wicked, have encouraged a belief in child witches. Although Ukpabio claims that she simply prays over accused children, large numbers have been attacked, burned with acid, abandoned, beaten, and starved by adults who were convinced that these apparent innocents in fact were exercising demonic powers. The children’s terrible fear and misery are shown in heartbreaking detail in the documentary Saving Africa’s Witch Children (www.hbo.com/documentaries/saving-africas-witch-children/index.html). As I mentioned in the earlier post, the deaths of children thought to be witches or demon-possessed have not been confined to Africa, but have also taken place in the United Kingdom and the United States.

The organization Stepping Stones Nigeria (www.steppingstonesnigeria.org) deserves much of the credit for publicizing Ukpabio’s activities and mobilizing resistance to her entry into either the UK or the US. According to information sent me by the ethicist Leo Igwe, Ukpabio claims that she received written death threats warning her away from her trip to Houston (see http://www.allvoices.com/contributed-news/11990019-apostle-helen-ukpabio-cancels-visit-to-us-cites-threat-to-live). The article quotes criticisms of Stepping Stones leader Gary Foxcroft and suggests that he has orchestrated a campaign in order to profit financially. However, according to a press release from Africans Unite Against Child Abuse (AFRUCA),  a recent summit conference of concerned British political leaders and others was convened by Chuka Amunna, a Member of Parliament. The discussion included the suggestion that the Home Secretary prohibit entry into the UK of persons who have encouraged the branding of children as witches. This discussion paralleled the recent campaign in the United States, asking the State Department  to refuse entry to Ukpabio. It’s clear that resistance to her visit was strong and that no death threats would have been needed to show Ukpabio what the consensus was.

The concerns about Ukpabio’s visit raise  questions about freedom of speech and religion in the United States. If Ukpabio genuinely believes in mermaid spirits and witch children, is she not entitled to hold those beliefs here--  even to speak publicly about them? If she has not herself harmed children, but her preaching has been taken as encouragement for others to do so, is it legitimate to exclude her? (I ask these questions even though I myself very much want her to be excluded.) The famous exception to the First Amendment  is that one cannot claim a First Amendment right to shout “Fire!” in a crowded theater, when there is no fire. But what if you actually think there is a fire (as Ukpabio presumably does, metaphorically speaking), and people are trampled to death because of your mistake?

In Ukpabio’s case, these points are somewhat moot. As a non-citizen, she has no presumed right to enter either the U.K. or the U.S. to begin with, and those countries have responsibilities to protect their citizens. However, the points are far from moot with respect to citizens, and they go far beyond religious beliefs. I have discussed elsewhere the repeated cases in which parents have received inappropriate advice from therapists or coaches, have harmed their children as a result, and have ended up in prison, while their advisers remain free to pass along harmful suggestions. How far do things need to go before we become aware that although parents who do harm should not be excused, the givers of potentially harmful religious or other advice are also culpable?