Concerned About Unconventional Mental Health Interventions?

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

Thursday, June 21, 2012

More About Adoption and Reactive Attachment Disorder: Mind That Diagnosis

At, some people are incensed by the fact that “someone” has said that the diagnosis of Reactive Attachment Disorder does not include symptoms like violent behavior. They say that anyone who says that ought to see what their kids can do.

But, as Lyndon Johnson and the Bible used to say, “Come, let us reason together.” No doubt their children are violent, as reported. If they aren’t, well, some children assuredly are. No one has said that children aren’t ever violent, just that violence is not one of the symptoms of Reactive Attachment Disorder.

So, we have kids whose violence has been reported, and those are also kids who have been said (by somebody) to have Reactive Attachment Disorder. Suppose one of those things is not true? Which is it more likely to be--  that they aren’t really violent? No, it would be a bit too conspiracy-theory to imagine that a group of parents have invented this report. What about the alternative—that they don’t actually have Reactive Attachment Disorder, or, if they have it, they have some other serious problems as well? Those problems could be other diagnostic categories that haven’t been stated or mentioned, or of course the problems could result from various difficulties of one or more other people in the household, as family therapists have told us over and over.

Not knowing the families, I am not about to say whether violence may reflect family problems. Knowing how the Internet has presented Reactive Attachment Disorder, however, I am prepared to say that a diagnosis that is based on one of the many “checklists” (like the one at is not going to be an accurate statement about the presence or absence of that specific disorder.  And I’d like to put in a request: before people fulminate about whether their beliefs about violence and RAD have been attacked, they should get a complete assessment done by a licensed clinical psychologist, with a doctoral degree in clinical psychology from an accredited university, and by a physician with some training in behavioral issues. Do those practitioners diagnose Reactive Attachment Disorder, or was the diagnosis done by the parent using a checklist, or by a “registered attachment therapist” with no training in any other aspect of childhood emotional disturbance? If the latter, I would suggest, folks, that you re-think what you’re dealing with.  An assessment, by the way, doesn’t stop with a diagnosis, but describes specific problems that need help.

To go on with this issue, let me point out that only your health insurer really cares what name you give a disorder. Treatment focuses on what symptoms are shown, and within some limits that treatment will be the same no matter what DSM code is written on the bill.

A lot of people have gotten the idea that if a child has had a poor care history—is post-institutional, for example--  that’s all the evidence needed for a diagnosis of Reactive Attachment Disorder. As I’ve pointed out in other posts, the work of Michael Rutter and the English-Romanian Adoptees study group has shown that most children adopted from really awful orphanages do very well. The biggest general problem in the early years is delayed language development.  An American group has shown that improving orphanage conditions improves child outcomes (even though they’re all still separated from their birth mothers, etc. etc.).

Writing in Infant Mental Health Journal (2011, Vol. 32[2]), Christina Groark, Robin McCall, and Larry Fish, in “Characteristics of Environments, Caregivers, and Children in Three Central American Orphanages” have described both children and experiences in those institutions.  The authors point out that children may have very different experiences in orphanages, and that they may have had harmful experiences even before entering the institution.

The characteristics of the orphanages give some possible insight into children’s developmental difficulties and show us how much more there is to think about than a simple diagnostic category. Most of the wards had 8 to 12 children aged birth to 7 years (grouped by age), but in one orphanage there was also one single room with about 50 infants and young children, with each caregiver informally taking charge of a certain part of the room. Child to caregiver ratios were from 8:1 to 12:1. Caregivers worked long shifts—even 24 hours—and then had 1-3 days off. Children thus had little opportunity to spend much time with any one caregiver, and there was little time for a caregiver to get to understand each child well. Children also “graduated” to a new ward periodically. As Groark and her colleagues put it, “while caregivers were stably employed, they were not consistently present in the lives of children, who tended to see new caregivers from a set of 6 to 9+ every day or every other day, experience different substitute caregivers as needed, and graduate to new wards.”

The children (mostly under 7 years of age) were described as having “exceedingly low” behavioral development. They also showed quite high rates of indiscriminate friendliness to a stranger and were frequently noncompliant and provocative, and even interpersonally violent, but unlike some other post-institutionalized children who have been described, they did not show much impulsiveness, impatience, or frustration, or stereotyped or withdrawn behavior.

It’s notable that this article did not use the term Reactive Attachment Disorder or any other diagnosis of the children’s characteristics, and it’s hard to see what good would come of anything other than describing what the children were like. Groark’s work was not a study of therapy, but it’s easy to see how helpful it would be for parents or therapists to have specific information about child behavior rather than a diagnosis which gives a general--  possibly incorrect--  description, which may apply much better to some children than to others. A diagnosis describes the disorder, not the child, and when we come down to it, we treat, or adopt, children, not disorders.    

Saturday, June 16, 2012

ATTACh Tells Us About Attachment Disorders: An Unrecommended Video

You can see at a video entitled “ Attachment Disorder: Diagnosis and Treatment”. The video does not make it clear who made or sponsored it, but shows the logo of the Association for Treatment and Training of Attachment in Children (ATTACh), a parent-professional hybrid group that claims special expertise in mental health problems of children. Those presenting on the video are leaders in ATTACh, but would not be regarded as prominent in mainstream approaches to infant and child mental health. You may want to watch this production, but please read this post first.
Here are some statements from the video that I want to comment on:

1.      (1:25) Sally Popper comments on the inadequacy of the usual definition of attachment disorders, presumably referring to the DSM-IV-Tr criteria for Reactive Attachment Disorder and the ICD-10 criteria for Disinhibited Attachment Disorder. She states that these definitions are not very useful, and that discussion of attachment disorders should include facets such as attention problems. She also states that attachment disorders involve children’s lack of  trust in the caregiving environment. Finally, she refers to such disorders as being caused by interruptions (or other difficulties) in caregiving, especially for babies, but she does not comment on an age range in which such interruptions are most likely to have ill effects.

Popper’s remarks reflect many years of ATTACh claims about the existence of some form of attachment disorder which is “not yet” included in DSM. Unless, it has suddenly been changed, lists a series of signs and symptoms of attachment disorders that are completely incongruent with the DSM criteria. The Randolph Attachment Disorder Questionnaire, once well-thought-of by ATTACh proponents, was stated by its own developer not to be an evaluation of Reactive Attachment Disorder, but of “something else”. ATTACh members have claimed for many years to be able to recognize a disorder caused by a  poor attachment history and not known to anyone else; Elizabeth Randolph stated that she could diagnose this problem when children were unable to crawl backward on command. These claims have been ways of positioning ATTACh as possessed of an expertise that was not available to mainstream mental health practitioners.

The absence of any statement about an age period in which children are especially sensitive to disrupted caregiving relationships is also typical of years of ATTACh statements. Omitting this critical point allows practitioners to claim that any adopted or foster child, no matter how old the child was at placement, suffers from an attachment disorder. There is a connection here to the claim that emotional attachment occurs prenatally and that babies adopted on the day of birth nevertheless suffer emotionally from the separation from the birth mother.

2.      (2:48) Richard Kagan talks about the discoveries of neuroscience about the impact of the brain of neglect and abuse and states that abused or neglected children show poor self-regulation because some brain structures are “shrunken”. Then, abandoning the showing of the neuroscience flag, he goes on to say that children may have learned frightening behaviors as ways to get help when neglected. As Kagan does not mention any diagnostic or treatment usefulness of information about brain structures--  and as he does not seem to see that frightening behaviors as he discusses them may be a form of self-regulation—it is difficult to see the relevance of any of these statements to the supposed topic of the video.

3.      (5:39) Victoria Kelly introduces the idea of Developmental Trauma Disorder, the diagnosis suggested by Bessell van der Kolk but probably not to be included in DSM-V, and proposes that this diagnosis is what really captures the nature of attachment disorders as proposed by ATTACh. Kelly stresses the difficulty of diagnosis and states that children may be seen as having ADHD or bipolar disorder--  but because the real, underlying problem is not being treated, interventions are not successful.

N.B. Nobody in this video talks about how appropriate therapy would be different from ordinary methods, but van der Kolk’s claims that the real problem cannot be accessed cognitively imply that physical methods associated with emotional reactions might be the way to go, in spite of the fact that such methods have no foundation in systematic evidence.

4. (7:11) Gregory Keck is supposed to be speaking about the history of understanding of attachment disorders, and of course I listened to this with great interest. He even begins by citing Foster Cline--  but rather than talking about holding therapy and why (or whether) they don’t do that any more, he simply says that Cline had seen attachment disorders (as he defined them) as psychosocial in nature, and now the field sees them in terms of trauma and brain development. What difference this would make to diagnosis or treatment, the supposed topics of this video, was left unstated.

5. (8:40) Barbara Rila comments on what will happen to children with attachment disorders (undefined)  if they don’t get  proper treatment (also undefined). She claims that the consequences in adulthood will be borderline personality, anti-social personality disorder (this of course has been the mantra of ATTACh for years, usually with names like Jeffrey Dahmer associated), depression, and suicidality. Proper treatment is supposed to ameliorate all of these.

Rila does not compare these statements with the reports of Michael Rutter and the English-Romanian Adoptees study to the effect that the great majority of the children they studied, who had been adopted from the worst possible conditions and therefore most likely to show attachment disorders, did very well. Some were reported as having quasi-autistic features, and some were unusually friendly with strangers as young children, but all were doing quite well in their teens. None were reported as anti-social in behavior; the most common problem was delayed language development.

Rila, by the way, was the author of a chapter on attachment disordered adoptees in a 1997 book edited by Roszia. In the abstract for that chapter, she says "The process of attachment therapy essentially reenacts the attachment cycle. An attempt is made to elicit the child's emotional pain or experience that is blocking present attachments"--  in other words, Rila at that time, at least, was a supporter of holding therapy.

             6. (10:49) Michael Trout states that practitioners now have most of the tools needed to treat attachment disorders (undefined) and that there is hope for children with problematic early experiences. One of his reasons for this statement, he says, is that “babies remember” and their behavior has meaning that helps us understand what they remember.

Let me just point out that Michael Trout is involved not only with ATTACh (which gave him an award) but with the Association for Pre- and Perinatal Psychology (APPAH), a group dedicated to the idea that babies are conscious of their prenatal and even pre-conception experiences as well as remembering the details of their births, and that telepathic communication before birth traumatizes babies whose mothers consider terminating their pregnancies.

One member of APPAH, William Emerson, has performed and encouraged infant massage techniques that will make babies re-experience the discomforts of birth, cry, and thus experience catharsis. His position is that babies need to cry in order to express themselves and escape the effects of early experience. This APPAH position, and Trout’s statements about how “babies remember”, raise the question of physically-intrusive treatment of the holding therapy type and the extent to which they have actually been rejected by ATTACh.

As is so often the case, a careful examination of this ATTACh production in the light of other information suggests that there is less expertise here than appears to meet the eye.

Why Tummy Time?

A young baby I’m acquainted with has been sleeping on his back (the supine position), as recommended, for the last two months. His parents have been busy with a list of things you can well imagine, and had not been doing any “tummy time” with him. Now he has a little flattening of the back of his head, and his pediatrician has started to urge “tummy time”--- putting him in the prone position (on tummy, not back) while he’s awake and ready to play a bit.

What’s the purpose of this? Is it all about keeping a nice round head?

It’s true that people in industrialized countries (as well as many others) don’t like a person’s head to be flattened in back. Some cultures have liked skull shapes that we would think strange, and put babies on cradleboards or bound their heads in other ways so they would grow into high-fashion shapes. Babies’ skulls are not yet completely hardened and bony, nor are the skull bones fused into a solid dome—that’s why there’s still a “soft spot” on top of the head. Because the individual bones are still somewhat soft, and because not all the skull plates are connected, it’s easy for continuing pressure on one spot to change the shape of the skull. Lying in one position all the time may deform the skull, and it’s a lot easier to prevent this deformation than to cure it.

But---  there’s a lot more to the issue than having a nice head. Babies’ muscular, bone, and motor development is affected by the movements they get to make. This seems surprising, I know, because we usually think of the baby’s development as just unfolding bit by bit, physical growth and movement control emerging according to a genetic timetable as long as the baby is well fed and cared for.

Young babies (let’s say, birth to three months) can make some movements when lying on their backs. They can kick, wave their hands, and so on--  although for the first month or so they’re “prisoners” of their own reflexes, and their movement of one arm forces the other arm and the head to go into new positions. They can’t lift their heads, though. The head is very heavy compared to the rest of the baby, and even adults find that to lift the head in the supine position (back-lying) is much harder than to lift it when prone. Remember, too, that young babies are likely to lie with the legs somewhat drawn up rather than extended, and this makes it even harder for the weight of the body to counterbalance that big head.

When in tummy position, babies can work toward a lot of new skills that are too difficult in the supine position. Even a newborn can usually lift the head enough when in prone to be able to turn the head from side to side, which is difficult for the back-lying baby. Lifting and moving the head in that way fosters the development of the neck muscles and helps steady the head in all sorts of positions--  which, by the way, helps the baby move the head to look at interesting things and get more involved with the world around him.

Once the head is being lifted a bit, it’s easier for the hands to come forward and provide a steadying base for the baby in tummy position. This works the arm and shoulder muscles, and enables the baby to move toward pushing on the supporting surface and bit by bit getting not only the head but the chest up--  essential steps toward crawling, but also important for getting a good look at the world. Incidentally, while pushing up, the baby works on opening up and flattening out the hands that were clenched fists most of the time in earlier weeks. The increased arm and shoulder strength, and the development of the chest muscles, also contribute to being able to sit on someone’s lap with a little support of the hips, and to join in the social whirl. Sitting up makes it easier to reach, also to see people’s faces and learn about them--  and so on and on.

Would it be a big problem if the baby didn’t get tummy time? The possible flattening of the head is certainly undesirable, but everything else would probably develop after a while. Even a back-lying baby eventually learns to turn over into the prone position and goes on from there, but with motor skills emerging later or in a different order than what you might think.

Here’s one of the issues to keep in mind: most “baby books” and lists of motor milestones tell you what babies did many years ago. Until perhaps ten years ago, parents in the United States had been advised for decades to keep their babies on their tummies. As a result, the babies developed head and chest control and other abilities earlier than back-lying babies do. “What the book says” may be somewhat different from what today’s back-lying baby does. “Tummy time” is designed to give the babies the health and safety advantages claimed for back-lying as well as the types of motor development the prone position encourages, and the cognitive development that goes along with them.

A baby who has been lying on his back for a couple of months will probably not be best pleased when placed in the prone position. Lifting that big head may be frustrating and difficult, and he’s not used to it. The most helpful thing a parent can do is to put is to put his or her face where the prone baby can see it with a little effort. The social support of a smiling, attentive face helps the baby organize this new activity. If the baby is on the floor, it may be hard to put your face in the right place without dislocating your neck, so try a tabletop with a blanket on it, and sit right beside it. (Naturally, you’re not going to step away for even a minute and leave the baby there!) If you have an old-fashioned crib whose side lets down, that makes an even better arrangement.

One other hint: if you place a hand lightly on the baby’s bottom, you help him counterbalance the heavy head so it’s easier to lift. When he succeeds, it’s so exciting that he’s likely to work even harder and can soon manage without your help.

There’s no real need to rush development along, and I don’t mean to suggest that your child is in some kind of race or won’t get into Harvard if you haven’t done plenty of tummy time. But as motor and cognitive skills move along, babies and parents have more to do together and have more fun, and that always helps when young families are navigating this complicated part of life.


Tuesday, June 12, 2012

"Adoption Today" and the ATTACh Belief System

The June 2012 issue of the magazine Adoption Today is available for free at (It’s supposed to be available at the magazine web site, too, but I wasn’t able to make the pages turn when I went there.) It’s worth looking at under a strong light--  in a discouraging kind of way.

This issue contains no articles by people with advanced professional research backgrounds, or by anyone usually considered to be an outstanding researcher or clinician in adoption or related fields. (It has an advertisement by someone who has claimed his methods are evidence-based, but that’s a whole ‘nother story.) That situation may not be too surprising in a publication that’s aimed at adoptive parents, of course—but it is surprising to see that many of the articles are by leading members of the Association for Treatment and Training of Attachment in Children (ATTACh), an organization that has its own belief system about attachment and has shown little interest in the realities as demonstrated by systematic investigation. Those who doubt this statement may want to go to and look at the list of behaviors that are claimed to be indicative of disorders of attachment; compare those with the actual definition of Reactive Attachment Disorder in DSM-IV-Tr, and note the absence of any other “attachment disorder” in that volume, and you’ll see what I mean.

Adoption Today, at least in this issue, is a vehicle for advertisement of the books, videos, and services offered by a small number of practitioners. But it also includes articles under the bylines of many of the same people, and some of these deserve closer attention as they reveal how the authors follow the “party line” rather than evidence-based material about either attachment or adoption. Incidentally, the last page of the issue contains a “CEU quiz” for pre-adoption preparation, although it acknowledges that most states have no requirement for this type of training.

Starting on p. 14, an article by Lark Eshleman, who I believe is an educational psychologist, discusses attachment in terms borrowed from ATTACh. (Eshleman apparently worked with the Craver family who were recently convicted in the death of their adopted child, as I discussed at In her article, Eshleman provides a definition of attachment quoted from ATTACh: “Attachment is a reciprocal process by which an emotional connection develops between an infant and his or her primary caregiver.” Let’s give this some consideration.
First, is attachment actually a reciprocal process? Its foundations are in reciprocal behaviors, but attachment itself is not reciprocal. Attachment is the name given to a motivational change in a young child, one which leads him or her to show preferences for familiar people (not just the primary caregiver, by the way). Attachment is shown most often as an attitude, or readiness to behave, in which social preferences are acted upon when threat or discomfort is present, not all the time.

To say that attachment is a reciprocal process implies mutuality and suggests that the caregiver is experiencing the same motivational changes as the child, which is certainly not the case; if it were, mothers with headaches would rush to be with their children, rather than hoping for some quiet time alone. If the process were reciprocal, there would be no sad cases of young children grieving over their removal from the homes of neglectful or abusive parents who show little sign of caring about the kids.

It is true that attachment develops in the context of social interactions with other people. But infants are so ready to form attachments that they need relatively little encouragement or reciprocity from adults to do so--  in fact, many adults would much rather that their toddlers showed less attachment behavior, and rather than encouraging the behavior may actively discourage it (but without successfully altering it).

It’s also true that adult caregiving and infant bids for care  (the usual context of attachment development) are reciprocal. Students of parental behavior used to use the terms epimeletic (meaning caregiving) and etepimeletic (meaning soliciting caregiving) to emphasize the interactions between these two types of behavior. And most social interactions take place in the caregiving situation, so attachment is developed in association with reciprocal actions--  but that is not the same as saying attachment is reciprocal. When the claim is made that attachment is reciprocal, it’s easy for adoptive parents to feel that “something is wrong” when an adopted child does not share the parents’ excitement, pleasure, and love.

Incidentally, the focus of the ATTACh definition on the "primary caregiver" is problematic. Attachment to several familiar people (even those who are sociable but not caregivers) is a feature of toddlers' lives. We can see this because toddlers can use people other than the primary caregiver as secure bases for exploration and also can turn to those people when threatened or uncomfortable. The ATTACh approach turns on the theory that the mother is absolutely central to the child's emotional development, as originally assumed by Bowlby, later dropped by Bowlby, and shown to be unlikely in this age of LGBT etc. families.

So Eshleman is pushing a concept created by ATTACh which is in fact not in line with the realities of attachment as systematic research has shown them to be, and Adoption Today is presenting this idea as reliable thinking about attachment. What else can we find in this issue, other than advertising for Eshleman’s services and publications? Ah—let’s look at this article by Mershona Parshall, starting on p. 18. (Parshall was the business partner of Elaine Thompson, an “attachment therapist” who was involved in the case of the caged Gravelle children in Ohio; Parshall was not accused in that case nor as far as I know was she involved in the treatment of the Gravelle children.) Parshall’s article describes the use of “neurofeedback” for treatment of severe behavior problems in an adopted boy. Over a period of two years, the boy received the treatment (usually described as “possibly efficacious”), and his behavior improved, an outcome that Parshall attributes to neurofeedback rather than to maturation. Parshall states that apparent regressions in behavior are to be expected at the beginning of the treatment and that it is critical not to increase medications, but actually to decrease them, at this point--  a potentially dangerous statement if there are serious biological reasons for the problems, and one which Parshall makes without explanation.

Interestingly, on p. 24, we see an article (and accompanying advertisement) by Terry Levy and Michael Orlans, founding members of ATTACh and formerly attachment therapists involved with Evergreen, CO (the home of holding therapy), and still listing an Evergreen address. Levy was the editor of a 2000 book published by Academic Press that featured a chapter by Nancy Thomas, the “therapeutic foster parent”, who advised removing furniture from children’s rooms and placing alarms on their doors, requiring them to ask for all “privileges” including use of the toilet, limiting the quantity and variety of their food, and insisting on periods of “strong sitting” without motion or speech. Thomas also advocated withholding information from children in treatment, including answers to their questions about when they would see their parents again (these, of course, were children who were said not to be attached to the parents they were asking for).

Speaking of Nancy Thomas, the piece by Julie Beem on p. 30 seems to be on the same page with the Thomas philosophy. A sidebar lists “therapeutic parenting” programs as suggested by Thomas, by Heather Forbes, by Katherine Leslie (all fans of the restrictive approach), as well as by the Love & Logic company, headed up by Foster Cline, one of the originators of holding therapy and related approaches.

Have I said enough to show what’s going on here? I could, but won’t, go on to discuss the numbers of therapists listed at the end of the issue who have been associated with potentially harmful treatments for children and with the less harmful but not demonstrably effective approaches now sponsored by ATTACh. I do not see on that list the names of respected, evidence-oriented clinicians like Mary Dozier or Sheila Eyberg!

Adoption Today, can’t you do better than this? Adoptive parents need information that is both reliable and accessible. A magazine that functions as the house organ of ATTACh and as an advertising medium is not living up to its responsibilities.

Sunday, June 10, 2012

Who Can Pick Up the Baby? Or, If It Doesn't Walk Like a Duck, It Won't Imprint Like a Duck

A recent phone call reminded me how easy it is for a little learning to be a dangerous thing--   or, to be more specific, how easy it is even for highly educated people with backgrounds in the social sciences to get confused about attachment and bonding.

Here’s the story. A friend of mine was calling to tell me about the adventures of another friend, just recently a grandmother for the first time. New Grandma had been asked by her daughter to come and “help out” after the baby was born, and she had traveled some distance for that purpose. But New Grandma now discovered that there was a rule about the baby that she was not to break: he was to be picked up only by his mother or father. That rule was planned to last until the baby was about two months old and had “settled”; then others could pick him up. New Grandma found this situation not only frustrating but deeply puzzling. What could the new parents be thinking?

I’m not in touch with the new parents, nor is my crystal ball functioning well in this hot weather, so of course I don’t know exactly what’s going on. But I’m going to hazard some guesses about the beliefs the “rule” could be based on.

My first guess is that the rule is focused on the baby’s relationships with other people. It’s not just about health and safety--  if it were, the parents might refuse to let strangers touch the baby, and be concerned about anyone who is careless or inexperienced with little ones, but not prohibit other contacts. The parents believe, not foolishly, that there is something special about the relationships between the parents and the baby.

My second guess is that the parents believe that a baby of less than two months old is forming a special kind of relationship to the parents called “attachment”, a powerful developmental phenomenon that is thought to determine some aspects of later behavior, thinking, and emotion about relationships. While it would be harsh to call this belief foolish, in fact it is not an accurate understanding of early emotional development. Babies of less than two months--  actually, of less than 6 or 7 months--  do not  behave in ways that suggest the formation of attachment to familiar people. They may seem more comfortable in the care of people who know them well, but this is probably because the people who are familiar to the baby are also familiar with the baby and know how he or she responds to handling. If the parents are worried that the baby will not form attachments to them, they should actually be more concerned about social interactions when the baby is older and closer to the age when attachment usually becomes evident--  a baby who has not “settled” is nowhere near that age.

Of course, although the young baby is not yet forming attachment relationships, his or her caregivers are experiencing “bonding”, a change in their feelings, rather like falling in love, in which they become preoccupied with the baby and even forget their own personal concerns in favor of worrying about the baby’s needs. Just as lovers often imagine that their feelings are mirror images of each other’s, parents can easily feel that the baby is as concerned about them as they are about her--  although all the evidence is against this idea. Parents do need to interact with the baby in order for bonding to progress, so a rule forbidding others to care for the baby might help them bond if there were any difficulty in this (which there usually is not if everybody is healthy). Even then, there would be no reason why New Grandma or others should not occasionally have some baby time, as long as all was going well with the parents and their attitudes toward the baby.

One more guess to hazard: why are the parents so concerned about this early time period? I think this may be because much of the early discussion of attachment by the British psychiatrist John Bowlby was connected in some ways to the work of ethologists like Konrad Lorenz on the behavior of young birds toward a parent bird. Anyone who has done an introductory psychology course is likely to remember the famous picture of Lorenz walking in a crouch across a field, followed by a little crowd of ducklings. Lorenz’s work examined the phenomenon of “imprinting” (the behavioral, not the genetic kind), in which ducks and some other birds learn rapidly to prefer and follow the first moving object they see after they hatch. In the wild, this is likely to be their mother, but it could be a fox---  and in captivity it could be another duck, a toy train, or Konrad Lorenz. Imprinting learning occurs within a critical time period of a couple of days after hatching and is impossible after that time has passed. Imprinting is also extremely powerful and long-lasting, and affects not only the entity that the ducklings follow in early life, but also their choice of mates in adulthood. In zoos, bird caregivers who are hoping to breed more birds must be careful not to let the young birds see them, or the adult birds will later refuse to mate with members of their own species and instead try to court human beings.

Although one of the indications of attachment of a baby to an adult is that the baby tries to follow and stay near the adult—a situation similar to the results of imprinting--  there are very few other resemblances between the two phenomena. (And, by the way, not all birds imprint, and few mammals do.) While some have argued that there is a critical period for attachment, the ability of orphaned children to develop new attachments later contradicts this, and in any case it is clear that such a period does not occur in the earliest months of the baby’s life. Babies may be “ducky”, but they aren’t ducks.

Nevertheless, the young parents in question, like many other people who know a little about this, may well have confused human attachment with duck imprinting and developed some unnecessary worries about how they should regulate their child’s social interactions with other people in order to have a good developmental outcome. The result is a family fuss that need not have happened, and a situation where they do not get the help and social support that they could probably use just now. However, I want to point out that unless the parents are too exhausted to do their jobs, it’s not going to make any difference to the baby--- and New Grandma can develop an excellent relationship with him in times to come. All the same, it’s a shame that this confusion exists.

Sunday, June 3, 2012

Mental Health Mantras versus Evidence-based Treatment: A Clash of Attitudes?

Several days ago I was at a meeting of the board of a non-profit child mental health group, and a discussion ensued which was both predictable in its attitudes and suggestive of behind-the-scenes beliefs in mental health and social services circles.

The discussion began when I brought up some concerns about bad advice to parents--  for example, a couple of things I’ve mentioned on this blog, like the idea that babies must be made to crawl, and the idea that instead of spanking one can put nasty tastes like Tabasco sauce on children’s tongues. I tried to float the idea that the group might publicly oppose such advice. But in fact I knew that this very pleasant, kind, energetic, well-trained, intelligent group of colleagues would not agree to any such thing, and sure enough they didn’t.

Several people carefully explained their reasoning to me.

One recommended that we should speak only in positive terms and about the right way to do things. If something negative must be mentioned, it should be more than balanced by a discussion of positive ideas.

Another member of the group suggested that when we object to an idea, we should not say that it’s wrong, but present it as an alternative point of view and describe our own views in the same way.

A third member gave the opinion that “talking about it gives it life” --  that we give energy to mistaken ideas by discussing them at all, and need to ignore them and emphasize better ideas.

Now, these were all attitudes that I have met many times before, and two of them stem from educational principles. Teachers are reminded again and again not to begin by telling students what is NOT true, but to focus on what is true, and to deal with common mistakes later if at all. In teaching and in behavior modification, professionals are advised to withhold reinforcement for undesirable behavior, to “catch them being good” and to reward desirable performance rather than calling attention to undesirable actions. These two ideas have to do with the best way to get a message across and to influence other people.

The third idea is not so much about how to persuade, but about moral conduct. Considering other people’s views as genuine alternatives to our own, however much we disapprove of them, can be morally right and even intellectually productive. It’s also possible that we can be more persuasive if we do not waste time arguing about whether a belief is totally unacceptable, or offending by our attitudes people whose co-operation we need.  

As a general rule, these mantras of mental health and of social services apply pretty well to real life. Most people appreciate it if we “accentuate the positive” and treat their views as worthy of respect.

But what if there are beliefs and practices that are actually wrong and demonstrably harmful—or even wrong and harmless, but a waste of time and resources? Adults who molest children often have excellent rationales for what they do and believe they do no harm; should we treat their claims as just “a different point of view”? And if the molesters are in the wrong and should be stopped, why does the same reasoning not apply to less sensational harmful behavior and beliefs?

I understand very well that sermonizing and shouting about issues is less persuasive than cheerful proselytization of better methods. However, I believe it is a mistake to fail to point out to professionals working in mental health and social services that some ideas  may be attractive but are nevertheless unsupported by reason or evidence.

I am especially concerned about these issues because I wonder whether they are behind the reluctance of many mental health and social services professionals to stress evidence-based treatments--  interventions whose effectiveness has been supported by several well-designed empirical studies. It was not long after the concept of evidence-based treatment came into mental health circles that the principle of an evidentiary foundation began to be diluted into “evidence-based practice”, in which “practice wisdom” and patient preferences were given equal weight with  evidence of effectiveness, and the very definition of evidence-based treatment became so blurred that it came to mean little more than that a study had been done.

What’s the connection with my colleagues who want to stick to the positive, ignore the negative, and frame rejection of a treatment as an opposing point of view? You can’t consider the evidence basis of an intervention unless you are willing to say that the treatment was more or less effective than another treatment or than no treatment. You can’t assess any treatment accurately unless you pay attention to adverse events--  cases in which harm seems to have been caused by the treatment itself. In order to examine and report on the effectiveness of  a method, you must be willing to talk about whether it worked as well, better, or worse than another method, not just about how good it was. You must be willing to talk about failures or adverse events, not to assume that they will go away if you don’t mention them. And you must be able to marshal and describe all the facts of your data and analysis as they support a considered opinion which is by no means simply a “point of view”.

Sticking with the mantras keeps people from paying attention to the evidence for a method, and thus potentially wastes resources or does other kinds of harm. Would we be happy if a physician treating cerebral palsy had not considered what harm a treatment might do? Then why is it all right to ignore negative aspects of mental health, social services, and child welfare practices, including parenting techniques? If anyone can argue that it is all right, I’d like to hear from them.