Concerned About Unconventional Mental Health Interventions?

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

Friday, October 26, 2012

When Psychologists and Others Abandon Ethical Principles: Child Custody Issues


Like physicians, psychologists are expected to follow the dictum primum non nocere--  first, do no harm. Ethical principles like beneficence, respect for people, and justice all seem to me to follow from that original rule.

Psychologists who teach, do clinical work, or concentrate on research all have obligations to pay attention to ethical guidelines and to do no harm. But, of course, there are tasks done by psychologists where the possibility of doing harm--  and the importance of avoiding harm—is especially great. One of these is child custody evaluation, in which a psychologist assesses children and parents with an eye to making a recommendation about primary custody, about visitation, or even about termination of parental rights. Such recommendations walk a fine line between possible errors, and always involve some risk of causing harm to the child and/or interfering with the rights of parents to retain a relationship with a child. Inaccurate assessments may cast serious aspersions on the characters of parents and interfere with their professional lives as well as personal relations with the child or with other people—or, on the other hand, they may expose a child to continued harm from an abusive parent.

We usually hope that psychologists making custody recommendations will pay heed to ethical standards and will not deliberately flout them, even though they may still, being human, make mistakes in their assessments. Unfortunately, these hopes are not always realized. One story of an apparently intentional abandonment of ethical principles is told at www.dpdlaw.com/Kleinman.html. In writing about this situation, I will refer to the psychologist as Dr. X, which seems a bit fatuous because anyone who reads about this can identify her, but somehow it seems appropriate to me.

Dr. X specialized in child custody evaluations in divorce cases, so her job was to assess children and divorcing parents and to make recommendations to the court about appropriate parenting plans, including primary custody, visitation, and supporting procedures like psychotherapy. In one case, when a divorcing mother thought that her former husband might have sexually abused their toddler daughter, Dr. X conducted play therapy sessions with the child and used them to put together a report to the court claiming that the child’s play and statements indicated that the sexual molestation had taken place. Dr. X refused to let the father speak to the child on the telephone and told the child that the father did not want to talk to her. She also told the father that he could speak to the child only if he admitted wrongdoing and apologized to the child.

The father maintained that he had never molested the child, and hired another psychologist, the well-respected Dr. David Martindale, to review Dr. X’s report and the videotapes she had made of the play sessions. Dr. Martindale concluded that the videotapes did not support Dr. X’s claims and that she had reported to the court only statements that she had coached or elicited from the child, and not the child’s actual uncoached comments. In other words, there was no evidence that the father had been abusive in any way.

A second complainant against Dr. X came into the picture by accidentally overhearing Dr. X’s name discussed with respect to the situation just described. She filed her own complaint, which stated that when she sought Dr. X’s help during a divorce, and when it was known that her former husband had been treated for sexual addiction, Dr. X suggested that to accuse the husband of molesting their infant would be an excellent ploy to make sure she retained custody of the child. She also reported that Dr. X said that she herself had done this during her divorce and had succeeded in terminating the father’s parental rights.

Dr. X denied all these allegations, and has argued at http://thetruthaboutdrkleinman.com that she is the victim of a politically-motivated attack by father’s-rights groups. Nevertheless, the court concluded that Dr. X “has engaged in gross and repeated malpractice which damaged or endangered the welfare of [a child] and threatened [the child’s] relationship with her father. [She] misused her influence in a manner that exploited [the child’s] trust and dependency, resulting in the creation of great distress and confusion for the child… [In addition, she] created a situation whereby law enforcement would have been unable to conduct a criminal investigation had such action been appropriate. She isolated the child from all outside help had it been warranted.” Dr. X was also concluded to have deliberately misled the court and misrepresented her training, and in particular to have improperly acted as both therapist and forensic psychologist. The court recommended the revocation of Dr. X’s psychology license by her state’s board of professional licensing.

There are several points I would like to make about this egregious situation, in addition to noting that videotaping of the therapy sessions was the key to unraveling this set of twisted claims. One important consideration is the extraordinary ease with which mental health practitioners can state that if someone denies an action, this is proof positive that they actually committed it. If it appears that they genuinely believe they did not do it, the argument becomes all the stronger--  look, he’s even repressed it because it was so bad! Whether the accused person confesses (perhaps untruthfully and in order to bring an ordeal to an end) or denies guilt, it doesn’t matter; either outcome is interpreted as indicating wrongdoing.

Because men are somewhat more likely to approach children sexually than women are, it is not surprising that fathers are more often the targets of this strategy than mothers . However, mothers too may be accused of physical abuse. In one case I’ve recently been observing, the children are in the custody of a stepmother who has placed them in an unconventional treatment. The therapist is acting as an evaluator, and the mother has been told that she cannot have contact with the children unless she admits to having abused them physically and apologizes to them. Medical records exist that show no evidence of the children having been abused while in their mother’s care, but part of the unconventional therapy in use involves extracting from children statements about their mistreatment by an adult. Although being accused of sexual abuse carries much greater penalties in our society than accusations of physical abuse, this mother has already been denied a professionally-related activity because of her legal situation.

One more point here: as Dr. X’s case shows, it is considered improper for psychologists to act both as evaluator and as therapist, and this was one of several concerns that caused the court to recommend license revocation. As far as I am able to tell, however, there are no similar restrictions for social workers. The therapist and evaluator in the case I described in the last paragraph is a social worker, so the mother appears to have no way to demand correction of this situation. In cases where courts accept recommendations from other types of mental health professionals, the same problems may well exist.

Not only do psychology licensing boards need to take special care about these child custody issues, but other mental health professions need to set standards and demand that they be observed.

Wednesday, October 24, 2012

"My Adopted Girl": Many Issues, Many Interventions



An organization I belong to recently received an e-mail from a mother with the subject line, “my adopted girl”. The mother, whom I will call M, tells her story and asks if there is a good book to read to help with the troubles the family is having.

M’s daughter is now 8 and ½ and has been with M’s family since she was 17 months old. She was severely neglected by her 15-year-old parents, according to M. Daughter was angry when first brought into M’s family and M describes her situation by saying “it was hard for us to attach” (although she does not explain exactly what she means by this).  The biological mother was not only very young but was said to have had ADD and bipolar disorder and to have used and cooked meth in the home where M’s daughter lived with her.

M says she has always been very firm and consistent with this child, but is now concerned because the daughter steals and lies and does not seem remorseful. M is puzzled about what consequences might curb these behaviors and is worried that as the daughter gets older she will discover even more serious and dangerous behaviors.

There are some other interesting features to the situation. One is that M’s family also adopted three of this daughter’s siblings, one of whom came to them at 9 months after five months of foster care and a brief return to the biological mother. According to M, none of the siblings have any of the same issues that the daughter she is concerned about has.

M also brings up briefly the possibility that she herself has been overwhelmed by the demands of this family, and states that the daughter’s own problems may be only part of the picture. (This is an important insight and makes me feel optimistic about M’s ability to think through and handle whatever is happening.)

Finally, M states that her husband keeps asking if they should get the daughter therapy or not. She doesn’t mention what is meant by this, exactly.

I am going to make some comments and suggestions, but before I do so let me say that I have never met any member of this family and cannot make specific statements about them. In addition, I am not a clinical psychologist and am not presenting myself as such or offering any services.

The first point I’d like to make is that on the basis of M’s description it does not appear that the daughter has Reactive Attachment Disorder, in spite of her troubled early history. Stealing and lying, though very disturbing and problematic behaviors, are not aspects of Reactive Attachment Disorder. I think it would be a mistake to seek therapy that concentrated on attachment issues as a major cause of these behavior problems. If M and her husband seek treatment for this child, it would not be sensible to look for a practitioner who focuses on attachment therapy or on attachment as a primary problem. The fact that the other siblings do not share this daughter’s troubles indicates that this is not simply a problem of separation and adoption.

A second point is that the biological mother’s ADD may have been passed on genetically to this child, and she may be impulsive and lack self-control for that reason. Why do the other siblings not have the same trouble? Genetic transmission does not give the same results every time, and what’s more it isn’t necessarily the case that all these children have the same father. If ADD is a factor in the daughter’s behavior, she may benefit from medication.

Children who have been exposed to drugs either before or after birth have usually been exposed to alcohol too. Effects of fetal alcohol exposure may or may not be apparent in the child’s appearance, but a medical examination might help on this. If alcohol exposure is an issue, the daughter may need special education and may also benefit from medication.

The story of the daughter’s early life also suggests that she may have had little early language experience and may have had language delays with which she has not yet caught up. These would make her easily frustrated, especially in school, and could result in undesirable behavior and poor understanding of other people’s wishes and the consequences of what she does. I would suggest a speech and hearing assessment and speech therapy if recommended.

M’s recognition that she may be overwhelmed is an important one. A mother’s frustration, anxiety, and depression can have devastating effects on children’s development. In this case, it seems that the troubled daughter was adopted first and the other siblings later--  M does not make this completely clear. It is easy to see how even very competent parents could be thrown by dealing with one angry toddler and then having three more young children added to the mix. None of the children may have gotten all the attention they needed at this point, but the troubled daughter may have biological vulnerabilities that gave her real difficulties in giving up the attention she had been getting.  M’s e-mail sounds as if she still feels overwhelmed, and this may be one of the keys to the whole set of issues. A good counselor (well-trained and licensed) for M could help support this mother and enable her to help the troubled daughter as well as the other children (who must be affected by their sister’s behavior). This is not to suggest that I think M is emotionally disturbed --  simply that having some professional support can be very beneficial to someone who has taken on the responsibilities M has.

Finally, I’d like to address M’s question about appropriate “consequences”. I doubt that changing ways of punishing the troubled daughter will be of any use. If punishment is to be used, it can only be effective if it occurs very quickly after the undesirable behavior, and this is hard to do with stealing and lying, where the problem is usually not detected until later. In any case, the first question should be whether any of the points I mentioned before can be of help in correcting these disturbing behaviors. More attention, more guidance, and the use of cues to remind a child about what to do are more likely to be effective than any specific “consequences”. Although this child is a little older than most for whom this treatment works, some of the ideas of Parent-Child Interaction Therapy can be very helpful.

I hope M and her family will be able to find a good outcome for this very challenging situation.

Monday, October 15, 2012

Holding Therapy as an International Problem


Some readers of this blog will be aware of my years-long concern about Holding Therapy (also called Attachment Therapy, Z-therapy, soul therapy, rage-reduction therapy, etc.). Holding Therapy, which I’m going to abbreviate as HT, is an alternative psychotherapy---  the psychological version of  complementary and alternative medicine (CAM). By this I mean that it is based on implausible assumptions, at odds with conventional understanding of personality and early development, and is also without a systematic evidence basis with a foundation of randomized controlled trials or well-designed nonrandomized trials. HT is used primarily with children, although some of the “sexual conversion” proponents have employed it, and its practitioners are more often social workers or licensed mental health professionals than they are psychologists or physicians. Child injuries and deaths have been associated with HT.

When most people see the word “psychotherapy”, they assume that the treatment in question is some form of talking therapy. They may think of highly-directed cognitive therapies or of psychodynamic approaches that seek basic motivations and may explore memories of early life, but they have in mind an intervention that relies on discussion between the therapist and the client. Even when people consider treatment of young children, they expect psychotherapies to focus on communication, perhaps through play methods rather than through speech.

HT, however, is a talk therapy only in the most minimal sense. It has strong physical components, including physical restraint of the child, demands that the child kick on command or do push-ups or jumping-jacks, and painful grasping and prodding of the child’s body. Children in treatment are required to shout statements like “I hate my mother! I want to kill her!” at the command of the therapist. The originator of this treatment, one Robert M. Zaslow, a California psychologist whose professional license was revoked after he injured an adult patient, suggested that clients sign a waiver noting that bruising was to be expected from the treatment.

Discussions of HT have often attributed the practice to a sort of American backwoods mentality, associated with religious fundamentalism and an approval of the use of force to achieve desired ends. In fact, people outside the United States have essentially said “it can’t happen here”.

But in the last few years it has become plain that although HT is not common, it does happen in England, as has been described at http://invisibleengland2.wordpress.com and in the book Invisible England. In fact, HT has a long history in Great Britain, as I have described in a paper recently accepted by the British journal Adoption & Fostering.

A recent e-mail from the Czech Republic alerted me to the fact that the HT practitioner Jirina Prekopova , who had practiced for many years in Germany, has returned to her homeland and is advocating and practicing HT. Here are two videos of the proceedings:
http://www.youtube.com/watch?v=jqj_mLYKmxo

{Note-- 10/16/12-- these videos now come up as unavailable. If you want to see them, try searching Jirina Prekopova youtube, because there were a number that could be seen yesterday.}

But BE WARNED: THESE ARE VERY DISTURBING! ON NO ACCOUNT PLAY THEM WHEN CHILDREN CAN HEAR THE AUDIO. The language is Czech, but you will get the picture all too well without understanding the words.

One of my correspondents has said that Prekopova uses these methods with children who have tantrums, including, according to her, an infant under a year of age. The correspondent has complained to the Association of Czech and Moravian Psychologists but has received no answer.

Prekopova lectures widely, and groups using her methods have been formed in several European countries and in Latin America.

How Prekopova developed her HT methods, and how she received encouragement, is an interesting story with several clear morals. The story goes back to the 1980s, when the New York psychiatrist Martha Welch visited the town of Evergreen, Colorado--  usually thought of as the nursery of HT—and developed her own version of the treatment, which she initially called “holding time” but today refers to as “prolonged parent-child embrace” (PPCE). Welch’s method involved face to face contact in which a small child was held on the mother’s lap, and older children lay supine with the mother lying on top of them, supporting some of her weight on her elbows. Children resisted this strongly and fought to get away, while the mother shouted and cried in expression of her own negative feelings. Eventually, both were expected to calm down and to express tender affection for each other. Welch originally presented this as a treatment for autism.

In the early ‘80s, Welch  met Elisabeth Tinbergen, the educationalist wife of Nikolaas Tinbergen who had received the Nobel Prize for Medicine or Physiology in 1973, together with Konrad Lorenz and Karl von Frisch. Tinbergen’s work involved instinctive responses of animals to specific stimuli, and in his Nobel speech he attempted to bridge that work to work on human behavior and especially on the problem of autism. Mrs. Tinbergen introduced her friend to the Nobelist, who was impressed with the connections between “holding time” and his own ideas about early development and autism. The Tinbergens wrote a book about autism and holding, and although they noted that there was no systematic evidence to show that Welch’s method was effective, they also included a lengthy appendix by Welch, with many photographs. The support from the famous Niko Tinbergen was one of the factors that led to the publication of Welch’s own book, Holding time, and her tour of Great Britain, publicized by the BBC in films that show her guiding groups of mothers to restrain their crying autistic children. (One of the morals here is, just because a person gets the Nobel prize for one thing, that doesn’t mean he knows a whole lot about other things--  cf. Linus Pauling and vitamin C.)

Jirina Prekopova met with Tinbergen and Welch and adopted the Welch method. Apparently also present at this meeting was Bert Hellinger, a German therapist. Hellinger has a method he calls systemic family therapy. Hellinger’s approach includes the idea that one’s soul may be “entangled” with those of ancestors in ways that cause the individual to act out ancestral issues. For example, a boy may be homosexual because of the desires of a deceased sister. Similarly, when incestuous relationships occur, perhaps between father and daughter, both partners are responsible, and the daughter must forgive and respect her father. Prekopova refers to and supports Hellinger’s system, although it is not clear to me in what way she actually uses it.

So, there we are. As a result of various personal contacts, and a lack of guidance from professional and licensing organizations in Europe and elsewhere, HT has spread and continues to do so. Is it not time for an international conference to discuss what can be done about this? “Anya Chaika”, author of Invisible England, what do you suggest?  




Tuesday, October 9, 2012

Starving and Beating Adoptees in Allegheny County: Some Speculations


Has everybody breathed a sigh of relief that the State Department has got everything fixed for Russian adoptees? No more starvation, no more restraint? Great, let’s move along to the Ethiopian children. No Ethiopian Pavel Astrakhov has yet appeared on the scene, but one is needed.

Last  week, adoptive parents of two young Ethiopian children were arrested in Allegheny County, PA (http://pittsburgh.cbslocal.com/2012/10/04/deputy-attorney-general-wife-charged-with-abusing-adopted-children). One child, a boy of 6, was badly malnourished, and an 18-month-old girl had skull fractures that may leave her blind. The children, who were adopted through a church organization, had been since March in the home of the adoptive parents, Douglas and Kristey Barbour. Mr. Barbour is a Pennsylvania deputy attorney general.

What was happening here? Very little has been revealed so far. I’ve seen considerable Internet speculation that the elite adoptive parents were deliberately cruel to the black children, and although I acknowledge that the children’s ethnicity did not stop the parents from abusing them, there are too many cases of “white-on-white” abuse for me to think that the parents were especially motivated to abuse by the children’s skin color.

There are other possible explanations---  and I don’t bring these forward in an attempt to excuse the Barbours, but because understanding these situations can help us to prevent them from occurring again. Neither do I suggest that a single explanation can do the entire job, so more than one possibility needs to be considered here.

  1. The first possibility I want to consider is that the Barbours were in fact encouraged to use certain “tools” in dealing with the children, and that this encouragement gave them permission to go much too far. There are groups like the “No Greater Joy” ministries that advise physical punishment for disobedience for children as young as 4 months (yes, months ). There have been some deaths associated with that sort of treatment, but they have involved shock from being whipped severely, rather than the skull fractures in the Barbours’ case. The key to understanding this will be to find out whether the Barbours were committed to the idea that instant cheerful obedience must be obtained at all costs, and failing to achieve this easily, they turned to blows.
In addition to the physical punishment “tool”, there are various sources for the recommendation that a child’s diet be restricted in order to display the authority that these people claim is the cause of emotional attachment (see the beliefs of Nancy Thomas, for instance). I have discussed this before at http://childmyths/blogspot.com/2010/12/federici-v-mercer-story-behind-lawsuit.html.  To the best of my knowledge, practitioners do not advise parents not to feed a child at all, but just as a mild spanking can turn into a beating when an adult feels the need to escalate, so can food restriction become a starvation situation.

  1. A second possible explanation for the Barbours’ abusive behavior is the Post Adoption Depression that has recently been discussed on this blog. Depression in many adults involves irritability and shortness of temper as well as the characteristic sadness. Irritability adds to the potential for physical lashing-out against a child whose normal behaviors are found annoying, who perhaps does not go to sleep as instructed or who drops food by accident. Although maternal depression has often been attributed to hormone changes following pregnancy, it’s pretty clear that it can also depend on the challenge of life with young children. (A reader recently pointed out that adoptive parents tend to be older than biological parents and may have life difficulties associated with their greater age--  perhaps responsibility for care for elderly parents rather than a younger person’s expectation that their own parents may be helpful. Adoptive parents may also have very high standards for themselves and feel depressed at their failure to live up to an unrealistic level of performance.)

  1. I have no explanation to offer for the battering of the little girl, beyond what I’ve said so far. But I have to wonder whether starving the boy was associated with poor understanding of the eating habits and nutritional needs of children from other cultures. A 6-year-old is old enough to have strong habits and expectations of what food should be like and how you eat it (hands versus forks, plates versus a communal pot). Adults from the United States suddenly shifted to an Ethiopian diet (delicious but spicy by our standards) might well suffer stomachaches and be reluctant to eat. What was this child’s experience? How did he respond? Did the Barbours take his reluctance as disobedience that had to be nipped in the bud? For other adoptive parents dealing with this kind of situation, I’d like to point out the enormous help that the SPOON foundation (www.spoonfoundation.org) can be in understanding what a child’s past diet and eating habits probably were, and how to make a dietary transition and ensure that nutritional needs are met.

I am hoping that information about these points will emerge in the course of the trial. I would not be surprised to find that all the points mentioned above worked together to cause the terrible outcome. If any reader knows more about this case than has so far appeared in the news, I would like to hear from you.



Tuesday, October 2, 2012

Adoption and Post-Adoption: A Guest Post



  1. Marianne Milton wrote the following as a comment on my post about Post-Adoption Depression. I thought it was so substantive and well-put that I asked her whether I could make it a "guest post":



    I like the idea that post-adoption depression can lead to parents looking to extreme (or faddish) forms of child-rearing advice. That makes sense to me, especially considering that (1) raising adopted children is different than raising birth children in some respects, (b) there's a paucity of sound (evidence-based) advice for dealing specifically with adoption-related issues in child-rearing, as compared to the enormous amount of advice (albeit not all sound) related to child-rearing in general (perhaps due to the low incidence of adoption), and (c) raising older, foster/adopted children, often with multiple and severe special needs, which may not be documented or diagnosed prior to placement, is even more of a journey across an uncharted landscape.

    The allure of such approaches as attachment therapy, EMDR, tapping, "training up" a child, love & logic, tough love, etc., is twofold, I believe: it sets the parents apart as special (super-heroes even) because the obscurity of the approach suggests that their children are damaged and challenging beyond the norm (which may, in fact, be true), thus requiring both super-special treatment and super-special parenting; and it gives parents a way to dismiss any criticism that might come at them from outside the particular cult of treatment they've chosen as uninformed because "our kids" are not like other kids, so other parents have nothing to offer us.

    Not only do the treatment providers end up feeling and acting messianic, but the parents can as well.

    However, I'm not sure that it's post-adoption depression that leads parents to wanting (however unconsciously) to hurt or punish their children through punitive/shaming treatment approaches---or through simply nonstop "treatment," of whatever sort, which convinces the child that he/she is broken and in need of far more intervention than any other kid---that "our kids" thing, again, that Trauma Mamas so often bring up.

    Parents who are depressed aren't necessarily driven to punishing or hurting their children. In fact, that may take far more energy and focus than many depressed people can muster. One of the most damaging aspects of being raised by a severely depressed parent is the neglect born of parental depression. I'd be careful about equating depression with maleficent intent.

    Having said all that, I've personally felt the despair (and yes, also, post-placement depression) of raising children who are survivors of a foster care system (and the initial abuse/neglect of birth family) that left them traumatized beyond what I or local helping professionals could help them deal with in the short term. The task is large and can be overwhelming, and there's really not a whole lot of research-based help out there for, say, how to help a sexually abused child who witnessed lots of domestic violence, and then himself became a perpetrator of violence, who now suffers from PTSD, and who has ADHD (likely a genetic gift, given the birth family history) as well as FASD because his teen birth mom was already an alcoholic and drug addict by the time she got pregnant with him, and never got any prenatal care nor abstained from alcohol during her pregnancy, which she didn't fully recognize until after the first trimester, in any case.

    This is a not atypical story, sadly. And if the child has been passed from foster home to foster home, experienced multiple hospitalizations, a stay or two in residential treatment, and a cocktail of psychotropic drugs, reassigned whenever a new placement occurs, with its concomitant changes in mental health providers, no one, frankly, knows what the hell is the best approach to help this child.

    And, I've come to the conclusion, that that's the "gold standard"---that's where we are, currently, in the research. No one really knows what to do, or what to treat first, or how to manage it all, while childhood is speeding by and school calls for attention.
  2. (cont'd)
    So, we do the best we can: we find a psychiatrist who can work on the most flagrant symptoms (PTSD-related insomnia and aggression, for example), we find a nutritionist who can work on the anorexia brought on by sexual abuse, for example, we find a psychotherapist who can work on the suicidal ideation and the externalizing threats and the complete (and understandable) lack of social skills, and we find a family behaviorist that will work on building a sense of safety and consistency in a home that is being torn apart by the effects of the traumatic history of a child who has grown up, for all practical purposes, in a war zone.

    So, yeah, a little holding therapy sounds good, especially if the professional proponents of it say that will cure *everything*---that the root of all the child's problems are attachment, and if we can go back and redo that terrible gap in mother/child attachment, all the rest of the trauma will not need to be addressed, or will be easily and secondarily treated.

    We mess up a few children in our culture really, really badly, and we don't yet have the means to repair the damage we cause. Perhaps we never will. And perhaps that's where we ought to start, when we talk about adopting older children, or any children whose prenatal circumstances we know nothing about (because "only" FASD is no picnic).

    We've adopted severely injured children, and they won't ever be "fixed" fully. All we can do is our best: our best to love them as fully human, to educate them as fully human, and to show them the respect and dignity they deserve no matter where they are currently standing on the injured/fixed spectrum.