International Concerns with Holding Therapy

The following material summarizes the work of a conference that discussed Holding Therapy and similar interventions as they continue to be used and in fact spread into new territory. The report has been sent to a list of professionals and officials involved with child welfare. Readers are invited to comment and to send a link to persons who may be interested.   

                                  Summary Report of the Meeting

 of the International Working Group on Abuses in Child Psychotherapy, 20 April 2013

            All over the world, psychologists and social workers deplore child abuse and work to prevent it. Paradoxically, however, a small number of mental health practitioners choose to use a treatment that has been described as abusive and has been associated with a number of child injuries and deaths. This treatment, usually called “holding therapy” (HT) (or “attachment therapy” [AT]), uses prolonged physical restraint in various forms as a therapeutic method. HT appears to have originated in the United States but has spread internationally as a treatment for autism and for attachment disorders. In response to the spread of HT, concerned individuals from the United States, the United Kingdom, the Czech Republic, and Russia have formed the International Working Group on Abuses in Child Psychotherapy with the goal of public and professional education about HT and prevention of its use. The group met in London on 20 April 2013. This document summarizes background information and the presentations made at the conference, which without exception argued against the use of HT.

Background

            International attention was attracted to the problem of HT in 2000 when a 10-year-old American girl died in the course of treatment. Other deaths, caused by parents following the advice of therapists, have been less well publicized (Mercer, Sarner, & Rosa, 2003). In the United States, a Congressional resolution rejected the use of one component of HT; the American Psychological Association, the American Psychiatric Association, the National Association of Social Workers, and other groups joined in this opinion. In the United Kingdom, the British Association for Adoption and Fostering passed a similar resolution in 2004. The American Professional Society on Abuse of Children (APSAC) mounted a task force to investigate the use of HT and published a report (Chaffin et al., 2006) rejecting the use of the treatment or related methods. The absence of an evidence basis for HT has been noted (Mercer, 2013).

            In spite of these rejections, practitioners in several countries have continued to use or support HT in its various forms.  The U.S. organization Association for Treatment and Training of Attachment in Children (ATTACh), at one time the leading advocacy group for intrusive HT, has now redefined holding of children as a nurturing approach. In 2010,  Adam Pertman, executive director of the Evan B. Donaldson Adoption Institute, a leading U.S. adoption organization, stated approval in an Institute publication of a HT-based treatment publicized in a made-for-TV movie. In the U.K., professional publications (Howe & Fearnley, 2003; Sudbery, Shardlow, & Huntington, 2010) have argued in favor of HT, and a survivor of the treatment has come forward to describe his experiences (Chaika, 2012) . In the Czech Republic, a form of HT has been promoted by the psychologist Jirina Prekopova, who practiced the method in Germany for 20 years, and who has the support of Jaroslav Sturma of the Czech-Moravian Association of Psychologists. A Russian adoption group recently invited a well-known U.S. HT proponent to visit, and HT books have been translated into Russian.

Forms of HT and their implications

            HT exists in several forms, all of which involve physical restraint of children by adults. The original form practiced in the U.S. (Zaslow & Menta, 1975) was brutally intrusive and is known to have caused at least one adult death as well as death and injury to children. It was originally directed toward treatment of autism but later focused on disorders of attachment as defined by HT proponents. Following the 2000 child death mentioned earlier, HT advocates reworked their methods and reported that holding was done only with the child’s agreement. Both the original and the revised forms were often accompanied by parent and foster parent practices that involved withholding of food and water, limitation of toilet use, demands for hard physical tasks, and other efforts to demonstrate adult authority.

            An alternative form of HT was advocated by Welch (1989) with the encouragement of the Nobel laureate Nikolaas Tinbergen and was adopted by Jirina Prekopova. This method involves restraint of a child by the mother, either in a face-to-face embrace for smaller children or with the mother lying prone on the supine child. The period of restraint lasts an hour or more and is to be carried out every day as a treatment for autism or oppositional behavior. As far as is known, Prekopova’s method is not accompanied by the parenting practices described in the previous paragraph.

            No acceptable outcome research has provided evidence to support the use of any HT form. Use of HT methods involves risk of physical harm in some cases, and risk of a failure to treat serious emotional problems by means of evidence-based practices in all cases.

Presentations at the London conference

            At the meeting of the International Working Group in London, presentations were made by a British social worker and a British barrister, a Czech psychologist and a Czech activist, an American psychologist, and a Russian biochemist with an interest in cult-like activities. It will be notable in the summaries to follow, that two presenters chose to be identified by assumed names out of concern for professional and personal repercussions that might follow their speaking out.

1. “Anya Chaika”, a British social worker and author of Invisible England, discussed a British case in which a boy had been subjected to HT while under the care of a major provider of residential children’s homes. As a teenager, the boy was moved from the residential treatment center to foster care provided by the person who had been his therapist in the center, and was persuaded by her to change his surname to hers. “Chaika” was contacted by the now-adult former patient after becoming aware that the organization was using HT and starting a blog to try to collect information about the practice. The former patient has been able to bring a lawsuit against the children’s homes organization and this suit is in progress.
2. Lucinda Davis, a British barrister, commented on legal issues concerning child abuse of any kind, and ways in which child abuse laws could be used against the practice of HT. Discussing the differences between tort law and human rights law, she noted that British or Czech cases needed to be approached initially as involving torts, with appeal to the European Court of Human Rights possible only after all other appeals were exhausted. As is the case in all the common law countries, the practice of HT can be attacked legally in Britain only when actual harm to the child can be demonstrated or assumed. Physical restraint methods are not in themselves prohibited by law.
3. “Mrs. Alena”, a Czech autism activist, described the history of HT as performed by Jirina Prekopova and her students. Prekopova, who had practiced HT in Germany (where she worked with the alternative psychotherapist Bert Hellinger), returned to the Czech Republic in the 1990s and in 2001 developed a HT working group as part of the Czech-Moravian Psychological Society. A movement against HT began following the broadcast of a documentary film praising the method, but Prekopova has continued to receive the support of the Catholic Church, government officials, the Ministry of Education, the  “Our Child” Foundation, and the president of the Czech-Moravian Psychological Society. Prekopova has created outreach programs in Slovakia, Austria, Mexico, Venezuela, Spain, and Italy.
4. Katerina Thorova, a Czech psychologist, discussed psychological mechanisms that might lead parents to the choice of alternative psychotherapies like HT. Thorova emphasized the role of a social climate that is friendly to occult and pseudoscientific beliefs. She described a wide range of problems for which Prekopova recommends HT, including autism, attachment disorders, attention deficit hyperactivity disorder, oppositional and defiant disorder, and conduct disorder. Prekopova’s presentation of HT has cult-like features, attracts the public by manipulative techniques involving logical fallacies, “global truths”, and false analogies. HT propaganda appeals to emotion and proposes a universal solution of “love” for most problems. Because people are subject to cognitive and confirmation biases, cognitive dissonance, and the desire to comply with authority, they find it difficult to resist the appeal of HT.
5. Jean Mercer, an American psychologist, discussed claims that Prekopova’s HT method was based on scientific evidence. These claims were originally based on the support for HT given by the Nobel laureate Nikolaas Tinbergen, whose ethological studies suggested that specific experiences could direct personality development. In the 1980s, Prekopova and German colleagues published several articles concluding that HT was demonstrated to be an effective treatment, but all of the studies were inadequate in that they had small Ns, the outcome measures were vaguely defined, and the outcome measures depended on parent judgments. Scientific support for Prekopova’s HT method, like that for other HT techniques, is extremely weak, and indeed Prekopova has dropped claims about scientific evidence and today presents religious and spiritual arguments in favor of her practices.
6. On behalf of Yulia Massino, a Russian biochemist who attended by Skype, Jean Mercer discussed the intrusion of U.S. HT advocates into Russia at the invitation of some cult-like groups. The major concern of this presentation was the use of “parenting” techniques adjuvant to HT, as recommended by the HT advocate Nancy Thomas, who recommends the establishment of adult authority by parental control of a child’s food, drink, toilet use, and exposure to cold, heat, or darkness. These methods have been associated with malnutrition and in some cases with child death. Books by Thomas and other HT proponents have been translated into Russian. Nancy Thomas visited and lectured in Russia in 2012 at the invitation of an American Pentecostal minister.

Conclusion

            The International Working Group concluded that HT methods are neither safe nor effective as treatments of childhood mental illness, and that their spread internationally is an alarming phenomenon that should be recognized and countered by professional and parent groups. What can and cannot be done about this problem?

Legal challenges to HT have so far been ineffective in common law countries, where freedom of speech issues are privileged. Professional groups have opposed specific legislation about HT methods, claiming that they can regulate members of their own disciplines. In addition, it is difficult to write legislation that describes HT methods in such a way that a change of language or a minor change in methods cannot evade a prohibition. Where government appears to support HT, as in the Czech Republic, legal challenges would seem of little use.

            Professional and public education on the existence and nature of HT methods may be the most effective way to reduce the use of these treatments. However, in the U.S., efforts by professional groups occurred after a well-publicized child death and diminished within a few years. With respect to the almost-nonexistent public education about the HT problem, it should be noted that HT proponents in several countries have for years bombarded the public with propaganda in the form of television “documentaries” and films, and that journalists have contributed to these persuasive efforts by assuming that statements by HT advocates are accurate.   

            What is really needed is for professional groups to mount a proactive campaign of education about HT, rather than waiting for harm to another “poster child”. This will require the kind of political will that usually exists only when a few members of a group are convinced of the need to solve a problem. Such a campaign needs to direct accurate information to mental health professionals and to take into consideration the emotional arguments to the public that, as Dr. Thorova noted, have been effective in persuading parents to accept HT.   

            The International Working Group has taken a small step in the direction of professional and public education and is now asking mental health professionals and professional organizations to join in this work.

References

Chaffin, M., Hanson, R., Saunders, B.E., Nichols,T., Barnett, D., et al. (2006). Report of the APSAC task force on attachment therapy, Reactive Attachment Disorder, and attachment problems. Child Maltreatment, 11, 76-89.

Chaika, A. (2012). Invisible England. Charleston, South Carolina: Chalk Circle.

Howe, D., & Fearnley, S. (2003). Disorders of attachment in adopted and foster children: Recognition and treatment. Clinical child Psychology and Psychiatry, 8, 369-387.

Mercer, J., Sarner, L., & Rosa, L. (2003). Attachment therapy on trial. Westport, CT: Praeger.

Mercer, J. (2013). Holding therapy: A harmful mental health intervention. Focus on Alternative and Complementary Therapies, 18(2), 70-76..

Sudbery, J., Shardlow, S.M.,& Huntington, A.E. (2010). To have and to hold: Questions about a therapeutic service for children. British Journal of Social Work, 40, 1534-1552.

Welch, M. (1989). Holding time. New York: Fireside.

Zaslow, R., & Menta, M. (1975).The psychology of the Z-process: Attachment and activity. San Jose, CA: San Jose State University Press.