Thursday, December 12, 2013
Should Therapy Hurt?
Everybody knows that medical and surgical treatments can be frightening, humiliating, and painful to undergo. When there’s evidence that they are effective, though, we grit our teeth and make ourselves go through with them. Parents may have to make decisions to put young children through very distressing treatments, without being able to explain the reason to them, and as an article in the most recent issue of Zero to Three points out, the experience may be traumatic for the child.
But let’s suppose that the treatment we are talking about is not medical or surgical, but psychological or behavioral. If those treatments are frightening, humiliating, or painful, is that acceptable? The German psychologist Michael Linden recently wrote that such experiences created additional “emotional burdens” for patients, and that if there were an effective treatment that was not frightening, humiliating, or painful, it would be completely unethical for a therapist to impose those burdens. Where some degree of fear is likely to be experienced, as in desensitization treatments for anxiety, therapists do their best to offer support and make the experience bearable for the patient. Humiliation and pain are not normal parts of most mental health interventions, and painful aversive treatments are expected to be used only when a behavior is uncontrollable and dangerous enough to justify deliberate causing of pain.
There seem to be a lot of rules about not distressing adult psychotherapy clients-- but many clinicians of various disciplines seem much less concerned about frightening or hurting children. In fact, there seems to be a whole school of thought that holds that pain and fear are needed to cause psychological and behavioral change, or at least that they are harmless byproducts of such change. I’ve repeatedly referred to the various schools of “holding therapy” as having this position, but it appears that there are a number who share these attitudes among professionals whose focus is not on mental health.
Ute Benz’s edited book Festhaltetherapien notes a similar viewpoint among occupational therapists in Germany. In Benz’s chapter in that book, she describes how she was contacted by a number of teachers and others who were disturbed by hearing about occupational therapists doing a form of holding therapy, KIT or Koerperbezogen Interaktions-Training (body-related interaction training). According to one commenter, in KIT the child is ultimately forced under the control of the mother by physical and emotional contact; he goes on to say that for many children who could trust no one, this method gives a helpful lesson in the persistence of love. The commenter also notes how much sincerity it takes to restrain a child who fears or hates you, who screams, curses, complains, cries, scratches, bites, pees his pants in self-defense and despair. I would point out that such last-ditch defense behavior is unlikely unless a child is frightened or hurt, and that fear and pain are apparently tools of the “sincere” KIT therapist.
Authors in Benz’s edited book also refer to the “Vojta method” which had been [happily] unknown to me. This method was originally developed for treatment of the spasticity resulting from disorders like cerebral palsy, but is now promulgated for a range of other problems, including those of children and even newborn babies. The website www.vojta.com notes that “The therapeutically desired activated state often expresses itself during treatment in newborn babies as crying. This understandably leads to parents feeling concerned, and makes them assume that it is ‘hurting’ their child. At this age, crying is an important and appropriate means of expression for the little patients, who react in this way to unaccustomed activation. As a rule, after a short familiarization period, the crying is no longer so intense, and in breaks from exercise as well as after the therapy, newborn babies calm down immediately. In older children who can express themselves in speech, crying no longer occurs.” However, the following clip of treatment of a three-year-old, who is old enough to talk, appears to contradict this claim [N.B. This is quite a distressing display-- please do not watch it while children can hear or see]: www.youtube.com/watch?v=GrtF415N3Gc.
Yulia Massino kindly sent me materials about advertisement in Russia of the Vojta method and the collection of funds for parents who want to take their children to Germany or the Czech Republic for treatment (e.g., http://forum.sibmama.ru/viewtopic.php?t=830157-- in Russian,so please use a translation service if you need to). Vojta therapy is also advertised in English, but apparently not in the U.S.
Yulia also sent information about Elena Fokina’s method of treating children, including young infants, by repeatedly plunging them into cold ocean water, as well as by throwing them around in the infamous “baby-yoga”. Here is an account of Fokina’s “swimming” methods by an observer: http://www.liveinternet.ru/users/nianfora_n/post220258301 (again, in Russian). There is no recording of screaming here, but I warn you that this account disturbed me considerably even though I spend much of my time reading about horrible treatments.
Can these frightening and painful treatments be effective therapies for any childhood problem, physical, neurological, or psychological? They do not offer anything but anecdotal evidence to support their claims. However, as a general rule, sensitive and responsive parenting methods have been shown to nurture good development, and rough, insensitive treatment to have the opposite effect. Psychotherapies for children are often (whether correctly or incorrectly) thought of as operating in analogy with good parenting methods. There seems to be no rationale for inverting this analogy so that good therapy would imitate bad parenting methods. The obvious conclusion is that neither research nor theory supports the use of methods that frighten and hurt children. On the contrary, these methods involve an “emotional burden” (as Linden had it) that can be expected to exacerbate old problems and create new ones.
What sources can such actively harmful treatments have? KIT and Vojta therapy appear to share with the often-rejected American method of “patterning” the view that imitation of early behavior and events will cause those aspects of development to “re-wind” and re-play in a more typical fashion. In both cases, and in other methods pushed by the Association for Pre- and Perinatal Psychology and Health (APPPAH), crying in pain is either dismissed as “expression” or encouraged because of the belief that it erases memories of earlier distress. In these and similar techniques, there may also be a metaphoric glance at exorcism, where a fight with demons, and the distress of the possessed person, are necessary before healing can occur.
Fokina’s cold-water plunges and baby-yoga are more difficult to comprehend. Are these simply the sadistic acts of a woman whose personal charisma attracts the adulation of people who are desperate for a guru and supernatural guide? Is it all just the culmination of a commercial enterprise? I’m at a loss to say, but there seems to be no shortage of parents who will pay someone to tell them to do cruel and pointless things to their children.
What happens with these treatments is not, as the Vojta method author says, “hurting”. It’s hurting with no quotation marks. And therapy for children should not hurt, unless there’s a very good reason.