Concerned About Unconventional Mental Health Interventions?

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

Tuesday, February 18, 2014

Deceptive Commercial Practices and Attachment Therapy

In the United States (and in most other nations), laws prohibit deceptive commercial practices. If someone who sells refrigerators tells customers that a refrigerator is larger than it really is or that it keeps food colder, it’s possible for charges to be brought against that seller. When such charges are brought, it’s usually done by an annoyed customer--  and of course when the purchased object is a refrigerator, it’s possible for the buyer to ascertain whether the volume or the temperature are what they were claimed to be.

Laws about deceptive commercial practices apply to services as well as to goods, and to services sold by non-profit groups as well as by those that operate as for-profit organizations. However, it can be a lot harder to detect whether a service is what the seller has advertised. It can take a long time to see whether a service is effective, and in many cases a purchaser might not know exactly what the service should be like.
These problems are especially relevant to the sale of psychotherapy services. Although there are effective brief therapies, it’s traditionally—and not unrealistically--  thought that psychotherapies can take a long time to “work”. It’s also the case that most psychotherapy customers have no clear idea of what a treatment should be like, except perhaps that they’ve seen movies that included psychotherapy scenes. Therapy clients may be and remain quite confused about how they should be feeling or acting, whether a treatment is ineffective or whether their case is just much less tractable than they thought. If they feel distressed by the treatment or even think the problem is getting worse, they may believe that these are normal aspects of  “healing”. They will probably not be aware if they have been attracted to a treatment as a result of deceptive material about it.

It will not surprise anyone when I say that the Internet is an ideal medium for the posting of deceptive material for commercial purposes. There are hundreds of websites advertising psychotherapies in deceptive fashions—and I am not even talking about attempting to pass off testimonials as equivalent to systematic research evidence. Some of these sites include specific claims that are easily recognized as untrue by anyone with a thorough background in psychology. When recommendations for treatment are derived from such false claims, I would say that the statements amount to deceptive commercial practices.

Let me provide an object lesson by examining a single website, http://instituteforattachment.org, belonging to the Institute for Attachment and Child Development in Colorado. Here are some statements on the home page about Reactive Attachment Disorder: “Traditional therapy only feeds it.” “Love infuriates it.”

Are these statements correct? Does traditional therapy exacerbate Reactive Attachment Disorder (whatever they mean by that, but that’s a separate issue)?  There is absolutely no evidence to the effect that any “traditional” therapy--  by which I presume the authors of this material mean a cognitive or behavioral therapy—causes any childhood mental health disorder to become worse. This is a claim that has been made by proponents of Attachment Therapy/Holding Therapy for two decades. It is not only without foundation, but is a profoundly ethically questionable statement for mental health professionals to make, as it intentionally deceives potential clients. To quote the National Association of Social Workers code of ethics on the principle of integrity: “Social workers behave in an ethical manner. Social workers are continually aware of the profession’s mission, values, ethical principles, and ethical standards and practice in manner consistent with them. Social workers act honestly and responsibly and promote ethical practices on the part of the organizations with which they are affiliated.” Surely it cannot be argued that anyone is behaving honestly and responsibly by making unfounded statements that serve only for their own commercial advantage.

Now, how about “Love infuriates it” (Reactive Attachment Disorder)? To begin with, this really means nothing, as “love” is an abstract noun referring to an emotion or motivation, and it’s hard to see how a psychological disorder can be “infuriated”, any more than measles can. Presumably this really means that behavior usually interpreted as loving, like kissing, hugging, mutual gaze, or gift-giving,  has a different effect on some children than some caregivers would expect or like it to have, and that if such affectionate advances are pressed in spite of the child’s obvious withdrawal, the result may be an angry interaction ending in a tantrum. But that’s not what is communicated by the website’s claim, which deceptively suggests that the fact of love for a child, not a parent’s behavior, causes the child (or perhaps the disorder, in a demonic fashion?) to become furious.

I think the deceptive aspects of this website are pretty clear already, but let’s soldier on and look at some specifics at http://instituteforattachment.org/learn-about-attachment-disorder/common-questions/#1. Hmm, this is interesting, isn’t it? The home page referred repeatedly to Reactive Attachment Disorder, which is an “official” DSM disorder, although with some redefinition in DSM-5. But here we see that the discussion is of  something called attachment disorder, a term that is applied here to Reactive Attachment Disorder, oppositional defiant disorder, post-traumatic stress disorder, childhood trauma, Pervasive Developmental Disorders, and “pervasive developmental delay”. These are conventionally seen as different disorders, although more than one may be a problem for a particular individual. It is deceptive to present all of these as part of the same disorder, and especially to assign a purely speculative overarching category to them without explanation.

There are quite a few other points you may notice if you look at this page. But let me go on to one of particular interest with respect to the code of ethics mentioned earlier. Scroll down to the orange headline, “I’ve sought traditional therapy in the past. It didn’t work for me. Why?” The response is this: “In traditional therapy, the client with a maladaptive upbringing usually functions more from his frontal lobe--  the part of the brain that performs abstract reasoning. For them, traditional talk therapy tends to be more of a cognitive process. Basically, they never access and deal with their limbic-based emotions. The more intelligent the client, the better they are at defending their stored up feelings of inadequacy. As a result, they tend to get frustrated by traditional therapy.” Now, this is nothing but neurotrash talk. There is no evidence that any of this is true. In addition, it exposes this approach as a  “parts” therapy that views human beings as collections of unintegrated entities (curious, because I expect the practitioners call themselves “holistic”).

One more bit, then I’ll rein myself in. Below the part just mentioned, you’ll see another orange headline: “Does my child have attachment disorder?” Here we have a good many of the same-old same-old “symptoms” of attachment disorders, promulgated by AT/HT practitioners for lo, these many years. “Lacks cause and effect thinking”! Have these people ever stopped to consider what someone would be like if they actually did not have this ability, which starts to develop a few months after birth? What they actually mean is that no matter how much people have been yelling at and punishing the kid, they have been unsuccessful in changing the behavior they find a problem. It is a deceptive practice to claim that any of the “symptoms” listed here are part of an attachment disorder, much less part of PDD, especially when by doing so the authors imply that their form of treatment can ameliorate the problem.

By the way, the outfit that has posted these deceptive statements is the one that has prevented “Eve Innocenti” (see http://childmyths.blogspot.com/2012/12/the-attachment-therapist-wears-two-hats.html) from seeing her children for some years now. As the organization sells its services to the county, perhaps there is more here than simply deceptive commercial practices that could lead to charges if a victim had legal help. Many states have “false claims” acts that punish the sale to governmental agencies of substandard goods or services. But a whistle-blower needs to report what is happening. Is there one out there?




Monday, February 10, 2014

Foster Care, Institutions, and International Adoption: Re-focusing on Developmentally Appropriate Practice

Eton, Harrow, Marlborough, Roedean; Lawrenceville, Andover, Hill, Hotchkiss, Miss Porter’s, Sacred Heart…  these are all boarding schools, institutions if you will, to which affluent British and American parents have been sending their children for over a hundred and fifty years now, for the purposes of education and socialization into the culture of their class. Some people have had horrible experiences there (cf. George Orwell), but great national leaders have also emerged from such schools (cf. FDR and Winston Churchill).

Can knowing these facts help us decide whether all institutions that do congregate care for children of any age are either acceptable or unacceptable? I’m afraid not, because not only are such   institutions different from each other, children of different ages and different backgrounds are also different in their needs and abilities.

However, the facts about the great independent schools do tell us that it is quite possible for an institution’s care to create excellent outcomes for some children. Similarly, Richard McKenzie’s recent piece, “Foster Care versus Modern Orphanages” (http://www.ncpa.org/pub/ib136) tells us about the successes of the Crossnore School in North Carolina--  an institution whose graduates have done well in spite of challenges rarely known to the students of Harrow or Hotchkiss.

Of course, none of this tells us that institutional care, even for adolescents, is uniformly good. To be aware of this, we need only look at the track record of the World Wide Association of Specialty Programs and Schools, quite a number of whose members have been charged with serious maltreatment of children in their care. Or we might have a glance at the Miracle Meadows School in West Virginia (www.miraclemeadows.org), where on line complaints suggest that at least some outcomes have been less than successful, in spite of--  or perhaps because of--  the school’s claim to have a policy not to expel any child, perhaps meaning that the school will act as a private prison at parents’ wishes until the child ages out. A document describing a state investigation of events at the school mentions isolation of a child in a small space and beating of another child with a board (www.caselaw.findlaw.com/wv-supreme-court-of-appeals/1042637.html). Parents who had sent children to the school evidently did not want an investigation to proceed. (Incidentally, I know of my own knowledge of a Russian girl who was placed at this school as an investigation into abuse by her adoptive parents in another state was about to begin--  this being her second set of adopters, the first having decided that they did not like her and that she was not being changed by holding therapy. I see on the school website the presence of other Russian and of Ethiopian children, who were presumably adopted, or at least I can’t picture Russian and Ethiopian parents planning their children’s education in West Virginia.)

Similar stories of excellent and of abysmal conditions and outcomes can easily be told for both foster families and international adoptions. Institutions, foster care, and adoption are equal in their capacities to facilitate or to discourage good development. The care method is not the important thing; the details of how children are treated are the essential factors, and those details have not been transparently reported in materials published about the Bucharest Early Intervention Project (BEIP), the “scientific foundation” for many current claims about care for parentless children. Neither are they made very clear in the epidemiological study by Kathryn Whetten and her colleagues, published in 2009, and concluding that health and well-being of children aged 6 to 12 are not negatively affected by institutional living (www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0008169). Whetten noted the need for clarity about these details, pointing out the need to “understand which characteristics of care promote child wellbeing”, and adding, “Such characteristics may transcend the structural definitions of institutions or family homes.”

What details of care should we look for in studies about care of parentless children? Beyond simple issues like appropriate food and medical care, this depends on the ages of the children being considered.  And, I should point out, this fact makes “apples and oranges” of any attempt to set the BEIP study in direct contradiction to the Whetten report. The BEIP study dealt with an intervention that began when the children were toddlers; Whetten’s work focused on children who were already “school age” when studied.
Much is already known about the different developmental needs of children at different ages. Designing environments that satisfy these needs and foster good development is known as developmentally appropriate practice (DAP). DAP concepts have been used primarily in discussion of children in early childhood (including infancy and the toddler period), and they focus on the importance for good development of having a small number of sensitive, responsive adults  as caregivers for a small group of children, with consistent rules and practices guiding children’s social development, and a stable but interesting physical environment. Although caregivers often resist this idea, it has been suggested many times that caregivers should remain with their group of children as they move “up” to more advanced classrooms and activities (this is actually practiced, I believe, in the Waldorf Schools).

Although less has been said about this point, “school age” children also have their DAP concerns, and different ones than were the case in early childhood. Familiar caregivers are preferred, but by this age children much more easily engage with new adults who are friendly and interesting. These children still benefit from the presence of familiar people at bedtime or when sick or frightened, but they can explore new activities and people without needing the frequent “emotional refueling” of their younger days. They are strongly interested and involved in their peers and benefit from having a stable group of friends. This is a period of learning to negotiate and compromise with others and of developing skills in making social and moral decisions in a safe environment where helpful adults can buffer the effects of mistakes. Schooling and learning some adult-like tasks are another focus during this age period.

DAP with adolescents is somewhat different, as teenagers are in the process of moving toward adult status. They still appreciate and benefit from adults who respond warmly and helpfully when they are sought, but they need to be working toward independent judgment and decision-making. The advent of sexuality and increased aggressive impulses means that help is needed with insight into emotions as well as with self-control. Adolescents are also preparing for adult lives in the sense of working toward further education and refining their ability to do adult tasks, in anticipation of independent living.

Care for parentless children thus needs to be different for each of these age groups, and it also needs to be fine-tuned with respect to the child’s age when entering the care placement.  Good outcomes cannot result from “warehousing” at any of these stages, and it’s possible to see how either a good job or a poor one could be done at any stage by an institution, a foster home, or adoption. 
  
As Richard McKenzie pointed out, a “full menu” of care options for parentless children is needed world-wide. Glorification of a single option probably has real political benefits for those who do this, but it entirely avoids consideration of the real needs of orphaned and abandoned children. We need to re-focus on a variety of needs and a variety of developmentally appropriate solutions.


Wednesday, February 5, 2014

The Remarkable Consistency of Ronald Federici

I usually don’t look at Amazon reviews of my books, because most of them are intended as textbooks or supplementary texts. I doubt that too many people buy them because they see them advertised or critiqued on Amazon—they are more likely to be ordered because of publishers’ advertising or comments by publishers’ reps visiting campuses. However, this morning a friend called my attention to a series of “reviews” by the Virginia psychologist Ronald Federici, which you can see at http://www.amazon.com/gp/pdp/profile/AXNT5EBH90QQB/ref=cm_cr_rdp_pdp.

Anyone looking at a single book would see a review that would appear to be directed at that book alone, but Amazon happily makes it possible to see all of a reviewer’s reviews (as at the link above). Thus we can easily see that Federici has written almost identical comments on each book, and has complained in each case that I offered no solutions to parents. This is, of course, perfectly true, because most of the books were not addressed to parents particularly (although they may have been marketed as text/trade books in some cases). The infant development textbook  and the “myths and misunderstandings” books that gave rise to this blog have sections that deal with parent beliefs and parent behaviors, but they are far from being books of advice. One of the reviews refers to my teaching at a community college, and I did indeed teach one course at such a college about 40 years ago--  but this is of course not an element of a  review, but instead an ad feminam argument designed to distract the reader from the real point.

Federici is nothing if not consistent, as he has spent quite a few years cursing my positions and praising his own (note the laudatory review of his own book shown at the same link, apparently written under another name at one time but now reverting to its real author). He has been especially consistent in his use of proof by assertion, simply repeating the same points without any effort to bring evidence to his support. This is certainly what occurred the only time I ever spoke to him face to face, when he sued me in Small Claims Court in Fairfax, VA, claiming that he had lost clients because of what I had said about him on the Internet. He brought a pile of printouts of e-mails and placed them in evidence--  but provided no evidence that the writers were real people, or indeed that they were written by anyone but himself. As a result, the judge found in my favor. Within an hour after leaving the courtroom, I received an e-mail (and later a hard copy) inviting me to come and work with Federici! (If this bit appears inconsistent, just think of it as a consistent focus on “whatever works”).  

That trial was in 2010, and a later suit (dismissed by a federal judge) was brought to court in 2011. I had not heard from Federici for quite a while. But now we have these repetitive reviews, the most recent written in late 2013, with a pause since the one before that in 2011. Federici has also been active in another sort of nuisance lately--  I hope to be able to talk about this when it is resolved, but it’s probably better not to comment just now.

It’s probably pointless to ask why Federici does not simply present data to support the claims he makes in his book about the use of methods like prone restraint of uncooperative children. If he had the data, he’d give them, no doubt. Nor is there much point in asking why he puts his energies into personal attacks; this is what he does, and I don’t suppose it will change now. But what has re-awakened Federici’s interest in me? Could it be that he wonders whether I was involved in discussions expressing concern about what role he might play in Russian decisions about adoption? Or is it that, having been thanked for his help in the recently published book by Nelson, Fox, and Zeanah, he feels he may share in some political benefits that might be forthcoming for supporters of international adoption, and therefore is entitled to throw his weight around? Could it be that a personal matter going back about two years has irritated him? Or could it just be that he is really consistent, and I am on his enemies list, so whatever little noodge he can provide is worth doing?

Seeing Federici’s “reviews”, and thinking a lot recently about the Bucharest Early Intervention Project, I went back to Roelie Post’s 2007 book, Romania, for Export Only: The untold story of the Romanian ‘orphans’. There’s no index to this daily journal kept by a Dutch employee of the European Commission, so it can be hard to find details, but I did find some references to Federici’s involvement in Romanian adoption affairs. This is a complicated story connecting international adoption with child trafficking, but what is especially interesting to me in terms of Federici’s consistency is an e-mail quoted on p. 79, one of a number sent by him to Post in 2001. My point in quoting this is to show Federici’s presentation of his own credentials ( a point on which I filed a complaint with his professional licensing board several years later). He said:

“Dear Madame, My name is Dr. Ronald Steven Federici , Neuropsychiatrist* in Washington DC area and specialist in the neuropsychiatric* evaluation and treatment of post-institutionalized children. They tell me I am regarded as one of the world’s experts in the most complicated cases of children who have been institutionalized, and I lecture all over the world with my medical* team from my international charity Care for Children International Inc. I am also Director of a large group medical-psychiatric* practice and Professor* of Child Development.” (* added by JM)

I have starred points on which Federici has consistently made claims that cannot be supported. By referring to himself as a neuropsychiatrist, he implied that he has a medical degree (as psychiatrists do), whereas in fact his degree is Psy.D., with original specialization in school psychology and later licensure in clinical psychology. He made the same suggestion by speaking of neuropsychiatric evaluation and treatment, neither of which he is qualified to do, and by referring to his medical team and medical-psychiatric practice. Incidentally, although he has been a “professor” in the sense of teaching a course as an adjunct, he does not hold the faculty rank of Professor at any college or university.  (And of course, whether “they” really told him he was regarded as one of the world’s experts, I couldn’t possibly say.)

Federici is remarkably consistent, it’s true. He consistently does not want to respond to critics by arguing the evidence for the safety and effectiveness of the methods he advises in his self-published book, and he consistently does want to take whatever backdoor approach he can think of to attack those who are concerned about those methods. Isn’t it time for him to come out and discuss differences in a straightforward professional manner, as his real credentials suggest he should be able to do? I, as well as several others, would be happy to engage in a public debate with him.